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zhengyun21

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PMC-Patients

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3982338-1

noncomm/PMC003xxxxxx/PMC3982338.xml

Suppurative Parotitis and Submandibular Sialadenitis

The present case report is about an 18 days old full term female neonate presented to our department with swelling in parotid and submandibular area on left side for 6 days. The swelling was associated with fever. Further history revealed a small hole below the mandible draining pus. On examination, the baby was toxic running high grade fever and irritability. The local examination revealed a swelling about 5 cm × 4 cm in size in parotid area extending down to submandibular and submental area. There was a pustule near submental area draining purulent material. Overlying skin was erythematous and swelling was fluctuant [].\nFurther examination revealed that upon pressing the swelling, purulent material was extruding through the floor of the mouth []. Aspiration of the swelling revealed pus. The base line investigation were done which showed leucocytosis - 18,000/μl with neutrophillis - 80%, kidney and liver function tests were normal, Incision and drainage of the abscess was done about 30-40 ml of frank pus was drained. Pus was sent for culture sensitivity. Patient was already put on amoxicillin + clavulanate (15 mg/kg orally every 12 h). Post-operatively, patient was given antibiotics for 2 days. After 4-days no abscess was found on follow-up clinical examination. Pus culture sensitivity grew Staphylococcus aureus. Mothers milk was sent for culture and sensitivity and was sterile. Local examination of mothers breasts was also normal. In follow-up after two weeks and then at 1 month of discharge from hospital, baby had completely recovered.

[[18.0, 'day']]

F

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{}

3982339-1

noncomm/PMC003xxxxxx/PMC3982339.xml

Congenital Tuberculosis Complicated by Interstitial Pulmonary Emphysema

The present case report is about a 6-week-old female child who presented to the Department of Pediatric with difficulty in breathing since birth and progressively worsening cough since 15 days. The child was a preterm baby born at 34 weeks by normal vaginal delivery. There was a history of previous still birth. Prior to being hospitalized, and had received multiple antibiotics.\nOn further examination, the child was pale and malnourished. She had hepatosplenomegaly. She was tachypneic (Respiratory rate = 98/min), with severe subcostal and intercostal recessions. Respiratory system examination revealed decreased air entry and wide spread coarse crepitations. Her SpO2 was 86% with 100% oxygen inhalation by mask. Thus, she was put on ventilator. Investigations revealed: Hb 7.4 g%, total leukocyte count 10,500. Bacterial cultures of blood, cerebrospinal fluid and urine were negative. Her chest radiograph showed milliary mottling of both lungs. [] Ultrasonography showed hepatosplenomegaly with tiny hypoechoic nodules in spleen suggestive of granulomatous pathology. Montaux test was negative. Bronchial washings and gastric washings were negative for acid fast bacilli (AFB).\nThe child's mother was counseled and investigated for tuberculosis. There was no abnormality detected on chest radiograph of mother and her sputum was negative for AFB. However, the diagnosis of genital tuberculosis was confirmed by endometrial biopsy which was positive for AFB. Thus, the child and the mother both were put on anti-tuberculosis treatment.\nThe child remained on ventilatory support for 6 days and was put on bubble continuous positive airway pressure for the next 10 days. Thereafter, she showed respiratory distress whenever weaned from oxygen. Thus, she was put on oxygen inhalation by nasal prongs and remained oxygen dependent for 2 months. Computed tomography scan report showed multiple diffuse consolidations and thin walled cystic lesions in upper and middle lobes. [] The multiple cystic lesions were reported by the radiology department as interstitial pulmonary emphysema/tuberculous bullae; and were the explanation for air entrapment and prolonged oxygen dependence. Thus, the case was a unique case in which congenital tuberculosis, a rare entity itself was complicated by PIE, resulting in prolonged oxygen dependence. The child recovered slowly and was put off the oxygen inhalation by nasal prongs after 2 months. He was thus discharged in a satisfactory condition from the hospital after 2.5 months. On follow-up visit to the outpatient department after 2 weeks, there was marked clinical improvement. Repeat chest radiograph and ultrasonography showed clearing of tuberculous lesions.

[[6.0, 'week']]

F

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{'6598396-1': 1}

3982350-1

noncomm/PMC003xxxxxx/PMC3982350.xml

De-Novo Histoid Hansen Cases

A 29-year-old female presented with multiple grouped papular lesions over lower part of face and abdomen with few hypopigmented patches over buttocks since 2 months.\nThere was no history of fever, epistaxis or loss of chappals. No complaint of any ulcer or deformity of hands and feet.\nThere was no h/o contact with leprosy patients. No h/o any drug intake for leprosy.\nOn examination there were multiple shiny papulo-nodular lesions over lower part of face (; Case 1) with few hypopigmented scaly lesions over buttocks. Bilateral ulnar nerves were thickened. Crude touch and fine touch were normal. Hot and cold sensations were altered below knees in both legs. Corneal and conjunctival sensations were normal. Motor examination was normal. All routine investigations were normal.\nOn histopathological examination: The microphotograph shows thinned out epidermis with chronic inflammatory infiltrate which shows storifirm pattern consisting of lymphocytes, histiocytes, and foamy macrophages. Heavy bacillary load was seen on Fite Faraco stain []. Split Skin Smear revealed acid-fast bacilli of BI: 6+

[[29.0, 'year']]

F

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{'3982350-2': 2, '3982350-3': 2}

3982350-2

noncomm/PMC003xxxxxx/PMC3982350.xml

De-Novo Histoid Hansen Cases

A 28-year-old female with 9-month amenorrhea presented with lesions over face, both hands, and legs since 3 months and complaint of epistaxis and nasal stuffiness. Lesions progressed to involve B/L limbs and back.\nThere was no history of fever, joint pain, or loss of chappals. There was no h/o contact with leprosy patients. No h/o any drug intake for leprosy.\nOn examination multiple papulo-nodular lesions with few nodular crusted lesions were present over forehead, earlobes, periorificial area (; Case B), and both upper and lower extremities. Also few discrete hypopigmented patches over buttocks were observed. Both ulnar nerves were thickened. All sensations were slightly altered over both upper and lower extremities over glove and stocking distribution. Corneal and conjunctival sensations were normal. Motor examination was normal. All other routine investigations were normal.\nOn histopathological examination: Section shows thinning of epidermis with collection of macrophages foamy nodules in dermis. Clear grenz zone is evident. Skin adnexa and other dermal appendages are not seen. Heavy bacillary load was seen on Fite Faraco stain []. Split Skin Smear revealed acid-fast bacilli of BI: 6+

[[28.0, 'year']]

F

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{'3982350-1': 2, '3982350-3': 2}

3982350-3

noncomm/PMC003xxxxxx/PMC3982350.xml

De-Novo Histoid Hansen Cases

A 21-year-old male presented with papular lesions over face since 20 days. He had no complains of fever, epistaxis, or loss of chappals. On examination multiple shiny papulo-nodular lesions were found over forehead, ears, and cheeks (; Case 3). Nasal stuffiness, congestion, and watering from eye present.\nBilateral ulnar nerve, greater auricular nerve, common peroneal nerve, anterior tibial nerve, posterior tibial nerve were thickened. Glove and stocking anesthesia present upto elbow and knee. Corneal and conjunctival sensations were normal. Motor examination was normal. All routine investigations were normal.\nOn histopathological examination: Section shows extensive cellular infiltration in dermis mainly composed of macrophages, lymphocytes, and plasma cells. There are clear Grenz zones below the flattened epidermis. Hematoxylin and eosin-stained sections showed classical histocytic Granulomas [] with heavy bacillary load on Fite Faraco stain. Split Skin Smear revealed acid-fast bacilli of BI: 6+ [].

[[21.0, 'year']]

M

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{'3982350-1': 2, '3982350-2': 2}

3982351-1

noncomm/PMC003xxxxxx/PMC3982351.xml

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) in Strongyloides stercoralis Hyperinfection

A 76-year-old Hispanic male presented to our hospital with a 2-month history of fatigue, nausea, intractable vomiting and a 30-pound weight loss. Past medical history was significant for idiopathic thrombocytic purpura (ITP) diagnosed 4 months ago, which was treated with steroids for 3 weeks. The patient had immigrated to the United States from Columbia 17 years ago and had travelled to Venezuela a month prior to presentation. He had a history of smoking 1 pack per day for 40 years.\nOn physical examination there was nonpalpable purpurae. Abdominal examination revealed a soft nondistended abdomen with mild epigastric tenderness, with no associated guarding, rigidity, rebound tenderness, or organomegaly.\nLaboratory examination revealed elevated white cell count of 11,400/μl, with a normal eosinophil count of 1%. Biochemistry revealed sodium of 122 meq/l. Other significant laboratory abnormalities were a total protein level of 4.5 g/dl and albumin level of 1.7 g/dl. The rest of laboratory examination was normal []. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain were unremarkable. The patient tested negative for both HIV and human T-lymphotropic virus (HTLV).\nThe patient was initially treated with 0.9 normal saline infusions suspecting hypovolemic hyponatremia due to persistent vomiting, but showed only minimal improvement in serum sodium levels. A diagnosis of SIADH was then made based on his high urine osmolality, 564 mOsm/kg and low plasma osmolality 261 mOsm/kg. Fluid restriction increased his serum sodium to 133 meq/l.\nTo evaluate his symptoms of intractable vomiting, an esophagogastroduodenoscopy (EGD) was performed which showed erythema in the stomach and duodenum. Histopathology showed acute and chronic duodenitis, with marked blunting of villi and reactive cellular changes, active gastritis, and presence of parasites consistent with S. stercoralis [Figures and ]. Stool examination showed many S. stercoralis larvae.\nThe patient was treated with two doses of ivermectin 12 mg (calculated at 200 μg/kilogram) following which his nausea and vomiting improved and serum sodium increased to 139 meq/l. Repeat stool examination after 2 weeks of ivermectin therapy did not show any S. stercoralis larvae.

[[76.0, 'year']]

M

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{'6392699-1': 1}

3982352-1

noncomm/PMC003xxxxxx/PMC3982352.xml

Pancreatitis in Scrub Typhus

A 48-year-old female homemaker from a rural area was admitted with complaints of intermittent high fever, abdominal pain and vomiting, and reduced urine output. On examination, she had a pulse rate of 110/min, blood pressure 130/80 mmHg and was afebrile. Conjunctiva were pale and sclera were icteric and no rash was noted. On abdominal examination, diffuse tenderness was elicited and hepatomegaly was present. Hemoglobin was 8.0 g/dL, platelet count 64,000/μL, leukocyte count 10,300/μL with 78% neutrophils and 18% lymphocytes. Erythrocyte sedimentation rate was 88/min. Total bilirubin was 3.5 mg/dL, direct bilirubin 2.3 mg/dL, aspartate aminotransferase 47 IU/L, alanine aminotransferase 64 IU/L and alkaline phosphatase 125 IU/L. Total protein was 6.4 g/dL, albumin and globulin were 3.1 g/dL and 3.3 g/dL, respectively. Serum urea was 174 mg/dL and creatinine was 4.5 mg/dL. Urine analysis revealed 2-4 white cells/high power field, 15-20 red cells/high power field and no casts. Serum amylase was 2662 U/L and lipase was 3822 U/L. The test for malarial parasite by quantitative buffy coat was negative. Blood culture remained sterile after 7 days of incubation and immunoglobulin M (IgM) antibodies to leptospira by enzyme linked immunosorbent assay (ELISA) were negative. Weil-Felix test showed significant titers of OX K - 1:320, OX 19 - 1:80, OX 2 - 1:40 and IgM antibodies to Orientia tsutsugamushi by ELISA were positive.\nThe patient was treated with doxycycline 200 mg/day and ceftriaxone 2 g/day alongside supportive measures. The initial ultrasound scan performed on the 3rd day of admission revealed hepatosplenomegaly, features of acute medical renal disease and ascites. No abnormalities were noted in the pancreas. However, the patient continued to have abdominal pain and a review ultrasound scan was performed on the 9th day, which showed fluid along the body of the pancreas in the lesser sac indicative of a pancreatic pseudocyst. Contrast enhanced computerized tomography of the abdomen was not carried out in view of the deranged renal parameters. The patient was stable upon discharge on the 11th day and on follow-up 6 weeks later, all symptoms had resolved. Lab investigations through the course of hospital stay are given in .

[[48.0, 'year']]

F

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{}

3982355-1

noncomm/PMC003xxxxxx/PMC3982355.xml

Exuberant Oral Myiasis Caused by Musca domestica (Housefly)

A 42-year-old female patient reported with a chief complaint of pain and swelling in upper front teeth since past 3 days. History of present illness revealed discomfort and mobility with upper anterior teeth since 2 months and difficulty in eating since last 20 days.\nThe patient was a farm laborer with low socioeconomic background residing in rural area. Extra-oral examination revealed retruded chin and proclinated maxillary anteriors (Class II overjet with incompetent lips), few of which appeared to be on the verge of exfoliation. There was a diffuse swelling involving the upper lip with prominence of the vermilion border. The lip also appeared slightly erythematous, though there was no rise in local temperature [].\nIntra-oral examination revealed poor oral hygiene, fetid odor and severe periodontitis. There was a solitary swelling involving the anterior maxilla extending from mesial surface of maxillary right first premolar to the distal surface of maxillary left canine measuring approximately 6 × 4 centimeters. The upper anterior vestibule was obliterated and demonstrated cleavages and tunnels in labial mucosa and underlying tissues with numerous visible larvae that exhibited wriggling movement. The involved mucosa was swollen, erythematous and also bled easily. Maxillary anterior teeth exhibited pathologic migration along with extrusion and severe gingival recession extending to the apical thirds. Maxillary incisors (teeth # 11, 12, 21 and 22) were carious. Necrotic areas and calculus deposition was also associated with these teeth []. Occlusal radiograph of maxilla revealed destruction of the supporting alveolar bone with floating teeth []. Based on these clinical and radiographic findings, the case was diagnosed as oral myiasis.\nTreatment plan was primarily aimed at encouraging the larvae to come out of the involved area. Topical application of turpentine oil was done with autoclaved gauze soaked in it in order to asphyxiate the larvae. Subsequent mechanical removal of maggots with blunt cotton pliers harvested approximately 55-65 maggots. These were preserved in 40% formaldehyde and identified as larvae of Musca domestica or housefly []. Oral drugs including Doxycycline 100 mg BD on first day followed by OD dose for next 5 days, Metronidazole 400 mg TID for 5 days, Ivermectin 3 mg BD for 5 days and Diclofenac sodium 50 mg TID for 3 days along with a supplement of B-Complex (OD) for 15 days were prescribed. The patient was also advised to rinse with 0.2% Chlorhexidine gluconate mouthwash 10 ml BD for 7 days.\nLarvae were removed every day manually as described above. On the third day, when the infection was under control, the mobile teeth were extracted and the wound was debrided in order to remove the necrotic tissue. Finally, the involved site was re-examined for remaining larvae or tissue tabs before being sutured. The patient was educated and motivated with regards to personal hygiene measures with special emphasis on oral hygiene instructions. Three week follow-up demonstrated satisfactory and uneventful healing with complete resolution of lesions.

[[42.0, 'year']]

F

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3982356-1

noncomm/PMC003xxxxxx/PMC3982356.xml

Hemorrhagic Varicella in Chronic Liver Disease

A 12-year-old boy, follow-up case of chronic liver disease, was admitted in our hospital with 1-week history of fever, malaise and 5 days history of generalized discrete vesiculopustular rash over the entire body and oral ulcers. His palms and soles were also involved. Since the last 3 days, the rash became hemorrhagic with frank bleeding from several areas especially from the lesions on the face and also had malena. Since then, the patient became anorexic and weak. There was family history of similar illness in two younger siblings but of mild in nature and rashes were subsided in them without any treatment. He had history of jaundice off and on and abdominal distension since last 1 year. He was hospitalized two times for the complaint of jaundice and abdominal distension in the past 1 year. The patient belonged to a poor social background. On examination, the patient was looking toxic and he was conscious and oriented. He was febrile (temperature: 38.5°C) and had severe pallor. There were several hemorrhagic ulcers in his mouth and over the lips, multiple large hemorrhagic rashes over the face [], with frank bleeding from a few lesions and multiple discrete hemorrhagic pustules over the entire body [Figures and ]. On per abdominal examination spleen was palpable 8 cm below costal margin and liver was palpable 3cm below costal margin. On investigations, hemoglobin level was 4.7 g/dl, total leukocyte count was 4.3 × 109/l and platelets were 29 × 109/l and ESR was 65 mm fall. Serum bilirubin was 3.0 mg/dl, serum albumin was 2.3 g/dl with SGOT 154 and SGPT 88. Prothrombin and thromboplastin time were also prolonged. Level of serum urea was 31 mg/dl and creatinine was 0.98 mg/dl. The patient was HBsAg negative and antibodies to hepatitis-C were absent. ELISA test for HIV was negative. Abdominal ultrasonography revealed hepatosplenomegaly with coarse echotexture of liver with portal vein dilatation. Tzanck smear revealed multinucleated giant cells. Anti-varicella IgM antibodies were positive. We did not perform liver biopsy because patient's general condition was low and he had thrombocytopenia too. On the basis of clinical condition and laboratory parameters the diagnosis of chronic liver disease with hemorrhagic chickenpox was made. During the hospital stay the patient has also developed pneumonia on day 2 of admission. We have given aggressive supportive treatment as well as intravenous acyclovir 10 mg/kg 8 hourly, intravenous antibiotics, including cefotaxime 75 mg/kg 12 hourly and vancomycin 15 mg/kg 8 hourly to him for 10 days and were transfused packed cell volume along with platelet concentrate and fresh frozen plasma. Fortunately the patient got improved on day 7 and we discharged him and referred to higher center on day 10 for further management of his chronic liver disease. Written consent was obtained from the patient's father for the publication of case report along with photographs.

[[12.0, 'year']]

M

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{}

3982376-1

noncomm/PMC003xxxxxx/PMC3982376.xml

Benefits of thrombolytics in prolonged cardiac arrest and hypothermia over its bleeding risk

A 52-year-old non-smoking Caucasian male, who is allergic to shrimps, presented to the emergency room (ER) after he was found unconscious in the bathroom. At 6 days before presentation, patient had symptoms of severe cough with streaks of blood and dyspnea on exertion and was treated with azithromycin antibiotic for presumed upper respiratory tract infection. The day before presentation, patient's symptoms of cough and dyspnea started getting worse. Patient reported taking benzonatate antitussive, which caused tingling and numbness around his mouth and cheeks, which resolved spontaneously after 30 min. Patient did not report of hives, swelling of the face or tongue and difficulty in swallowing. Subsequently, patient got extremely agitated and short of breath leading to state of unconsciousness. Emergency medical services were activated, 100% oxygen was initiated and patient was transferred to our ER.\nIn the ER, patient presented with grey colored skin and symptoms of severe dyspnea. As per the patient's wife, he had no calf pain and/or swelling recently. There were no recent hospitalizations, prolonged immobilization or history of pulmonary embolism (PE) and/or deep vein thrombus (DVT). He had no other medical procedures and/or surgeries performed in the recent past. Patient's father has a history of PE secondary to extensive airplane travel and stroke. Patient has no history of familial clotting disorders. Consequently, patient developed complete heart block and received intravenous atropine and epinephrine. An electrocardiogram showed a right bundle branch block and ST-segment elevations in the inferior leads with elevated troponins of 13.5 ng/ml (normal <0.03 ng/ml). Cardiac monitor showed pulseless electric activity and patient was intubated and cardiopulmonary resuscitation (CPR) was initiated immediately. The cardiac arrest was presumed from ST elevation myocardial infarction and the patient was transferred to cardiac catheterization laboratory. Patient intermittently remained in cardiac arrest requiring intra-aortic balloon pump and temporary pacemaker. Short episodes of CPR were performed. Cardiac catheterization showed non-obstructive coronary arteries and a hyper-dynamic left ventricle. Patient's blood pressure remained low and so patient was continued on epinephrine, dopamine drips. Patient was then transferred to the intensive care unit and he remained intubated with mechanical ventilation and ongoing CPR. On physical examination, the patient was noted to have respiratory rate of 30 breaths/min, fixed and dilated pupils of 7 mm and endotracheal tube in place. His neck was supple without jugular vein distention. Chest examination revealed distant lung sounds, with no wheezing. Cardiac auscultation was tachycardia with no murmurs, gallops and rubs. On neurologic al examination, the patient's Glasgow coma scale was <9 with no gag reflex and response to Babinski. Rest of the examination was unremarkable. Laboratory data revealed white cell count of 11.7 × 109/L (normal 4.3-10 × 109/L) with the normal differentials, creatinine of 2.4 mg/dl (normal 0.7-1.3 mg/dl), ionized calcium of 4.0 mg/dl (normal 4.6-5.1 mg/dl) bicarbonate of 15 mmol/L (normal 22-30 mmol/L), serum osmolality of 322 mOsm/kg (275-295 mOsm/kg), anion gap of 21 mmol/L (normal 8-16 mmol/L) and lactic acid of 16 mmol/L (normal 0.7-2.1 mmol/L) and D-dimer of 6.68 μg/ml (normal <0.49 μg/ml). Other blood cell counts, liver function tests, alcohol, salicylate, methanol levels and urine toxicology screen were unremarkable. An arterial blood gas showed a pH of 6.8, pCO2 of 70 mmHg, pO2 of 90 mmHg on mechanical ventilation, consistent with mixed respiratory and metabolic acidosis. Electrocardiogram showed sinus tachycardia with occasional premature ventricular complexes and right bundle branch block. Chest X-ray showed bilateral basilar infiltrates and cardiomegaly. Stat bedside echocardiogram revealed moderate hypokinesis and enlargement of the right ventricle. Patient's clinical symptoms, laboratory investigations, negative cardiac catheterization of obstructive coronary arteries, electrocardiogram showing sinus tachycardia and echocardiogram proving hypo kinesis and enlargement of right ventricle suggested presumed diagnosis of PE causing cardiac arrest. At the same time, alteplase, tissue plasminogen activator (tPA) was administered immediately with the dose of 0.6 mg/kg over 2 min in a bolus form and heparin drip was started. During the course of the intensive care stay, patient was treated with hypothermic protocol for cardiac arrest with no bleeding complications. Intravenous sodium bicarbonate and calcium chloride were given, cardiac arrest was eventually terminated and patient got extubated. The blood pressure got stabilized and dopamine, epinephrine drips were stopped. Furthermore, intravenous hydrocortisone, benadryl was administered for possible anaphylactic reaction.\nSubsequently, patient rapidly improved with decreased requirement of oxygen. Repeated arterial blood gases within an hour were improved and revealed pH of 7.15, pCO2 of 47 mmHg and pO2 of 404 mmHg. Repeated echocardiogram noted normal size and function of the right ventricle. Venous Doppler's of the lower extremities showed DVT in the left distal femoral vein, gastrocnemius, peroneal vein and normal right lower extremity. The inferior vena cava filter was placed to prevent further occurrence of life-threatening clots or pulmonary embolus and heparin drip was continued. The renal failure secondary to the cardiogenic shock improved with 2 mg of bumetanide, oral diuretic therapy. During the hospital course, heparin was discontinued due to patient's low platelet count and positive heparin induced thrombocytopenia panel. Rivaroxaban, the oral anticoagulant was initiated and patient was transferred to floor with oxygen saturation of 95% on room air. On the medical floor, patient was walking and moving around, could talk in full sentences, was able to feed himself. Within 3 days of the hospital stay, he showed remarkable clinical and functional improvement and was discharged to home in a stable condition.

[[52.0, 'year']]

M

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3982619-1

noncomm/PMC003xxxxxx/PMC3982619.xml

Galactorrhea with menstrual irregularity: something other than a prolactinoma?

A 29-year-old female with no premorbidities was admitted with complaints of galactorrhea for the past week and menstrual irregularities over the past six months. Her last childbirth six years ago had been uneventful. She denied any history of substance abuse. There was no significant family history. General physical examination showed mild pallor. Systemic examination was entirely normal. Routine laboratory investigations showed elevated serum prolactin (190 ng/mL). Liver enzymes were minimally elevated, while albumin-globulin ratio was reversed (serum albumin: 2.3 gr/ dL, serum globulin: 4.1 gr/dL). Renal and thyroid function tests were normal (serum urea: 34 mg/dL, serum creatinine: 1.4 mg/dL, TSH: 2.6 mIU/L). Prothrombin time was prolonged (patient: 20.9 sec, control: 14.8 sec; INR: 1.49). Abdominal ultrasound demonstrated coarse echotexture of the liver, a dilated portal vein (12 mm) and mild splenomegaly (12.3 cm), features consistent with hepatic cirrhosis. Although stool examination was negative for occult blood, upper gastrointestinal (GI) endoscopy revealed grade I esophageal varices and mild portal hypertensive gastropathy. MRI imaging of the brain was performed and ruled out the presence of any pituitary mass.\nAs the patient continued to have galactorrhea, gynecological consultation was sought. Transvaginal ultrasonography was unremarkable; serum levels of gonadotrophins were normal (serum FSH: 11.82 mIU/mL, serum LH: 2.51 mIU/mL) and expectant management was advised.\nThe patient was now evaluated for the cause of cirrhosis. Serologic markers for hepatitis B and C infections were negative, as were tests for anti-nuclear antibodies. However, serum ceruloplasmin was low (9.0 mg/dL); 24-hour urine copper estimation was significantly elevated (758 mcg). Slit lamp microscopy revealed Kayser-Fleischer rings () and sunflower cataracts (). A diagnosis of compensated hepatic cirrhosis secondary to Wilson’s disease with symptomatic hyperprolactinemia was made. Retrospectively, the patient displayed no evidence of neurological involvement, either clinical or radiological, despite the presence of Kayser-Fleischer rings. Therapy with d-penicillamine was initiated at 300 mg TID, and subsequently increased to 600 mg TID. On follow-up she reported significant improvement in symptoms including cessation of galactorrhea within 3 months and regularization of her menstrual cycle.

[[29.0, 'year']]

F

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{}

3982636-1

noncomm/PMC003xxxxxx/PMC3982636.xml

Recurrent small bowel obstruction in a 60-year-old celiac patient: a rare entity of a common disease

A 60-year-old woman was referred to our gastroenterology clinic for evaluation of two episodes of abdominal pain and distention that started 3 months prior to her first presentation. Her abdominal pain was colicky, originated in the left lower quadrant and was followed by vomiting and abdominal distention. Each episode lasted for approximately 2 weeks and resolved spontaneously.\nHer past medical history consisted of celiac disease, diagnosed at the age of 10 years, and anxiety. Her medical treatment contained citalopram and tibolone. The patient did not follow a strict gluten-free diet. Her father died at the age of 60 due to colon cancer.\nThe patient was examined in the emergency department during the second episode. Her physical examination demonstrated left abdominal tenderness without peritoneal signs. Her white blood count was 12.05 K/mcL (4-10.8), with a left shift (absolute neutrophils count of 8.72 K/mcL, normal: 1.8-7.7) and her hemoglobin level was 14.5 g/dL (11.7-15.7). Blood chemistry results were unremarkable, and C-reactive protein level was 8.9 mg/L (normal range 0-5). A computed tomography scan of the abdomen demonstrated dilatation of several small bowel loops, up to 41 mm (). The patient was treated conservatively with gradual resolution of her complaints. After she was referred for our consultation, the patient underwent upper and lower endoscopies, which were normal. Biopsies from the proximal small bowel, taken to diagnose the activity of celiac disease, demonstrated partial shortening of the villi with increased number of intraepithelial lymphocytes, compatible with grade 3 Marsh classification. Anti-endomysial antibody was positive. We decided to further evaluate the small bowel by a video capsule. A single large ulceration, with partial occlusion of the lumen in the middle of the small bowel was demonstrated. Antegrade and retrograde double-balloon enteroscopies failed to reach the desired region, and the patient was sent for laparotomy. A firm lesion was palpated in the proximal ileum. The lesion was excised, and pathology revealed ulcerated, well to moderately differentiated adenocarcinoma invading the entire thickness of the small bowel wall into the mesentery. Surgical margins were free of tumor cells, and regional nodes were not involved. The tumor was classified as pT3, N0, Mx. The patient was prescribed capecitabine for 6 months. After one year the patient is free of any symptoms or evidence of recurrence.

[[60.0, 'year']]

F

{'19365735': 1, '12702783': 1, '15825131': 1, '20496543': 1, '20179237': 1, '16863573': 1, '21723236': 1, '21982968': 1, '21042749': 1, '11982470': 1, '24733274': 2}

{}

3982637-1

noncomm/PMC003xxxxxx/PMC3982637.xml

MRI diagnosis of rupture of pancreatic pseudocyst into portal vein: case report and review of literature

A 52-year-old male, chronic alcoholic and smoker presented to the emergency department with acute abdominal pain. The serum amylase level was elevated and a diagnosis of acute pancreatitis was made. The patient was managed conservatively and was satisfactorily discharged after a two week-stay in hospital. The patient developed abdominal pain again after 2 months and presented to the outpatient department at another institute where a diagnosis of acute on chronic pancreatitis was made. The patient was referred and when he presented to us he was ambulatory and complained primarily of vague upper abdominal pain with no signs of peritonitis. He also complained of occasional episodes of vomiting and weight loss. He was carrying a report of an endoscopic ultrasound (EUS) done elsewhere, films of which were not available. The EUS report showed a 3×3 cm pseudocyst in the region of neck of pancreas with possible communication with dilated main pancreatic duct (MPD). The pseudocyst was compressing the distal common bile duct (CBD) causing moderate biliary dilation. At our institution, he was further evaluated with a transabdominal USG and a contrast enhanced CT (CECT) to look for the severity and extent of disease. The USG () showed the portal vein as anechoic but with no color flow within and also showed communication between the cyst and portal vein. The CECT showed the pseudocyst () in the pancreatic neck and completely thrombosed portal vein and its branches () which was misinterpreted as dilated CBD on EUS. There were multiple periportal collaterals and areas of necrosis in segment V and VII of liver which showed subtle peripheral enhancement and were considered as cholangiolar abscesses. There was suggestion of communication of the pseudocyst with the MPD.\nMRI was performed to investigate a possible communication of the pseudocyst with the MPD and to further characterize the liver lesions. It showed the pseudocyst at the neck of the pancreas with communication with the dilated MPD. The cyst was seen just above the spleno-portal confluence with a defect in the posterior wall and a possible direct communication with the portal vein. The portal vein showed a signal characteristic consistent with fluid i.e. homogenously hyperintense on T2-weighted imaging and hypointense on T1-weighted imaging. There was some plaque-like material along the wall of the main portal vein and its branches which showed hyperintense signal on T1-weighted imaging and hypointense on T2-weighted imaging (, ). On post contrast images there was no opacification of the portal vein (). These features did not correlate with the expected signal character of the thrombus but rather confirmed the presence of fluid within the portal vein similar to that in the pseudocyst with the plaque-like material along the wall showing the character of residual lysed thrombus. There were non-enhancing areas of necrosis in segments V and VII of the liver and thrombus in the distal part of the superior mesenteric vein and splenic vein. The CBD was normal in caliber and there was no intrahepatic biliary dilation. Thus a diagnosis of rupture of pancreatic pseudocyst into the portal vein with lyses of the portal vein thrombus and associated liver necrosis was made. The MRI findings suggested this diagnosis thus obviating the need of any invasive diagnostic modality. Since the main complaint of the patient was generalized abdominal pain and distention which was well controlled with regular medication, a decision to continue with conservative treatment was taken and the patient was kept on close follow up and review. The patient did well thereafter with no significant increase or development of complaints on 6-month follow up. The patient is still on regular follow up and doing well.

[[52.0, 'year']]

M

{'2351306': 1, '15365199': 1, '3490165': 1, '15730995': 1, '19561436': 1, '18079345': 1, '27843518': 1, '24733302': 2}

{}

3982638-1

noncomm/PMC003xxxxxx/PMC3982638.xml

Splenic injury complicating ERCP

We report a case of a 64-year-old man who sustained a splenic injury following ERCP. He was admitted to hospital with obstructive jaundice, and he reported a past medical history of coronary heart disease, right lower pulmonary lobectomy due to lung cancer 5 years previously and nephrotic syndrome. The basic laboratory tests were normal except for liver function tests, which showed a bilirubin level of 12.6 mg/dL (reference level, 0.3-1.2 mg/L), an alkaline phosphatase level of 419 U/L (reference level, 40-129 U/L), and an amylase level of 708 U/L (reference level, 28-128 U/L). His clotting profile was normal.\nThe abdominal computed tomography (CT) showed a mass at the head of the pancreas with dilated pancreatic and common bile duct and additionally some paraortic and mesenteric lymph nodes. The CT was performed without intravenous contrast medium due to renal insufficiency. An upper GI endoscopy revealed duodenal stenosis (treated with balloon dilatation) and a deformed ampulla of Vater secondary to the tumor. An ERCP followed which confirmed the above findings and a plastic stent was placed in the common bile duct and draining was achieved.\nSix hours after the procedure the patient complained of epigastric pain. He was afebrile with a pulse rate of 85 beats/ min and a systolic and diastolic blood pressure of 100 and 70 mm Hg respectively. The physical examination revealed a soft abdomen with mild tenderness over the epigastrium and left upper quadrant without peritoneal signs. The next day (18 h after the procedure) a second CT was performed which showed a homogeneous mass lesion of the left subdiaphragmatic region in keeping with a splenic hematoma (). A hemoperitneum and a plastic biliary stent were also present. Laboratory blood tests including complete blood count showed a decrease of the hemoglobin (from 14.1 to 8.0 g/dL) and mild leukocytosis: 11.3 k/mL. Subsequently, an emergency surgical solution was offered to the patient. After entering the peritoneal cavity the following findings were observed: a) rupture at the hilum of the spleen; and b) a solid mass in the head of the pancreas obstructing the duodenum. Splenectomy was performed () with meticulous hemostasis and enterogastrostomy (stomach - jejunum) in order to bypass the obstructed duodenum.

[[64.0, 'year']]

M

{'29977934': 2, '8293913': 1, '28559784': 2, '18382023': 1, '1756925': 1, '2929211': 1, '15347118': 1, '19337638': 1, '11394431': 1, '33083066': 2, '27461259': 1, '8059310': 1, '8351610': 1, '15328812': 1, '21546711': 1, '1743138': 1, '29904296': 1, '11706215': 1, '12193500': 1, '22679404': 1, '24733368': 2}

{'5437448-1': 1, '6024491-1': 1, '7563073-1': 1}

3982977-1

noncomm/PMC003xxxxxx/PMC3982977.xml

Chorea disclosing a polycythemia vera

A 70 year-old woman attended the outpatient clinic of neurology department (Huadong Hospital) with a complaint of involuntary movements in her left limbs during the past 4 days, beginning with involuntary twitching of the muscles in the limbs. A diagnosis of chorea was made and she was treated with haloperidol 2 mg twice a day. One week later, her choreic symptoms had resolved. One month later, she experienced an episode of dizziness, and the next morning involuntary movements reappeared with new symptoms of dysarthria and dysphagia. Five days later, the twitching had escalated to jerking of the muscles which became generalized, extending to the shoulders and face but it ceased during sleep. Her speech and swallowing were moderately affected.\nThere was no family history of movement disorders, dementia or psychiatric illness, and no medical history of stroke, peripheral vascular disease, metabolic or endocrine disorders, or autoimmune disease. She had otherwise been well except for gingival bleeding as a result of taking aspirin. She was not being treated with chorea-inducing drugs such as antiparkinsonian drugs, amphetamines, tricyclic antidepressants, anticonvulsants, or antipsychotics.\nPhysical examination showed facial plethora and erythema of the hands with mild clubbing of the fingers but no splenomegaly. Blood pressure was 130/80 mmHg and temperature was 36.5°C. Neurological examination disclosed choreiform movements of the limbs and orofaciolingual muscles with writhing movements of the tongue, grimacing, grunting, and moderately severe dysarthria and dysphagia. All four limbs were hypotonic with decreased tendon reflexes and flexor plantar responses. Peripheral arterial pulses were palpable in all distal extremities. She was in a state of mild euphoria with a mini-mental state examination (Chinese version) score of 29/30.\nThe results of investigations were as follows and the figures in parenthesis are the normal ranges: hemoglobin 201.0 g/L (113–151 g/L), hematocrit 0.658 L/L, (0.335–0.450 L/L), mean corpuscular volume 89.4 fL (82.6–99.1 fL), oxygen saturation 93.7%, uric acid 390 umol/L (155–357 umol/L), total bilirubin 52.1 umol/L(3.4–25.0 umol/L), direct bilirubin 10.6 umol/L (0–8.0 umol/L), indirect bilirubin 41.5 umol/L(0–17.0 umol/L). The bone marrow aspirate and trephine biopsy specimens were hypercellular for the patient’s age, with biopsy cellularity approximately 80%; erythroid hyperplasia was present. The granulocyte/erythroid (G/E) ratio was 1:2, megakaryocytic 8–10/higher power field (HPF). Reticulin was graded 1 according to a modified Bauermeister scale. Serum erythropoietin was 5.74 mIU/mL (4.3–29 mIU/mL). Results of the following investigations were normal: vitamin B12, calcium concentrations, thyroid function, tests for syphilis and HIV. Retrospective review of laboratory test results revealed an elevated hemoglobin and hematocrit levels 7 months prior to the development of chorea. Apart from mild ischemic white matter lesions, no abnormalities were seen on magnetic resonance imaging. Chest computed tomography demonstrated slight pulmonary arterial dilation. Genetic analysis showed JAK2V617F in her peripheral blood granulocytes. A diagnosis of polycythemia vera was established according to the World Health Organization (WHO) criteria for polycythemia vera (PV).\nShe was treated with hydroxyurea 1,500 mg and clopidogrel 50 mg daily which led to resolution of her chorea within 4 days.

[[70.0, 'year']]

F

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{'6432831-1': 1}

3982982-1

noncomm/PMC003xxxxxx/PMC3982982.xml

Unexpected difficult airway with hypogonadotropic hypogonadism

A 53-year-old married man (weight: 85 kg, height: 187 cm, body mass index: 24 kg/m2) presented with a history of nasal obstruction for two years. Otorhinolaryngologists planned a septoplasty operation under general anesthesia for him. He had not had any prior operation under general anesthesia, so he did not have any history of difficult intubation, and he did not have any chronic systemic disease. The patient was evaluated for obstructive sleep apnea syndrome (OSAS) with a comprehensive questionnaire on his sleeping habits and medical history; no complaints or predictors pertaining to OSAS were identified.\nThe patient’s preoperative airway assessment was normal, Mallampati class was II, thyromental distance was 7 cm, inter-incisor gap was 5 cm, and head extension was >35°. His physical examination was characterized by lack of secondary sexual characteristics and presence of fine facial wrinkles. Although, as previously indicated, the patient was married, he had had no children. He had consulted urologists, and primary infertility and erectile dysfunction had been diagnosed. His hormone profile was: testosterone 0.3 ng/mL (reference range 1.75–7.81), free testosterone 0.91 (reference range 4.5–42.0), prolactin 1.31 ng/mL (reference range 2.64–26.72), luteinizing hormone (LH) 0.33 mIU/mL (reference range 1.24–103.03). His thyroid hormone levels were normal. No other pathological finding was obtained as the result of magnetic resonance imaging of the pituitary gland. Thus, the patients was diagnosed with primary hypogonadotropic hypogonadism.\nHe was admitted to the operating theater, and following the induction of anesthesia with a dose of 5 mg/kg intravenous thiopental, bag-mask ventilation was barely sustained. Fentanyl (1–2 μgr/kg) and, as a muscle relaxant, rocuronium (0.6 mg/kg) were administered. While the patient’s head was in the sniffing position, direct laryngoscopy and intubation of the trachea were attempted three times with different sizes of Macintosh and Miller blades by an assistant professor of anesthesiology with 5 years’ experience. However, unfortunately, the intubation failed. The lungs were then ventilated with 100% oxygen via a face mask in order to avoid desaturation. Glottic visualization was assessed with Cook’s modification of the Cormack–Lehane classification; a grade of 3A (with direct laryngoscopy, only the epiglottis can be visualized; the epiglottis can be lifted using an introducer or bougie) was assigned. The patient was subsequently successfully intubated with a gum-elastic bougie.\nAfter the operation, the patient was extubated successfully without any complication and then examined by otorhinolaryngologists via fexible laryngoscopy. The epiglottis was found to be in a slightly lower than normal position ().

[[53.0, 'year']]

M

{'18250207': 1, '10671848': 1, '15200543': 1, '12351303': 1, '16369144': 1, '16301264': 1, '23798919': 1, '7176619': 1, '4073745': 1, '24741333': 2}

{}

3983421-1

noncomm/PMC003xxxxxx/PMC3983421.xml

Endotracheal tube intubation with the aid of a laryngeal mask airway, a fiberoptic bronchoscope, and a tube exchanger in a difficult airway patient: a case report

A 28-year-old male patient diagnosed with occipito-atlanto-axial instability was scheduled for a cervical fusion. He was 76 kg, 169 cm, Mallampati class III, with a thyromental distance of 7.5 cm and limited head and neck mobility. He was intubated with a fiberoptic bronchoscope (Olympus LF-GP, Olympus Optical Co., Tokyo, Japan) in an awake state, and general anesthesia was maintained with sevoflurane. The operation was performed via the posterior approach in the prone position. Total operation time was about 6 hours, and there were no significant intraoperative events. During emergence, after confirming his stable condition (clear consciousness, adequate weaning profile), he was extubated in the operating room and sent to the intensive care unit. However, immediate O2 desaturation with dyspnea was noted. After giving the patient 5 mg of midazolam for sedation, reintubation with a laryngoscope was attempted twice but failed due to the short jaw-chest distance, neck rigidity, and the flexed cervical angle after cervical spine fixation. His Cormack and Lehane grade was 4. The laryngoscopic view did not improve, even with adequate repositioning of the head (BURP maneuver: backward, upward, and right lateral displacement of the thyroid cartilage). Oxygen supply was continuously provided through a face mask to maintain O2 saturation above 90%. Nasotracheal intubation with a fiberoptic bronchoscope was attempted but also failed due to severe swelling of the tongue, epiglottis, retropharyngeal soft tissue, and the upper airway. Another interfering factor was the bloody secretions in the oropharynx, which obscured the tip of the fiberoptic bronchoscope. As oxygen saturation was able to be maintained at 90% using bag-valve-mask ventilation and the patient was not at increased risk of aspiration of gastric contents, we decided to perform tracheal intubation via an appropriately sized laryngeal mask airway (LMA). Because there was no intubating laryngeal mask airway (ILMA) available in our facility, we used a proseal LMA as an alternative. A #4 LMA was easily inserted and functioned properly. We passed a 5.0 mm endotracheal tube (ETT, without a balloon) through the LMA with the aid of a fiberoptic bronchoscope into the trachea. We then passed a tube exchanger with an outer diameter 3.7 mm (Cook Critical Care, Bloomington, Indiana, USA) through the 5.0 mm ETT in order to exchange the 5.0 mm ETT and LMA with a 7.5 mm ETT (). After successfully securing the airway, the patient was sedated with continuous infusion of midazolam and was mechanically ventilated overnight. The next day, extubation was carefully carried out by the anesthesiologist after examining cervical lateral radiographs for any signs of soft tissue edema. No further airway complications developed.

[[28.0, 'year']]

M

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{}

3983422-1

noncomm/PMC003xxxxxx/PMC3983422.xml

Epidural hematoma after thoracic epidural analgesia in a patient treated with ketorolac, mefenamic acid, and naftazone: a case report

A 26-year-old male (height: 174 cm, weight, 72 kg, American Society of Anesthesiologists physical status class I) was scheduled for wedge resection of bullae and bleeding control. His past medical history was negative for cardio-respiratory diseases, diabetes mellitus, bleeding diathesis, or easy bruising. The patient had received medications for hemorrhoid for six days until the day before admission. Physical examination and laboratory findings were unremarkable.\nHe referred from other hospital to our emergency room to treat hemo-pneumothorax with massive bleeding. When he admitted to our hospital, approximately 400 ml of bloody fluid was drained from the chest drainage tube, and his hemoglobin (Hb) was11.0 mg/dl. Two units of packed red blood cells (PRBC) were infused to treat tachycardia (95 beats/min) with mild hypotension (95/50 mmHg). His admission coagulation profiles were within normal limit (prothrombin time (PT); 13.0 seconds, International normalized ratio (INR); 1.12, activated partial thromboplastin time (aPTT); 24.7 seconds, platelet count; 245,000/mm3). The patient's bleeding time was not checked.\nTwo hours later, his lab findings were Hb 10.5 mg/dl, Hct 30.4%, and platelet count 220,000 mm3. One unit of PRBC and three units of fresh frozen plasma (FFP) were infused. Eight hours after admission, more than 400 ml of bloody fluid was drained again, and his lab findings were Hb 11.5, Hct 33.6, and platelet count was 158,000 mm3. Thirteen hours after admission, he was transferred to operating room.\nA thoracic epidural catheter at the T5-T6 level was inserted through a 17 gauge Tuohy needle using loss of resistance to air technique. First attempt at T6-T7 level, inadvertent dural puncture occurred and blood tinged CSF was seen in the syringe. Second attempt at T5-6 level was performed uneventfully. No blood or paresthesia was noted during the successful needle and catheter insertion. A test dose of 2 ml of 2% lidocaine and 5 µg epinephrine was injected through the epidural catheter and hypaesthesia was confirmed at T4-6 dermatome with a cold alcohol swab. There was no specific symptom related to epidural analgesia during the surgery.\nBullectomy, hematoma evacuation and bleeding control was conducted under general anesthesia. The operation time was 2 hours and 40 minutes and the total infused fluids were crystalloid 900 ml, colloids 400 ml, and PRBC 2 units. Following operation, the hemoglobin level was 11.6 mg/dl, and the platelet count was 175,000 /mm3. Epidural patient controlled analgesia (PCEA) with 0.2% ropivacaine with fentanyl 3 µg/ml was started after the operation.\nOn the first postoperative day (POD 1) oral mefenamic acid 250 mg, three times a day was started to treat mild fever. On POD2 the patient complained of headache and oral acetaminophen 1,300 mg was given two times a day. PCEA infusion was stopped. On POD3 at 6:00 AM, the patient complained of headache, neck stiffness, dizziness, and nausea and vomiting during ambulation. These symptoms were aggravated with upright position, and decreased with supine position. The patient was treated with hydration and absolute bed rest, and the epidural catheter was removed at 5:00 PM. On POD4 the neurologist was consulted. The impression was rule out post-dural puncture headache and conservative treatment was recommended. The patient was treated with hydration, bed rest, mefenamic acid 250 mg three times a day, oral acetaminophen 1,300 mg two times a day. However, the patient complained headache and intravenous injection of ketorolac 30 mg was given three times within 20 hours.\nAt 5:20 AM on POD5, the patient complained of neck pain and right arm pain with tingling sensation. At 6:10 AM, the patient complained of weakness with numbness in both lower legs. The motor power of both lower limbs was 1/5 in all muscle groups and dorsiflexion of both feet was impossible. Deep tendon reflexes were absent bilaterally. Urgent magnetic resonance imaging of the patient () revealed a massive anterior epidural hematoma compressing the spinal cord from the first thoracic vertebrae to the first lumbar vertebrae. At 8: 45 AM, decompressive laminectomy and hematoma evacuation was performed from T1 to T9. At 10:30 AM, the surgeon reported coagulopathy on the operating field, but intraoperative lab findings which performed just before surgical incision were unremarkable (Hb: 10.8 mg/dl, platelet count 266,000 /mm3, PT: 13.7 (INR: 1.23), aPTT: 26.9, fibrinogen 506.7). We conducted a platelet function test with PFA-100® (Siemens, New York, USA) to rule out platelet dysfunction and found significant platelet dysfunction (collagen/epinephrine: more than 300 seconds [normal range: 61-192], collagen/Adenine di-phosphate: 124 seconds [normal range: 61-110]).\nAfter 10 units of platelet concentrate (PC) infusion, bleeding tendency of the operation field was improved. After the end of surgery, the patient recovered uneventfully and transferred to intensive care unit. The operation time was 10 hours and 5 minutes. Therefore, we transfused ten units of PC, nine units of FFP, and five units of PRBC during the operation. Following the operation (6:50 PM), his motor function in both lower limbs was 4/5 with tingling sensation. We asked the local clinic (where the patient's hemorrhoid was treated) about his medications and informed that he had been administered 10 mg of naftazone, three times a day, for seven days. On the POD2, the patient's motor and sensory function returned to normal in both limbs. On POD3, tramadol 37.5 mg with acetaminophen 325 mg three times a day was started instead of ketorolac or other NSAIDs. On POD8, four days after stop taking any kinds of NSAIDs or anticoagulants, his platelet function analysis value decreased to normal range (collagen/epinephrine; >300 → 107 seconds, collagen/ADP; 124 → 70 seconds).\nOn POD 13, the patient transferred to the rehabilitation department and to treat neurologic sequelae (neurogenic bladder and bowel). He was discharged on POD36 without specific complications except mild voiding difficulty.

[[26.0, 'year']]

M

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{}

3983423-1

noncomm/PMC003xxxxxx/PMC3983423.xml

Conversion of supraventricular arrhythmia to normal rhythm by propofol and remifentanil: three cases report

A 52-year-old woman (height 160 cm, weight 47 kg) with a history of hyperthyroidism was scheduled for total radical thyroidectomy because of a gradual increase in the size of the thyroid nodules. The patient's previous medical history was unremarkable. Preoperative laboratory tests, including thyroid function test, and chest x-ray were unremarkable. An electrocardiogram (ECG) taken 1 month prior to surgery showed atrial fibrillation, and transthoracic echocardiography revealed normal left ventricular ejection fraction without regional wall motion abnormalities. She was not given premedication before surgery. In the operating room, non-invasive blood pressure monitoring, ECG (lead II) and a pulse oximetry monitoring were placed. Pre-anesthetic blood pressure was 120/70 mmHg, heart rate was 70 beats/min, and oxygen saturation was 95%. The ECG rhythm was same as preoperative state, suggesting atrial fibrillation is chronic. After preoxygenation, anesthesia was induced with propofol (3.5 µg/ml) and remifentanil (0.1 µg/kg/min) using target controlled infusion (TCI) pump (Orchestra® Base Primea, Fresenius Vial, Brezins, France) and she was intravenously given rocuronium 50 mg. After tracheal intubation, anesthesia was maintained using propofol and remifentanil TCI in an oxygen-air mixture (FiO2 = 0.5). After about 40 minutes, atrial fibrillation converted to the NSR (heart rate, 70 or so), which persisted. On postoperative day 4, the patient was discharged with NSR. One month later, the patient was still having NSR. The patient was lost to follow-up afterwards.

[[52.0, 'year']]

F

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{'3983423-2': 2, '3983423-3': 2}

3983423-2

noncomm/PMC003xxxxxx/PMC3983423.xml

Conversion of supraventricular arrhythmia to normal rhythm by propofol and remifentanil: three cases report

A 79-year-old male (weight 50 kg) was scheduled for clipping of aneurysm of subarachnoid hemorrhage. The patient was stuporous and had a tracheostomy. ECG taken immediately before surgery revealed atrial fibrillation and T wave inversion. The precise medical history was unobtainable; the patient's family was unaware of atrial fibrillation. A chest X-ray was consistent with emphysema. Preoperative laboratory results were unremarkable except for low serum potassium (3.2 mEq/L). No premedication was given before surgery. On arrival at the operating room, blood pressure, heart rate, oxygen saturation were 130/70 mmHg, 99 beats/min, and 92%, respectively. Anesthesia was induced with TCI of propofol (2.5 µg/ml) and remifentanil (0.1 µg/kg/min). Rocuronium 50 mg was administered intravenously, and endotracheal intubation was performed. Anesthesia was maintained with TCI of propofol and remifentanil in an oxygen-air mixture (FiO2 = 0.5). About 10 minutes after tracheal intubation, the rhythm changed to NSR, which reverted to atrial fibrillation on postoperative day 2 and persisted.

[[79.0, 'year']]

M

{'1443685': 1, '7631961': 1, '14564237': 1, '7639382': 1, '9141916': 1, '29269709': 1, '7717560': 1, '20659617': 1, '4743336': 1, '10083995': 1, '9843465': 1, '10793617': 1, '19457895': 1, '19151272': 1, '19949595': 1, '24729849': 2}

{'3983423-1': 2, '3983423-3': 2}

3983423-3

noncomm/PMC003xxxxxx/PMC3983423.xml

Conversion of supraventricular arrhythmia to normal rhythm by propofol and remifentanil: three cases report

A 71-year-old male with a history of hydrocephalus was admitted to the hospital for surgery of ventriculoperitoneal shunt. The patient had a history of hypertension, arrhythmia, cerebral infarction 10 years previously and was taking oral medications for hypertension (the name of medication was unknown). The patient had a history of unidentified arrhythmia, but he did not have cardiac symptoms; the patient was not taking antiarrhythmic drugs. A preoperative ECG showed frequent (70-80 /min) premature atrial contractions. Transthoracic echocardiographic findings were not remarkable. Laboratory results including electrolytes and cardiac enzymes were also normal. The patient was not premedicated. Prior to anesthetic induction, the patient's blood pressure was 100/60 mmHg, heart rate was 65 beats/min, and standard ECG lead II showed the same arrhythmia. Anesthesia was induced and maintained with propofol and remifentanil using TCI, and an oxygen-air mixture (FiO2 = 0.5). Rocuronium 40 mg was administered intravenously, and trachea was intubated. Ten minutes later, the patient's ECG converted to NSR, which was persistent on postoperative day 1. However, the NSR reverted to his preoperative cardiac rhythm thereafter.

[[71.0, 'year']]

M

{'1443685': 1, '7631961': 1, '14564237': 1, '7639382': 1, '9141916': 1, '29269709': 1, '7717560': 1, '20659617': 1, '4743336': 1, '10083995': 1, '9843465': 1, '10793617': 1, '19457895': 1, '19151272': 1, '19949595': 1, '24729849': 2}

{'3983423-1': 2, '3983423-2': 2}

3983424-1

noncomm/PMC003xxxxxx/PMC3983424.xml

Point-of-care monitoring of perioperative intraocular pressure using portable tonometry in a patient with Posner-Schlossman syndrome: a case report

A 56-year-old male, 168 cm tall and weighing 71 kg, with a traumatic right rotator cuff injury, was scheduled for arthroscopic reconstruction surgery under general anesthesia. This patient had a history of diabetes mellitus and was taking oral hypoglycemic agents and insulin. For several years, he experienced recurrent episodes of severe left ocular pain and increased IOP, which later resolved. On close ophthalmic examination, he was diagnosed with Posner-Schlossman syndrome. There was mild epithelial edema of the cornea with a few keratic precipitates, and his cup/disc ratio was 0.5 with no visual field change. During the acute crisis period, the measured IOP in his left eye was above 30 mmHg and the IOP in his right eye was 13 mmHg. His symptoms were relieved after applying eye drops containing dorzolamide, a carbonic anhydrase inhibitor, and prednisolone acetate, but frequently recurred. Three weeks before his scheduled surgery, the IOP in his left eye rose again and he became extremely anxious about the operation. After consultation with an ophthalmologist, we decided to measure the patient's IOP intraoperatively using portable tonometry, and obtained informed consent from the patient for this perioperative risk.\nPreoperative laboratory findings, including hemoglobin concentration, liver function and coagulation tests, and arterial blood gas analysis, were normal, as were chest X-rays. The patient had a left axis deviation and an incomplete right fascicular block on electrocardiography and a mild restrictive pattern on pulmonary function test without any significant symptoms. In the morning of the day of surgery, the patient received 7.5 mg of midazolam per os. Before entering the operating room, his vital signs were stable, with a blood pressure of 133/75 mmHg, a heart rate of 82 beats per min, and an oxygen saturation of 99%. Two drops of 0.5% proparacaine hydrochloride were applied to each eye, and IOP was measured by portable tonometry (Tono-Pen Avia, Ametek, NY, USA) (). Initially, IOP was 19 mmHg in his left eye and 16 mmHg in his right eye. A 20-gauge catheter was inserted into his left radial artery to monitor continuous arterial pressure. Anesthesia was induced with propofol 100 mg, lidocaine 75 mg, rocuronium 50 mg, and a supplemental dose of fentanyl 100 µg, and ventilation was controlled to maintain end tidal carbon dioxide at 35 ± 5 mmHg. Anesthesia was maintained with 2-2.5% sevoflurane in an oxygen-air mixture (FiO2 0.5). Immediately after tracheal intubation, IOP increased to 23 mmHg in his left eye and 21 mmHg in his right eye, but decreased within 5 min to 14 mmHg and 12 mmHg, respectively. Initial arterial blood gas analysis showed an Hct of 39%, a pH of 7.48, a PaCO2 of 34 mmHg, and a PaO2 of 240 mmHg. After changing the patient's position to left lateral decubitus, the IOP was 15 mmHg in his left eye and 14 mmHg in his right side, but increased to 20 mmHg and 14 mmHg, respectively, after skin incision and arthroscopic insertion. The concentration of inhaled sevoflurane was adjusted in response to instantaneous IOP variation, and the occurrence of IOP surge was closely monitored. During the 210 min operation, the patient's vital signs remained stable and no adverse event occurred. Serial measurements by portable tonometry showed that his IOP remained within an acceptable range throughout the entire perioperative period (). The patient's postoperative course was uneventful.

[[56.0, 'year']]

M

{'3158256': 1, '18090562': 1, '21560974': 1, '15659927': 1, '9602594': 1, '8831327': 1, '15557832': 1, '12045888': 1, '23204806': 1, '21943450': 1, '23028770': 1, '22274735': 1, '2869773': 1, '24729850': 2}

{}

3983425-1

noncomm/PMC003xxxxxx/PMC3983425.xml

Anesthetic management of laparoscopic pheochromocytoma excision in a patient with a Fontan circulation: a case report

An 18-year-old 170-cm-tall male weighing 51 kg was admitted via the emergency room complaining of palpitations, dyspnea, and cyanosis. The patient was born with complex congenital cardiac anomalies, consisting of a single ventricle (right ventricle type), a complete endocardial cushion defect, corrected transposition of the great arteries, right isomerism, and a supracardiac type total anomalous pulmonary venous return. The patient underwent correction of the total anomalous pulmonary venous return and bidirectional cavo-pulmonary shunt when he was 11 months old, and a Fontan procedure at age 3 years. The patient was taking aspirin (200 mg), digoxin (0.25 mg), enalapril (5 mg) and, atenolol (12.5 mg) daily. The initial vital signs were a systolic blood pressure (SBP) of 126 mmHg and heart rate (HR) of 116 beats/min. Arterial blood sampling was obtained on room air, and showed hypoxemia (PaO2 58 mmHg). The patient also had compensatory polycythemia (hemoglobin 15.8 g/dl) secondary to chronic hypoxemia. The last cardiac catheterization was performed when the patient was 12 years old, and it showed only mild atrio-ventricular valve regurgitation (AVVR). The mean pressure of the Fontan pathway was 13 mmHg. Laboratory testing revealed increased serum (3,533 pg/ml; normal < 1,050 pg/ml) and urine (768.2 µg/day; normal < 97 µg/day) norepinephrine and urine vanillylmandelic acid (8.8 mg/day; normal 2-7 mg/day) levels. Computed tomography showed a 4 cm mass in the left para-aortic area above the left kidney. With an impression of pheochromocytoma, the patient was scheduled for laparoscopic excision of the tumor. Phenoxybenzamine (10 mg) was administered daily for 2 weeks before the surgery. Preoperative electrocardiography showed supraventricular tachycardia and 24 h Holter monitoring showed no significant cardiac arrhythmia except intermittent junctional rhythm. Echocardiography revealed mild AVVR. The estimated ejection fraction of the ventricle was approximately 50% and the ventricular wall motion was normal. There was no obvious stenosis within the Fontan pathway or the scanned parts of pulmonary vessels.\nAfter being administered intravenous midazolam (1.5 mg), the patient was brought to the operating room. The initial SBP and HR there were 144 mmHg and 94 beats/min, respectively. Anesthesia was induced with intravenous midazolam (2.5 mg), etomidate (10 mg), remifentanil (40 µg), and rocuronium (50 mg). The trachea was intubated and anesthesia was maintained with sevoflurane and 50% oxygen in 2 L/min fresh gas. In addition, intravenous remifentanil was infused continuously during the surgery. The right radial artery was cannulated for continuous arterial blood pressure monitoring. A central venous catheter was placed in the right internal jugular vein, and continuous central venous pressure (CVP) monitoring was started. The initial CVP was 15 mmHg. A transesophageal echocardiography (TEE) probe was inserted smoothly and the echocardiographic evaluation revealed normal ventricular function with mild AVVR. After achieving hemodynamic stability, a continuous infusion of milrinone (0.5 µg/kg/min) and magnesium sulfate (MgSO4) (1 g/h) was started after a 1-g loading dose of MgSO4 to prevent severe pulmonary hypertension and maintain a stable blood pressure during the surgery.\nSurgery was started, and intra-abdominal CO2 insufflation was begun for the laparoscopic procedure. After insufflation, the CVP was increased to 28 mmHg and the SBP rose from 90 to 128 mmHg (). Simultaneously, the peak inspiratory pressure increased from 17 to 24 cmH2O. The arterial oxygen saturation decreased from 100 to 97%, and the arterial oxygen partial pressure dropped from 196 to 93 mmHg. The intra-abdominal pressure (IAP) was maintained between 13 and 15 mmHg. The inspired oxygen fraction was transiently set to 1.0, and an immediate TEE evaluation showed preserved ventricular contractility without aggravation of the mild AVVR. To prevent abrupt arterial hypertension, a continuous infusion of sodium nitroprusside (SNP) was started (0.5 µg/kg/min) and titrated up to 1.5 µg/kg/min. However, four further sudden increases in SBP over 160 mmHg, up to 194 mmHg, occurred during the dissection and approach to the tumor; these were controlled by intravenous bolus injections of SNP (30 or 40 µg) and remifentanil (40 or 50 µg). No significant cardiac arrhythmias were detected, except sinus tachycardia during the dissection.\nApproximately 2 h after establishing pneumoperitoneum, the surgeon decided to convert from laparoscopic surgery to a laparotomy, suspecting aortic invasion of the tumor. After exsufflation, the CVP decreased from 18 to 10 mmHg and the SBP dropped from 120 to 70 mmHg. Subsequent TEE showed decreased ventricular volume with preserved contractility. After fluid resuscitation and continuous infusion of dopamine (5 µg/kg/min) and norepinephrine (0.02 µg/kg/min) for approximately 7 min, the SBP recovered and was maintained at 100-120 mmHg. Arterial blood gas analysis showed that the oxygen partial pressure had increased to 157 mmHg. Subsequently, there were several abrupt increases in SBP up to 190 mmHg until the tumor was excised; these were well controlled with bolus injections of SNP and remifentanil.\nThe tumor was removed approximately 260 min after beginning the surgery. After removing the tumor, the MgSO4 was discontinued and the milrinone was tapered (0.25 µg/kg/min). Continuous infusion of dopamine (5 µg/kg/min) and norepinephrine (0.04 µg/kg/min) was initiated. The infusion rates were tapered to 3 and 0.02 µg/kg/min, respectively, before the end of surgery. The duration of the surgery and anesthesia was 490 min. The patient was transferred to the surgical intensive care unit and extubated 12 h later. Intravenous patient-controlled analgesia with fentanyl was used to manage postoperative pain, which was relatively well controlled. All inotropics were discontinued on the third postoperative day. Subsequently, the patient was moved to a general ward and discharged uneventfully on the 13th postoperative day.

[[18.0, 'year']]

M

{'29464136': 1, '15333393': 1, '11506098': 1, '15781508': 1, '15192002': 1, '32316959': 2, '10618948': 1, '5089489': 1, '12073213': 1, '1980050': 1, '6632950': 1, '11423283': 1, '10927994': 1, '15805711': 1, '7586425': 1, '24729851': 2}

{'7171803-1': 1}

3983509-1

noncomm/PMC003xxxxxx/PMC3983509.xml

Female Urethral Condyloma Causing Bladder Outlet Obstruction

A 39-year-old woman presented to our hospital complaining of frequency, urgency, and sensation of incomplete bladder emptying. Urinalysis revealed no microscopic hematuria or pyuria, and her urine culture remained sterile. An uroflowmetry was performed, and the free maximum flow rate (Qmax) was low at 14 mL/sec, with voided volume at 218 mL, and postvoid residual urine volume (PVR) at 25 mL. She was administered an alpha blocker for two weeks, but there was no symptom improvement. A follow-up uroflowmetry showed an even lower Qmax at 8 mL/sec, with voided volume at 206 mL, and PVR at 45 mL. To rule out any anatomical obstructing lesions, a physical examination was performed, and multiple small papillary masses were noted around the external urethral meatus ().\nThe rapid plasma reagin card test and Treponema pallidum hemagglutination test results were negative. Cystourethroscopy demonstrated nonspecific findings in the urethra and bladder. An urodynamic study revealed a detrusor pressure at maximum flow rate (PdetQmax) at 25 cm H2O with Qmax at 14 mL/sec, indicating BOO. The masses were surgically excised, and primary repair was performed. Histopathological examination indicated condyloma acuminata with papillomatosis, acanthosis, parakeratosis, and hyperkeratosis ().\nExcision of the masses resulted in near complete resolution of her symptoms. No obvious recurrence of condyloma acuminata has been observed for 6 months after the surgery. One month after the surgical excision, a follow-up uroflowmetry showed an improved Qmax, voided volume, and PVR at 17 mL/sec, 229 mL, and 10 mL, respectively.

[[39.0, 'year']]

F

{'16174218': 1, '18520756': 1, '34649539': 1, '17268907': 1, '15747342': 1, '24559567': 1, '16911596': 1, '24729927': 2}

{}

3983531-1

noncomm/PMC003xxxxxx/PMC3983531.xml

Predictive Capability of the Spetzler-Martin versus Supplementary Grading Scale for Microsurgical Outcomes of Cerebellar Arteriovenous Malformations

A 16-year-old female presented with sudden onset headache, nausea, and vomiting followed rapidly by coma. Brain computed tomography (CT) showed a large cerebellar hematoma resulting in tonsillar herniation and obstructive hydrocephalus. CT angiography (CTA) showed a left tentorial AVM measuring 12×8 mm in the middle cerebellar peduncle supplied by the left superior cerebellar artery (SCA) and anterior inferior cerebellar arteries (AICA) and draining into the left transverse and straight sinuses (). The AVM was Spetzler-Martin grade II and supplementary grade I. Due to compression of the brain stem by the hematoma, the patient was taken emergently to the operating room in order to undergo suboccipital craniectomy and AVM resection. No residual nidus was observed on post-operative digital subtraction angiography (DSA). The patient had transient abducens and facial nerve palsies, which had resolved at the time of discharge. At 2-month follow-up, the patient had mild dysmetria and intermittent diplopia but had returned to playing softball.

[[16.0, 'year']]

F

{'29733392': 1, '32300491': 1, '26856372': 1, '22986595': 1, '28503485': 1, '31538418': 1, '33679374': 1, '20190666': 1, '27790398': 1, '30696602': 1, '3760956': 1, '27695251': 1, '24729957': 2}

{'3983531-2': 2}

3983531-2

noncomm/PMC003xxxxxx/PMC3983531.xml

Predictive Capability of the Spetzler-Martin versus Supplementary Grading Scale for Microsurgical Outcomes of Cerebellar Arteriovenous Malformations

A 59 year-old female was found unresponsive. Brain CT showed a subarachnoid hemorrhage and fourth ventricular hemorrhage resulting in obstructive hydrocephalus necessitating placement of an emergent external ventricular drain. DSA showed a right cerebellar AVM measuring 14×15×13 mm supplied by the bilateral SCAs and posterior inferior cerebellar arteries (PICA) with multiple perinidal aneurysms arising from the feeding right PICA (). The AVM was Spetzler-Martin Grade II and supplementary grade III. Endovascular embolization with polyvinyl alcohol (PVA) and occlusion of the right PICA proximal to the aneurysms was performed prior to surgical resection. The patient subsequently underwent suboccipital craniectomy for AVM resection. The patient's post-operative course was notable for persistent dysphagia requiring placement of a gastrostomy tube, placement of a ventriculoperitoneal shunt, and subclavian thrombus necessitating long-term anticoagulation. The patient was discharged to a nursing home after three weeks of hospitalization.

[[59.0, 'year']]

F

{'29733392': 1, '32300491': 1, '26856372': 1, '22986595': 1, '28503485': 1, '31538418': 1, '33679374': 1, '20190666': 1, '27790398': 1, '30696602': 1, '3760956': 1, '27695251': 1, '24729957': 2}

{'3983531-1': 2}

3983532-1

noncomm/PMC003xxxxxx/PMC3983532.xml

Communicating Hydrocephalus Accompanied by Arachnoid Cyst in Aneurismal Subarachnoid Hemorrhage

A 69-year-old female with no significant prior medical history was referred to our clinic due to a headache of sudden onset. Head computed tomography (CT) scan performed at the time demonstrated an AC in the right middle fossa with a mass effect and diffuse SAH (). On clinical examination, the patient appeared lethargic and drowsy with a Glasgow coma scale score of 13 (E3, M6, V4), a Hunt-Hess grade of III, and a Fisher grade of IV.\nLeft carotid angiography revealed a left internal carotid-posterior communicating artery aneurysm, with a postero-laterally projecting dome (). Craniotomy was performed and complete aneurysm neck clipping and posterior communicating artery patency were confirmed intraoperatively by ultrasound using a micro-Doppler probe (). The post-operative period was uneventful. The patient's consciousness level gradually improved, and she was discharged on the 17th post-operative day. However, at two months after discharge, she reported that her mental status had been declining over recent weeks. A neurological examination performed at the time revealed decreased consciousness, that is, severe confusion with gait disturbance and urinary incontinence. Cranial CT revealed an interval increase in the size of the ventricle and an AC causing a midline shift (). We planned simultaneous ventriculoperitoneal shunt and cystoperitoneal shunt placement to correct the enlarged ventricle and AC. The patient was positioned supine with her head turned left to expose the right temporal scalp. A curvilinear skin incision was made over the temporo-occipital scalp for cyst access and another linear incision was made on the right Kocher's point for ventricular access by an intraoperative neuro-navigation system. Two intracranial catheters were connected using a Y-shaped titanium connector at the gate of the single valve (). A linear skin incision was made in the right upper abdomen to access the peritoneum for the distal end of the shunt catheter, and a programmable valve and distal catheter were tunnelled and passed in the usual manner.\nThe neurological deficits gradually subsided after the procedure and, two weeks later, the patient was discharged to home with no neurological deficit. Follow-up CT performed at one year post-operatively showed proper positioning of the shunt components and an interval improvement in brain condition including the hydrocephalus ().

[[69.0, 'year']]

F

{'7792704': 1, '7434187': 1, '10849636': 1, '17676464': 1, '3665460': 1, '10472987': 1, '10230664': 1, '8738368': 1, '18497496': 1, '7249813': 1, '9576557': 1, '21928029': 1, '3785499': 1, '424537': 1, '24729958': 2}

{}

3983534-1

noncomm/PMC003xxxxxx/PMC3983534.xml

Intra-arterial Onyx Embolization of Vertebral Body Lesions

A 74-year-old male patient with ongoing persistent lower lumbar spine pain, shortness of breath, and cough was initially treated symptomatically for his pain and for presumed pneumonia. Computed tomography (CT) demonstrated an 11 mm right middle lobe lesion and an indeterminate 13 mm right adrenal lesion, prompting further evaluation with positron emission tomography (PET)-CT. A PET-CT demonstrated a fluorodeoxyglucose (FDG)-avid left renal mass suggestive of malignancy with an associated L2 vertebral body and left humeral head destructive lesion. He underwent total spine magnetic resonance imaging (MRI) and lumbar spine CT imaging, revealing a large destructive L2 vertebral body lesion with a pathologic fracture and 4-mm soft tissue extension into the ventral spinal canal, resulting in moderate left-sided spinal canal narrowing (). Significant L2-L3 left subarticular zone, neural foraminal narrowing, and compression on the left traversing L3 and exiting L2 nerve roots were also identified. There was no cord compression or signal abnormality. The patient was referred for embolization prior to planned surgical resection.\nThe patient was placed under general anesthesia and standard access with a 5 French sheath in the common femoral artery was achieved. A 5 French Mickelson catheter (Cook Medical Inc., Bloomington, IN, USA) was employed to selectively catheterize the left L2 segmental artery and an angiographic run demonstrated an obvious pathologic blush in the region of the L2 vertebral body (). Opacification of a spinal pial artery (artery of Adamkiewicz) was not seen. An Echelon microcatheter (eV3, Plymouth, MN, USA) was advanced through the Mickelson catheter (Cook Medical Inc., Bloomington, IN, USA) into the distal left L2 segmental artery and Onyx-18 (eV3, Plymouth, MN, USA) was injected, creating a cast within the segmental artery. The injected Onyx-18 was allowed to reflux into the vertebral body until the metastatic lesion was completely embolized (). A total volume of 0.64 milliliters (mL) of Onyx was used. Subsequent selective injection of the right L2 segmental artery demonstrated minimal pathologic blush. The total fluoroscopy time for the procedure was 33 minutes, and the procedural duration was 2.5 hours. Post-procedure plain X-ray films confirmed Onyx distribution in the left half of the vertebral body, within the tumor (). The patient subsequently underwent an uneventful corpectomy and fusion with minimal blood loss (less than 100 cc) and recovered without complications.

[[74.0, 'year']]

M

{'23452246': 1, '23118137': 1, '23600580': 1, '16823305': 1, '8416240': 1, '2398386': 1, '3763864': 1, '4056870': 1, '7314355': 1, '13754556': 1, '25720346': 1, '21802857': 1, '16462482': 1, '10369341': 1, '26728798': 1, '3383128': 1, '11337348': 1, '2431111': 1, '28819591': 1, '8219564': 1, '19698039': 1, '18372419': 1, '24729960': 2}

{'3983534-2': 2}

3983534-2

noncomm/PMC003xxxxxx/PMC3983534.xml

Intra-arterial Onyx Embolization of Vertebral Body Lesions

A 52-year-old male patient presented with six months of progressive bilateral lower extremity weakness and worsening sensory function, leading to multiple falls. There were also spasms and spasticity of the lower extremities bilaterally, and several episodes of fecal and urinary incontinence. A CT and total spine MRI revealed multiple lesions with coarse trabeculae in the thoracic (T1, T3 and T11) and lumbar spine (L1), most severe within the T3 vertebral body. These lesions extended to the posterior elements and soft tissues in the surrounding paravertebral and epidural space, causing significant anterior cord compression ().\nAn open biopsy confirmed an intraosseous hemangioma, and the patient was referred for embolization prior to anticipated surgical resection. The patient was placed under general anesthesia and standard access with a 5 French sheath in the common femoral artery was achieved. The right T4 segmental artery was selectively catheterized with a Cobra catheter (Terumo, Somerset, NJ, USA). Angiography demonstrated a large pathologic blush in the region of the T3 vertebral body, corresponding to the known hemangioma (). Opacification of a spinal pial artery was not seen. An Echelon microcatheter was advanced into the segmental artery and the vascular supply to the hemangioma was embolized with a total of 0.24 mL of Onyx-18 (). The procedural total fluoroscopy time was 27 minutes, and procedural duration was 2.5 hours. Post-embolization angiography via the Cobra catheter confirmed no further pathologic blush (, ). The patient recovered uneventfully from the embolization and surgical resection, the latter with 300 cc of estimated blood loss.

[[52.0, 'year']]

M

{'23452246': 1, '23118137': 1, '23600580': 1, '16823305': 1, '8416240': 1, '2398386': 1, '3763864': 1, '4056870': 1, '7314355': 1, '13754556': 1, '25720346': 1, '21802857': 1, '16462482': 1, '10369341': 1, '26728798': 1, '3383128': 1, '11337348': 1, '2431111': 1, '28819591': 1, '8219564': 1, '19698039': 1, '18372419': 1, '24729960': 2}

{'3983534-1': 2}

3983535-1

noncomm/PMC003xxxxxx/PMC3983535.xml

Ophthalmic Artery Occlusion After Carotid Revascularization

A 75-year old man with right hemiparesis and motor aphasia visited our emergency department. Symptom duration was three hours. He had hypertension for which he had been under treatment for ten years. No hemorrhagic lesions or low density areas were revealed by brain computerized tomography. A right internal carotid artery (ICA) angiogram showed collateral circulation to the anterior cerebral artery (ACA) and the middle cerebral artery (MCA) via anterior communicating artery and leptomeningeal anastomoses (). The left ICA bifurcation was filled with thrombus (). A left common carotid artery (CCA) angiogram revealed left proximal cervical ICA occlusion (). The patient underwent CAS. After insertion of an 8 Fr sheath, an 8 Fr guiding catheter (FAS; Boston Scientific, Natick, MA, USA) was introduced into the left CCA. A 4×20 mm balloon (Ultra-soft SV; Boston Scientific, Natick, MA, USA) was used for pre-dilatation followed by stent implantation using an 8×40 mm carotid stent (Acculink; Abbott Vascular, Abbott Park, IL, USA) (). After CAS, the thrombus in distal ICA was removed using the Penumbra aspiration system (Penumbra, Inc., Alameda, CA, USA). Final angiography showed flow restoration in the occluded segment (). After the procedure, the right hemiparesis and motor aphasia improved. The patient was transferred to a hospital near his home.\nTwo months later, the patient visited our ophthalmology department for decreased visual acuity. A careful interview revealed that his visual acuity decreased soon after CAS. Upon examination, the patient's visual acuity in the left eye was finger counting at a distance of 50 cm. Fundus examination revealed a pale optic disc and macular edema. Fluorescein angiography revealed no abnormal finding except a mild delay (18 sec.) in the arm to retina time. We checked the previous cerebral angiogram after CAS and found ophthalmic artery occlusion (). Follow-up of the cerebral angiogram showed no occlusion in the left ophthalmic artery ().

[[75.0, 'year']]

M

{'10073757': 1, '10473333': 1, '11403808': 1, '11847042': 1, '22482349': 1, '12112883': 1, '20505173': 1, '9030990': 1, '8106642': 1, '17673838': 1, '19465793': 1, '19337482': 2, '24729961': 2}

{'2655744-1': 1, '2655744-2': 1}

3983742-1

noncomm/PMC003xxxxxx/PMC3983742.xml

Desquamative gingivitis - A clinical sign in mucous membrane pemphigoid: Report of a case and review of literature

This was a case report of a 57-year-old female patient who reported to the out-patient Department of Oral Medicine and Radiology, Saveetha Dental College and Hospitals, Chennai with a complaint of burning sensation and tenderness in the gums, which worsened on intake of spicy food since 9 months. The patient also noticed the appearance of blisters on her gums on and off which would heal subsequently without any medical intervention. Her medical history was non-contributory. There were no associated ocular, cutaneous or genital lesions. Intraoral examination revealed an erythematous and inflamed labial gingiva with interspersed areas of normal gingiva in relation to 11, 12, 21, 22. The marginal gingiva was scalloped in outline and had rolled borders with absence of melanin pigmentation []. There was a diffuse area of desquamation and erythema involving the buccal aspect of free, marginal and attached gingiva in relation to 24, 25, 26 and 27. Faint white striae were visible bordering the areas showing desquamation. The desquamated area showed loss of stippling. Single, isolated discrete hemorrhagic bullae, oval in shape, 1.5 × 1 mm in diameter was also appreciated on the buccal attached gingiva in region of 25. The bulla was relatively resilient to puncture []. Gentle manipulation of the normal mucosa induced a positive Nikolsky's sign. The patient's oral hygiene was poor and gingiva showed bleeding on probing with no attachment loss. After obtaining an informed consent from the patient, an incisional biopsy was taken from the buccal aspect of left maxillary gingival region (adjacent to the bullae region) for histopathologic and immunofluorescent studies. Histopathology showed variable thickness parakeratinized stratified squamous epithelium, subepithelial cleft and basal cell degeneration in few areas. Underlying connective tissue stroma revealed chronic inflammatory cell infiltrate, mainly plasma cells along with areas of hemorrhage [Figures and ]. Linear deposition of IgG and C3 at the dermo-epidermal junction was evident in direct immmunofluorescence []. Differential diagnosis was made solely on the basis of clinical features. Dermatological pathologies like bullous pemphigoid, MMP, pemphigus vulgaris and bullous lichen planus were considered as the most probable differential diagnosis. Absence of skin lesions excluded the possibility of bullous pemphigoid. Presence of intact bullae and absence of erosions clinically and subepithelial cleft histopathologically ruled out pemphigus vulgaris. The striking presence of desquamative gingivitis in a 57-year-old female patient with an intact hemorrhagic bullae (without coexisting skin lesions), in association with characteristic histopathological and immunofluorescent features confirmed the diagnosis of MMP. Thorough oral prophylaxis was done and the patient was counseled to maintain good oral hygiene. Thereafter, the patient was prescribed topical application of high potency steroids (Clobetasole propionate) thrice daily for 1 month and vitamin supplements (cap zincovit) once daily for 1 month. The patient was reviewed every 2 weeks for the first 1 month. The lesions improved considerably with topical steroids within 4 weeks of starting the treatment [Figures and ]. The patient was asked to stop the topical steroid application and reinforcement of oral hygiene instructions were given. Since the lesions may recur, the patient was under observation for 1 year and there was no recurrence.

[[57.0, 'year']]

F

{'5548985': 1, '17804127': 1, '3552187': 1, '8065723': 1, '11004612': 1, '6760033': 1, '7026756': 1, '33943058': 1, '8052655': 1, '9642531': 1, '19272168': 1, '9421223': 1, '15984952': 1, '3517743': 1, '1880886': 1, '33149430': 1, '1869688': 1, '11570526': 1, '11902988': 1, '27563211': 2, '20553242': 1, '30631236': 2, '20553241': 1, '34447217': 2, '10442946': 1, '18430176': 1, '31123607': 1, '24741281': 2}

{'8375960-1': 1, '4976558-1': 1, '6305090-1': 1}

3983743-1

noncomm/PMC003xxxxxx/PMC3983743.xml

Platelet rich fibrin and alloplast in the treatment of intrabony defect

The present case report is about a 29-year-old man who was referred to Department of Periodontics, Saveetha Dental College, India, with a complaint of pain in relation to the left lower tooth. On examination, the patient was systemically healthy and had not taken any long-term anti-inflammatory medications or antibiotics.\nOn periodontal examination and radiographic evaluation, the patient presented with an intrabony defect extending up to apical third of the mesial root [] of left mandibular first molar (#36) with a probing depth of 8 mm using William's periodontal probe []. The patient also presented with pain in relation to #36 tooth and had pain on percussion. There was a lingering type of pain when subjected to heat test using a heated gutta-percha point. The diagnosis was made to be primary chronic periodontitis with secondary endodontic involvement in relation to left mandibular first molar (#36).\nInitial therapy consisted of oral hygiene instructions, which were repeated until the patient achieved an O’Leary plaque score of 20% or below.[] Scaling and root planning of the teeth were performed. Patient was referred to Department of conservative dentistry and endodontics for root canal therapy in relation to #35 and #36 teeth (which were symptomatic to the heat test).\nAt 4 weeks following phase 1 therapy, a periodontal re-evaluation was performed to confirm the suitability of #36 tooth for this periodontal surgical procedure. Clinical measurements were made using William's periodontal probe with graduation to a precision of 1 mm.\nBlood sample was taken on the day of the surgery according to the PRF protocol with a REMI 3000 centrifuge and collection kits. Briefly, 6 ml blood sample was taken from the patient without an anti-coagulant in 10 ml glass test tubes and immediately centrifuged at 3000 rpm for 12 min. A fibrin clot was formed in the middle of the tube, whereas the upper part contained acellular plasma and the bottom part contained red corpuscles. The fibrin clot was easily separated from the lower part of the centrifuged blood. The PRF clot was gently pressed between two sterile dry gauges to obtain a membrane, which was later minced and added to the graft material (OSSIFI™) [].\nAn intrasulcular incision was made on buccal and lingual aspect of the tooth of left mandibular teeth (#35, 36 and 37) along with a vertical incision, extending to the muco gingival junction in relation to the distal aspect of #35. A full thickness triangular flap was raised and inner surface of the flap was curetted to remove the granulation tissue. Root surfaces were thoroughly planned using hand instruments and ultrasonic scalers. The left mandibular first molar demonstrated mesial intrabony defect. After removing granulation tissue thoroughly, mesial intrabony defect was found to extend in buccal and apical aspect [].\nBriefly, alloplast (OSSIFI™) and was applied to the defect walls and root surfaces [Figures , and ]. The alloplast with PRF was then condensed using amalgam condensers. The flap were repositioned to their pre-surgical levels and sutured with silk utilizing an interrupted technique [].\nAfter the operation, the patient was prescribed systemic antibiotics (amoxicillin 500 mg tid, 3 days), non-steroidal anti-inflammatory drug (combiflam tid, 3 days) and 0.12% chlorhexidine rinse (twice a day for 4 weeks). Sutures were removed after 7 days. Clinical healing was normal with neither infectious episodes nor untoward clinical symptoms. The patient was seen at 1st week, 2nd week, 1st month, 3rd and 6th month.\nPeriapical intraoral radiographs were obtained from the periodontal defect site at baseline, 3 months and 6 months after surgery []. The radiographs were obtained with paralleling technique using film holders. To standardize, putty index was made and patient was asked to bite on it along with that of the holder.\nIn this case report, the greater reduction in pocket depth and gain in clinical attachment were found after 6 months of the follow-up []. These are the important clinical outcomes for any periodontal regenerative procedures. Radiographs revealed significant bone fill in the intrabony defect compared with measurements at baseline [].

[[29.0, 'year']]

M

{'23155361': 1, '20850666': 1, '22126591': 1, '32110631': 2, '18282265': 1, '19961389': 1, '8354729': 1, '16504849': 1, '22624763': 1, '16398692': 1, '22126345': 1, '16504850': 1, '16504851': 1, '26604954': 1, '20623670': 1, '31983847': 1, '8330949': 1, '12442729': 1, '10960017': 1, '15655027': 1, '4500182': 1, '8724716': 1, '30947718': 1, '24741282': 2}

{'7014901-1': 1}

3983759-1

noncomm/PMC003xxxxxx/PMC3983759.xml

Local peritonitis as the first manifestation of Crohn's disease in a child

An 11-year-old girl presented to our hospital with abdominal pain and vomiting lasting 3 days. Her past medical history was uneventful. At the time of presentation the patient was quite unwell and had fever (37.8°C). Clinical examination revealed abdominal tenderness with a positive McBurney sign. She had a white cell count of 15,000 K/ml (neutrophils, 86.2%; lymphocytes, 5.9%) and an erythrocyte sedimentation rate of 25 mm; all other hematological findings were within normal limits. An abdominal ultrasound investigation of the patient revealed the presence of free fluid in the right iliac fossa and an inflamed appendix. The preoperative diagnosis was acute appendicitis, and the child was immediately prepared for surgery. At the operation, pus was found in the right abdominal cavity and the appendix appeared to be swollen, thickened, and covered by inflamed omentum. The adjacent terminal ileum was reddened and edematous. An appendicectomy was performed and a drain was placed in the Douglas space following irrigation of the abdominal cavity. On the 7th postoperative day, the patient developed fever (39°C) and wound infection despite administration of antibiotics. The wound was drained and her clinical condition improved. Nevertheless, on the 11th postoperative day the patient again developed pyrexia (40°C) and enteric discharge from the wound. Histological evaluation of the resected appendix revealed only periappendicular inflammation containing prominent lymphoid follicles. The pus culture from the abdominal cavity revealed Escherichia coli.\nComputed tomography (CT) of the abdomen revealed a pericecal collection, two enterocutaneous fistulae, and two strictures in the ileum, suggesting CD [Figure and ]. A colonoscopy was also performed along with biopsy of the terminal ileum []. The histological findings were typical of those for CD. The patient was managed with total parenteral nutrition, antibiotics, and corticosteroids. Despite this conservative treatment, the child deteriorated and a reoperation was performed on the 45th postoperative day. A mass measuring 5 × 4 cm containing the cecum, terminal ileum, and part of the omentum were noted; probably resulting from postinfectional adhesions. A right limited hemicolectomy including the fistulae and strictures was performed using a stapler, with anastomosis of the macroscopically appearing healthy bowel of the ascending colon and ileum. Histological investigation of the resected specimen confirmed the presence of CD in the terminal ileum. The patient's postoperative recovery was uneventful. The child was followed-up for 1 year and remained asymptomatic thereafter, receiving long-term azathioprine to keep the disease inactive.

[[11.0, 'year']]

F

{'8102900': 1, '9202538': 1, '20714732': 1, '21122489': 1, '17164582': 1, '11754865': 1, '18548995': 1, '12522533': 1, '22648194': 1, '9824343': 1, '3541802': 1, '11826334': 1, '24741214': 2}

{}

3983760-1

noncomm/PMC003xxxxxx/PMC3983760.xml

Herlyn-Weber-Wunderlich syndrome with ectopic ureter in prepubertal female

The present case report is about a 10-year-old prepubertal female, presented with complaints of vague abdominal pain and dysuria. On examination, there was a well-defined mass in the suprapubic region. The mass was tender to deep palpation, firm cystic in nature, had restricted mobility and its lower limit could not be reached. On examination of the external genitalia, there was a vulvar mass with a normal vaginal orifice and urethral orifice []. The vulvar mass increased in size on suprapubic pressure on the abdominal mass. On digital rectal examination, a cystic mass was palpable anteriorly. Ultrasound abdomen showed left renal duplication with hematocolpos. There was no mention of any uterine anomaly. To delineate the anatomy, a magnetic resonance imaging (MRI) was done. It showed the presence of uterine didelphys with hematocolpos (8.4 cm × 7.4 cm), with an ectopic left kidney and its ureter opening in the obstructed hemi vagina []. A Di-mercaptosuccinic acid scan showed poorly functioning left kidney with a differential renal function of 2% and a normal right kidney. A diagnosis of obstructed hemivagina with ipsilateral renal anomaly was made. On cystoscopy, there was a single ureteric orifice on the right side with a hemitrigone. The trigone on the left was not developed. A needle aspiration of the vulvar orifice showed thick hemorrhagic fluid []. The vaginal septum was divided and septoplasty was done to create a single vaginal orifice. A diagnostic laparoscopy was performed to confirm the anatomy described by MRI and to tackle the ureteric and renal remnant. This revealed uterine didelphys with normal ovary and fallopian tubes with left uterine horn dilated when compared with right. The ureter and ectopic kidney were not visualized. We explored the abdomen and found the ectopically inserting ureter in the obstructed hemi-vagina. The ectopic ureter (ER) continued blindly, superiorly, up to 8 cm from the pelvic brim, in a fibrotic renal remnant 1.4 cm in size []. The lower end was dissected and ligated at its entry point in the hemivagina. The anatomical details have been represented as a line diagram in . On histopathological examination, there was an oligonephric renal remnant with ureteric tissue. The patient on follow-up had no vaginal stenosis. An ultrasound abdomen done 2 months post-operatively showed normal hemiuterus.

[[10.0, 'year']]

F

{'22129802': 1, '15333604': 1, '19780744': 1, '16514622': 1, '16418966': 1, '18824497': 1, '17320871': 1, '21717167': 1, '21683238': 1, '24741215': 2}

{}

3983761-1

noncomm/PMC003xxxxxx/PMC3983761.xml

Ex-utero intrapartum treatment in the Indian scenario: Anesthetic challenges and positioning

A 29-year-old multi-gravida was referred to our hospital with an antenatal diagnosis of a large cystic hygroma diagnosed at 38 weeks of gestation. Fetal MRI revealed a large multiseptated cystic mass (measuring 12 × 8 cm) involving both sides of the neck with compression over the trachea []. Hence a difficulty in securing the airway was anticipated and EXIT procedure was planned. The parents were counseled and informed written consent was obtained. A multispecialty team comprising of obstetricians, anesthesiologists, pediatric surgeons, neonatologists, and radiologists were involved in planning and executing the procedure. Under general anesthesia elective Cesarean section was performed. Two teams of anesthesiologists were present, one for the mother and the other for the fetus. Apart from the routine monitoring, radial artery cannulation was done for invasive blood pressure monitoring. Patient was positioned in the supine position with left lateral tilt to prevent compression on the aorta. The legs were slightly abducted in order to allow easy access to the fetus for intubation. General anesthesia was commenced and maintained with higher concentration of isoflurane (for complete uterine relaxation), oxygen, nitrous oxide, and muscle relaxants. Before skin incision, ultrasound was done to locate the placental edge which revealed two loops of umbilical cord around the fetal neck. After skin and uterine incision, the fetal head and neck with the mass was delivered []. Warm Ringer lactate was infused into the uterine cavity to maintain the uterine volume. Fetal heart rate was monitored with an ultrasound probe and manually by umbilical cord pulsation. Initial attempts at intubation failed. Ultrasound-guided aspiration of the cyst was done but since most of the cysts were microcystic, adequate decompression could not be obtained. The neck was delivered up to the sternal notch [] and then intubated. Intubation could be accomplished in 3 minutes and 47 seconds and airway was secured with a 3-mm ID oral endotracheal tube and then ventilated with 100% oxygen. There was no fetal bradycardia and cord was clamped and handed over to the neonatologist for further resuscitation. Isoflurane was stopped and oxytocin 20 units in 500 ml Ringer Lactate solution was administered. Hemostasis was achieved and patient was extubated at the end of surgery. The neonate was taken up for definitive surgery after 4 hours of stabilization in the NICU. The lesion was excised and elective tracheostomy was done due to tracheomalacia. Second sitting of excision was done after 4 months and tracheostomy has been decannulated.

[[29.0, 'year']]

F

{'9369836': 1, '11305554': 1, '9802816': 1, '11877660': 1, '30104819': 1, '12632365': 1, '9574750': 1, '11993594': 1, '9044127': 1, '16838188': 1, '19468574': 1, '31057234': 1, '24741216': 2}

{}

3983764-1

noncomm/PMC003xxxxxx/PMC3983764.xml

Extraperitoneal Pelvic laparoscopic disconnection of accessory urethra from normal urethra in a case of urethral duplication

A 10-year-old boy presented with stress incontinence, splaying of urinary stream, and dorsal curvature of the penis. He had an intact foreskin, which, when retracted, revealed a dorsally grooved glans with two meati: one at the tip and the other smaller one at the corona. The prepuce itself was reverse aligned with the frenulum being dorsal, as in epispadias. A catheter could be passed independently through both meati into the bladder. Kidneys and the bladder were not palpable. He passed urine from both meati. Pelvic X ray, ultrasound for kidneys and the blood biochemistry were normal. Complete urethral duplication was the diagnosis.\nFirst surgery: Cystoscopy, correction of chordee, repair of glans, rearrangement of foreskin and partial excision of the dorsal urethra. On cystoscopy, the ventral urethra, bladder neck and posterior urethra were normal. A tube passed through the dorsal urethra was seen entering the ventral urethra at the posterior urethra just opposite the veru. Penis was degloved and chordee corrected by ventral Nesbitt. The dorsal accessory urethra was partially excised in the distal shaft and glans repaired to achieve a conical glans with normal coronal collar. The remaining stump of the dorsal urethra was fixed to the shaft skin proximally. The skin was re-arranged to give a circumcised appearance []. Post-operatively he passed urine through both the meati but finger occlusion of the dorsal meatus produced one stream through the normal meatus.\nSecond surgery performed after 1 year: Through a suprapubic 10 mm port the prevesical space was developed with finger dissection and CO2 insufflation. Two 5 mm ports were inserted as shown in (inset). In the space of Retzius the accessory urethra was identified as it entered the normal urethra at the prostate. The normal urethra was safeguarded by a transurethral catheter. The accessory urethra was severed from the normal urethra using bipolar cautery and scissors []. A drain was left through the left port site. The ports were removed and the linea alba repaired. The distal stump of the accessory urethra was obliterated by cautery ablation of the mucosa with monopolar electrode passed through the meatus []. The drain and catheter were removed on 3rd and 10th days, respectively. He passed urine through a single stream and his cosmetic appearance was satisfactory. He is well in 3 year follow up with maintained upper tracts.

[[10.0, 'year']]

M

{'19082604': 1, '19159761': 1, '534829': 1, '5556876': 1, '943804': 1, '19493478': 1, '15072905': 1, '10799233': 1, '24741219': 2}

{}

3983775-1

noncomm/PMC003xxxxxx/PMC3983775.xml

Mitra shunt (spleen preserving, side to side lieno-renal shunt) for portal hypertension with hypersplenism in early infancy

A 4-month-old male child was referred to us with repeated episodes of melena and progressive abdominal distension. The baby had umbilical sepsis at 3rd week, treated with intravenous antibiotics for 7 days. At 2 months of age, baby developed progressive abdominal distension, associated with a low grade fever, and repeated bouts of melena. During hospitalization in a remote district Hospital, he was found to have low hemoglobin (5 g/dl), leukopenia, and thrombocytopenia requiring blood transfusion. A second admission for melena prompted the physician treating the baby to refer the baby for further investigation and management.\nAt admission, the baby was mildly dehydrated, had pallor with marked abdominal distension. Massive splenomegaly was present along with ascites and melena. Blood investigations revealed hemoglobin levels of 6.5 g/dl, total leukocyte count of 2,800/mm3 and a platelet count of 39,000/mm3. The liver function tests were normal. A complete coagulation profile done to rule out any congenital coagulation defects was found to be normal. The endoscopic examination revealed Grade 4 esophageal varices with daughter varices, with a normal stomach and duodenum.\nUltrasonography (USG) [], contrast computed tomography (CT) scan, magnetic resonance imaging (MRI) abdomen [Figures and ] and endoscopy were done in another hospital before admission to our center. The diagnosis at this stage was established as extrahepatic portal venous obstruction (EHPVO) leading to portal hypertension and esophagogastric varices with hypersplenism. The parents were offered medical or surgical management for the condition highlighting the outcome of both approaches. Since they were from a remote district with no local medical facility and baby was small, they opted for surgical management.\nOn midline exploration, he was found to have ascites, large congested spleen. Splenic vein was identified by lifting the transverse colon cranially so that the pancreas got rotated along the whole body and tail. Pancreaticosplenic vein disconnection was done with individual ligation of tributaries and a good segment of splenic vein dissected for side-to-side anastomosis with left renal vein. The rest of the surgery was performed as the original description of Mitra et al., several years ago from Chandigarh.[] It was possible to construct a 1 cm long patent wide anastomosis despite the splenic vein being 5 mm across. The spleen was visibly changing on the operating table itself after the shunt was allowed to function. Postoperatively, the child required 1 day of ventilatory support without any inotropic support. Intravenous anticoagulation was started in the perioperative period and continued till the 10th postoperative day. Oral feeds were started by day 7 after surgery.\nIn the postoperative period, the hematological parameters steadily kept improving and spleen gradually regressed to half its size. The platelet count had reached over 100,000/mm3, total leukocyte count had risen to 6,400/mm3 and hemoglobin was 10.5 g/dl. Doppler evaluation was done on the 10th postoperative day to confirm shunt patency. At 6 months follow-up, spleen is just palpable with no features of hypersplenism and esophageal varices have regressed.

[[4.0, 'month']]

M

{'15877255': 1, '8468654': 1, '12081062': 1, '21922871': 1, '6618562': 1, '10781238': 1, '3390666': 1, '7826115': 1, '1735525': 1, '6600954': 1, '24741213': 2}

{}

3984061-1

noncomm/PMC003xxxxxx/PMC3984061.xml

Tolosa-Hunt syndrome masquerading as a carotid artery dissection

A 58 year-old female was evaluated for chest pain, bradycardia, severe headache, and left periorbital pain with ipsilateral ophthalmoplegia. A warm sensation on the left side of her face with decreased sensation to light touch was noted. Her past medical history included hypertension, arrhythmia, and trauma. She previously visited the emergency department at Sutter Memorial Hospital (Sacramento, CA, USA) on two separate occasions for severe hemicranial pain, which remained constant for 1 week. Computed tomography (CT) scans of the brain without contrast were performed during both visits, with neither showing any acute intracranial abnormalities. CT angiogram (CTA) showed no signs of a dissecting ICA or mass in the superior stellate ganglion of the neck, but it revealed 39% stenosis of the left ICA at the intracavernous portion (). No enlargement of the superior orbital vein was noted. The patient was observed to be bradycardic with a pulse ranging from 29 to 50 beats per minute, including a 3.2 second pause. However, electrocardiogram, cardiac serology (creatinine kinase, creatinine kinase-muscle/brain enzyme type, troponin I, prothrombin time, partial thromboplastin time), chest radiography, and coronary arteriography were all normal. Initial magnetic resonance imaging (MRI) and magnetic resonance angiogram (MRA) showed no abnormalities of the orbital apex or surrounding structures. Thrombus was not observed in the superior orbital vein or cavernous sinus. Neurologic consultation considered it to be an isolated third nerve palsy.\nOphthalmologic evaluation disclosed complete ptosis and ophthalmoplegia in the left eye, with the eye in central position (). Proptosis was not noted. Visual acuity was 20/25 in the right eye and 20/50 in the left eye. Both pupils were equal, round, and reactive to light. Intraocular pressures were normal. Ophthalmoscopy revealed a slightly edematous left optic nerve, but no engorgement or tortuosity of the retinal vasculature. Ophthalmologic findings were consistent with a partial third, and complete fourth and sixth nerve paresis with hypoesthesia in the ophthalmic and maxillary distributions of the left trigeminal nerve. A subsequent MRI performed 3 days after the initial MRI disclosed a lesion in the left superior orbital fissure with mild extension along the anterior aspect of the left cavernous sinus (), and mild edema of the lateral rectus (). Complete blood count, thyroid stimulating hormone, glucose, sedimentation rate, rheumatoid factor, antinuclear antigen, proteinase 3 antibodies, myeloperoxidase antibodies, Quantiferon®-TB Gold (Cellestis Limited, Carnegie, VIC, Australia), human immunodeficiency virus, herpes simplex virus, and fluorescent treponemal antibody absorption test results were normal. Two complete sets of cerebrospinal fluid studies (CSF), including opening pressure, India ink smear, glucose, total protein, angiotensin converting enzyme, and a venereal disease research laboratory test showed no evidence of malignancy or infection. The patient was administered 1 g of intravenous (IV) methylprednisolone (Solu-Medrol®; Pfizer, New York, NY, USA) over 45 minutes, followed by 250 mg every 8 hours daily for 3 days while in hospital. She was discharged with 40 mg of oral prednisone on a tapered course (40 mg for 5 days, 20 mg for 5 days, 10 mg for 5 days, 5 mg for 5 days, 2.5 mg for 5 days, then discontinued).\nThe patient’s periorbital and hemicranial pain was reduced within 48 hours. She was referred for neurosurgical consultation, but she declined. An additional MRI/MRA was obtained at a 4-month follow-up and revealed no lesions or abnormalities. The ophthalmoplegia and ptosis had also resolved. She continues to be monitored and remains symptom free (March 2014).\nWritten informed consent was obtained from the patient to allow the publication of photographs for educational purposes. This study adhered to the tenets of the Declaration of Helsinki and was Health Insurance Portability and Accountability Act (HIPAA) compliant. Sutter Health Central Area Institutional Review Committee ruled that approval was not required for this study.

[[58.0, 'year']]

F

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{}

3984204-1

noncomm/PMC003xxxxxx/PMC3984204.xml

A multidisciplinary approach for the management of hypodontia: case\nreport

A 17-year-old male patient in the final stage of orthodontic treatment presented with\nthe primary second molars in position for space maintenance. Hypodontia had been\npreviously diagnosed by the orthodontic team (), and the patient was referred to the Oral Rehabilitation Clinic (FOB/USP)\nfor extraction of those teeth and rehabilitation of the area. Analyses of the occlusal\ncondition revealed the presence of both canine and protrusive guidance achieved by\northodontic therapy and that the deciduous second molars were in infraocclusion (). The patient did not present with any\nsystemic or genetic disorder that could be associated with hypodontia, and the oral\nhygiene status was satisfactory.\nSeveral treatment options were considered, including adhesive or conventional fixed\nbridges and implants, because there were radiographic signs of root resorption in the\nprimary teeth. Considering the consecutive cephalometric analyses, which demonstrated\nthat the patient had reached physical maturity, the bone availability, the absence of\nmedical contraindications, and the patient consent, the treatment comprised the\nextraction of primary teeth and placement of immediate load implants. However, the\nmesiodistal dimensions of the primary teeth were larger than that required to restore\nthe anatomy of the mandibular second premolar but insufficient to restore the dimensions\nof a mandibular first molar. Thus, the only option was to reduce the mesiodistal\ndistance by orthodontic therapy before implant placement. To plan the prosthetic space\nand at the same time to guide the orthodontic movement, the occlusal surfaces of the\nprimary teeth were marked according to the mesiodistal dimension of a mandibular second\npremolar (), and the distal surfaces were\nreduced without changing the infraosseous anatomy to acquire space to fabricate the\nprovisional crowns with anatomic characteristics of mandibular second premolars (). This step of prosthetic planning was\nfundamental to the accomplishment of the orthodontic treatment.\nAfter the planned space closure (), the\nteeth were extracted, and external hex implants with a 4.1 mm rectangular platform were\nimmediately placed (Master Porous Grip, Conexão Sistemas de Implante, São Paulo, SP,\nBrazil) with immediate load (). The\nCeraone abutment was selected (Conexão Sistemas de Implante) and placed at a torque of\n32 N. The provisional crown was then adapted, cemented with temporary cement (RelyX\nTemp; 3M ESPE, St. Paul, MN, USA) and maintained in infra-occlusion for 4 months. During\nthis period, the orthodontic appliance was maintained for retention of the\northodontically moved mandibular molars. The implants were considered clinically\nacceptable after clinical (absence of pain, infection, mobility, or any other signal of\npathology into the soft tissues) and radiographic (no signs of periimplant radiolucency)\nexaminations.\nAn impression of the Ceraone abutment was taken with the emergence profile customization\ntechnique with silicone (Optosil® and Optosil Xantopren®; Heraeus\nKulzer GmbH & Co. KG, Germany). The metal-ceramic crowns were cemented with\nglass-ionomer cement (Relay X Luting 2; 3M ESPE). The patient was given maintenance\ntherapy every 6 months during a 2-year period.\nThe final outcome reflected the care taken, especially during the planning of the\nprosthetic space to be restored (). The\n2-year follow-up revealed maintenance of orthodontic treatment, occlusal plane and oral\nhygiene, esthetics ( and ), and the stability of the bone level (). No mechanical (ceramic fracture, screw\nloosening, and loss of retention) and/or biological complications (periimplantitis) were\nrecorded.

[[17.0, 'year']]

M

{'5283998': 1, '24554893': 2, '11989379': 1, '15739660': 1, '12658298': 1, '16036123': 1, '12682653': 1, '16543014': 1, '19093055': 1, '4948590': 1, '15835422': 1, '15151692': 1, '28770115': 2, '6611147': 1, '28356682': 1, '9002825': 1, '24795649': 1, '15954249': 1, '8639107': 1, '12835777': 1, '5278937': 1, '19061802': 1, '11709941': 1, '16196232': 1, '6362744': 1, '6997447': 1, '14666074': 1, '21986661': 2}

{'5523549-1': 1, '3917213-1': 1}

3985359-1

noncomm/PMC003xxxxxx/PMC3985359.xml

Aneurysmatic bone cyst of the craniocervical region: Surgical technique

An 11-year-old girl presented in our outpatient clinic with history of an expansible mass and local pain at the dorsal portion of her neck for the last 4 months. A CT scan was compatible with an intrinsic bone lesion, with multiple cysts, in the posterior aspect of the atlas []. No neurological compromise was noticed. A CT angiogram demonstrated that the tumor was highly vascularized. The child was taken to surgery. No prior embolization was performed. The patient was positioned prone using a head holder. With a midline incision, the lesion was completely dissected from the superficial layers of skin. A subperiostal dissection was then performed, exposing all the tumor limits []. The arterial supply of the tumor came from both occipital arteries that were occluded at the beginning of the dissection []. The tumor was then removed in small portions. After total removal, we could clearly see both C1 lateral masses and the dura mater exposed []. The total surgical bleeding estimated was 200 mL.\nThe patient was discharged at the second day after surgery without complaints. No radiological evidence of recurrence after 9 months of follow-up.

[[11.0, 'year']]

F

{'11148642': 1, '24741253': 1, '4056871': 1, '22865997': 1, '17922280': 1, '9530795': 1, '32922908': 2, '9810527': 1, '9680561': 1, '30981073': 2, '26000069': 1, '24741252': 2}

{'3985359-2': 2, '7398374-1': 1, '6461568-1': 1}

3985359-2

noncomm/PMC003xxxxxx/PMC3985359.xml

Aneurysmatic bone cyst of the craniocervical region: Surgical technique

A 28-year-old man presented at the emergency room with an important headache, somnolence, and nausea, but with preserved muscular strength. Concomitantly, he complained of a mass growing in the back of his head for the last 6 months and reported a severe head injury 1 year prior to admission. A CT scan was compatible with an important hydrocephalus and a posterior expansible lesion on the left side of his posterior fossa [Figures and ]. He underwent a ventriculoperitoneal shunt. MRI disclosed an expansible bone tumor, with cystic walls, filled with blood and extremely vascularized [ and ]. A surgical resection was then performed with no prior embolization. Using a head holder, the patient was positioned prone and a midline incision with a transverse extension directed to the posterior aspect of the left mastoid was performed []. The superficial skin and muscular layers were dissected from the bone, and the occipital artery was ligated at the beginning of the exposure, prior to directly entering the cyst. A subperiosteal dissection was then performed, exposing the tumor limits [Figure and ]. The bony parts of the tumor were then resected piecemeal, drilling the residual intact bone edges until total tumor resection was evident []. Once the contralateral occipitocervical junction was preserved, we opted for not fuse this patient with clinical and radiological follow-up of craniocervical instability.\nThe total surgical bleeding estimated was about 500 mL. The patient was discharged at the third day after surgery without neurological deficits. There was no recurrence after 7 months of follow-up [Figure and ].

[[28.0, 'year']]

M

{'11148642': 1, '24741253': 1, '4056871': 1, '22865997': 1, '17922280': 1, '9530795': 1, '32922908': 2, '9810527': 1, '9680561': 1, '30981073': 2, '26000069': 1, '24741252': 2}

{'3985359-1': 2, '7398374-1': 1, '6461568-1': 1}

3985361-1

noncomm/PMC003xxxxxx/PMC3985361.xml

A young patient with multisystem complications after cytomegalovirus infection

An 18-year-old previously healthy male presented to the clinic with the complaints of sore throat and generalized malaise. The patient denied any history of alcohol or drug use. He denied any history of recurrent infections. The patient had no history of bleeding diathesis. His platelet count was normal. He had a negative rapid monospot and rapid strep antigen test. He recovered from acute illness in 3 days.\nHe noticed dysphagia and paresthesias of both lower extremities and weakness in all extremities (lower > upper, proximal > distal) one day after recovering from sore throat. On neurological examination, patient had bilateral facial nerve palsy and bulbar palsy. Motor strength was grade 1 in lower extremities and grade 2 in upper extremities. Muscle tone of the limbs was decreased. Deep tendon reflexes on the upper limbs were diminished and absent on the lower limbs.\nBlood chemistry was normal, except for total bilirubin of 2.3 mg/dL, alanine transferase and aspartate transferase levels of 87 IU/L and 67 IU/L respectively, indicating hepatitis, which may be due to acute CMV infection. Test for human immunodeficiency virus was negative. His serology was positive for CMV immunoglobulin M (IgM) and Immunoglobulin G (IgG) antibodies. CMV polymerase chain reaction (PCR) was positive with <2000 copies of deoxyribonucleic acid (DNA). Cerebrospinal fluid analysis was done, and it was positive for CMV IgG antibody and increased amount of proteins. He was treated with ganciclovir for acute CMV viremia and received three doses of intravenous immunoglobulin without much response. Patient had diffuse decrease in sensory and motor amplitudes, low normal conduction velocities, prolonged distal motor latencies in the left upper limb, and absent or prolonged F-wave responses on nerve conduction studies with severely decreased recruitment throughout, and a few positive sharp waves and fibrillation potentials on needle electromyography. These findings were most consistent with an acute diffuse neuropathy, most likely acute inflammatory demyelinating polyradiculopathy in early stage.\nDay 4: Patient developed acute respiratory failure and was placed on mechanical ventilator.\nDay 12: He demonstrated a slow and gradual improvement in his strength mostly in upper extremities after starting plasma exchange daily for 5 days.\nDay 15: He was discharged to a rehabilitation facility. He had bifacial weakness; motor strength was 2/5 in lower and 3/5 in upper extremities. Sensations were intact.\nDay 16: He developed acute onset of abdominal pain in left upper quadrant with high grade fever (103.4 F) and was admitted to the hospital. He was found to have dislodged gastrostomy tube, which was replaced by the interventional radiology. After that, the patient had an exploratory laparotomy. He was started on broad-spectrum antibiotics and culture was sent which grew coagulase negative staphylococcus. The patient continued to have high-grade fevers (102.9 F) despite exploratory laparotomy and aggressive wash out. Repeat CMV PCR was negative. Serum IgG ganglioside GQ1b antibody was <1:100 titers.\nDay 21: Repeat computed tomography (CT) abdomen showed modest sized splenic infarct [Figures and ] and prominent colitis. Patient had a small hypodense focus in the periphery of the spleen on the follow-up CT abdomen on day 25 and day 32, which was consistent with evolution of splenic infarct.\nDay 42: CT abdomen on the day of discharge showed decrease in the size of splenic infarct. Patient's condition was improved gradually and ultimately he was discharged to a rehabilitation facility.

[[18.0, 'year']]

M

{'19483460': 1, '8994755': 1, '1552913': 1, '12476798': 1, '2164409': 1, '12588074': 1, '28053798': 2, '29158925': 2, '8797462': 1, '16271648': 1, '18946441': 1, '18371229': 1, '11056753': 1, '16332244': 1, '21833717': 1, '21427390': 1, '15018590': 1, '20926120': 1, '24741254': 2}

{'5660763-1': 1, '5178336-1': 1}

3985363-1

noncomm/PMC003xxxxxx/PMC3985363.xml

Guillain-Barre syndrome with posterior reversible encephalopathy syndrome

A 63-year-old non-diabetic and non-hypertensive male patient came with complaints of difficulty in walking of five days, inability to do activities of daily living with upper limbs of four days, dysarthria, dysphagia of two days duration, for which he was admitted in the local hospital. On the day of admission he had four generalized tonic-clonic seizures over the interval of 12 h. After the last seizure he did not regain consciousness and was referred to us. There was no history suggestive of sensory and bladder involvement. History was negative for fever, headache, vomiting, rashes, chronic drug intake or addictions.\nOn examination, for first three days the patient was stuporous with high blood pressure of 192/94 mmhg, flaccid limbs and bilateral plantar extensor. On fourth day, the patient regained consciousness and examination revealed bilateral lower motor neuron type of facial and bulbar weakness, hypotonic limbs with power of 1/5 in muscles of the shoulder, arm, hip, thigh and 2/5 in forearm and leg (according to MRC grading) along with the weakness of small muscles of the hand. Deep tendon reflexes were absent without sensory loss.\nOn investigation hemogram, serology, routine biochemistry, chest X-ray, electrocardiogram, echocardiography and abdominal sonography were normal and did not reveal any cause for hypertension. Cerebrospinal fluid analysis showed albuminocytological dissociation with 4-lympocytes, 176 mg/dl-of protein and normal sugar. No organisms were isolated on staining/culture. MRI brain showed bilateral cortical and subcortical altered signal intensities involving the parieto-occipital areas. They were hypointense on-T1W images, hyperintense on-T2W and FLAIR images with no diffusion restriction suggestive of PRES [Figures and ]. Nerve conduction studies showed prolonged latencies, reduced conduction velocity and absent f waves with reduction in the amplitude of compound muscle action potentials with normal sensory potentials suggestive of demyelinating type neuropathy according to HO et al. criteria.\nThe patient was treated with antihypertensives and antiepileptics initially to control his blood pressure and seizures. After resolution of encephalopathy, IVIg was given and his weakness improved over two months. Now after 6-months, the patient is ambulatory and is independent in his daily activities.

[[63.0, 'year']]

M

{'30078819': 1, '3999461': 1, '24741256': 1, '12904853': 1, '22318132': 1, '28904571': 1, '30019292': 1, '31297663': 1, '27621799': 1, '8559202': 1, '27489061': 1, '32851119': 1, '31300598': 1, '9922823': 1, '27821089': 2, '25652259': 1, '24741255': 2}

{'5100286-1': 1}

3985365-1

noncomm/PMC003xxxxxx/PMC3985365.xml

Neonatal meningitis complicating with pneumocephalus

A 7-day-old male newborn was brought to the casualty with complaints of refusal to feed and progressive increase in head size for the last 3 days. In view of his critical condition, the baby was immediately put on ventilator with supportive management. History revealed that though the mother had received two doses of tetanus toxoid during the second trimester of pregnancy, and rest of her antenatal period was also uneventful, the baby had been home delivered wherein a blade and the common home thread had been used for cutting and tying the umbilical cord. The baby had cried immediately after birth and was on breastfeeding since then, but he started refusing feed from the fourth day onwards, besides a gradual increase in the head size. On examination, the baby was hypothermic, pale, and had an enlarged head (39 cm). The umbilical cord had fallen on the 5th day of life, but the area showed signs of inflammation. His heart rate was 130/min, respiration was irregular, and capillary refill time (CRT) was >3 seconds. His blood glucose was 33 mg/dL. Results of the laboratory investigations done on his blood were as follows: Hemoglobin (Hb) - 13.9 g/dL, total leukocyte count (TLC) - 6.800 × 103/μL with neutrophils (N) 75% and lymphocytes (L) 25%, platelets - 85 × 103/μL, C-reactive protein - 20 mg/dL, total serum bilirubin - 8 mg/dL (direct 4 mg/dL), urea - 20 mg/dL, creatinine - 0.8 mg/dL, sodium - 142 mmol/L, potassium - 5.6 mmol/L, prothrombin time - 30 s (control - 15 s), and activated partial thromboplastin time 42 s (control - 30 s). In view of the enlarged head, bulging anterior fontanel and widely spaced cranial bones, congenital hydrocephalus, intraventricular hemorrhage, septicemia with meningitis, and battered baby syndrome were thought of as possible conditions. As his neurosonogram showed air like densities, a plain computed tomography (CT) scan of brain was done which revealed diffuse pneumocephalus along with large amount of air in subdural and subgleal spaces, besides showing hemorrhages and meningeal enhancement in the region of posterior fossa []. The diagnosis was clear now, that we were dealing with a case of meningitis with pneumocephalus and there was hardly any other possible differential diagnosis.\nA lumbar puncture (LP) was then done and his cerebrospinal fluid (CSF) examination showed cells - 550/μL (with N - 85%, L- 15%), glucose - 35 mg/dL, and protein - 228 mg/dL; the CSF and blood cultures were negative. In view of his critical condition, the baby was put on vancomycin (20 mg/kg/dose q8h, intravenous (IV)), meropenem (40 mg/kg/dose q8h, IV) along with supportive management. An attempt to decompress tension pneumocephalus was also made by putting an 18 G needle in subgleal plane, from which air came out under pressure. However, despite all this, the condition of the baby failed to show any improvement and he succumbed within 48 h of being brought to the hospital.

[[7.0, 'day']]

M

{'663812': 1, '6032371': 1, '21977100': 2, '20405340': 1, '1748798': 1, '14742399': 1, '24741258': 1, '9831162': 1, '4045239': 1, '2670144': 1, '24741257': 2}

{'3173927-1': 1}

3985367-1

noncomm/PMC003xxxxxx/PMC3985367.xml

Posterior reversible encephalopathy syndrome with PLEDs-plus due to mesalamine

A 32-year-old lady presented with convulsive status epilepticus, altered sensorium, andacute-onset visual loss of counting fingers at one-meter distance. Optic fundi were normal, pupillary reactions brisk, and plantar responses were bilaterally extensor. She had a history of Crohn's disease diagnosed 11 years prior to presentation and was on mesalamine (5-amino salicylic acid) 400 mg twice daily. She had sputum-positive pulmonary tuberculosis (TB) detected four years prior, which was multidrug resistant, andshe was on ethionamide, high-dose ethambutol, cycloserine, and levofloxacin daily. Two months prior to current admission, she had an exacerbation of diarrhea, and colonoscopy showed extensive linear ulceration with cobble stoning in the rectumand transverse and ascending colon. Biopsy showed mixed inflammatory infiltrate and noncaseatinggranulomaof colonic mucosa, consistent with Crohn's disease exacerbation. Her mesalamine dose was doubled to 800 mg twice daily since then.\nOn current admission, her cerebrospinal fluid study and vasculitic profile were normal, and viral markers including hepatitis B antigen, retro, and hepatitis C virus were negative. Computed tomography (CT) of the brain showed hypodensity in bilateral parieto-occipital subcorticalregions. Magnetic resonance imaging (MRI) of the brain [] showed T1 hypointense, T2, and FLAIR (FLAIR: Fluid-attenuated inversion recovery) hyperintense lesions in bilateral parieto-occipital (left > right) and frontal regions without contrast enhancement. Lesions showed no diffusion restriction and were suggestive of PRES. Electroencephalogram (EEG) [] showed medium amplitude 3-4 Hz delta and slow theta activity which was generalizedalong with periodic short-interval (0.75 Hz) sharp waves of 100-150 μV amplitude over the right occipital region. There were small-amplitude sharp wave discharges of ~50 μV amplitude superimposed over the after-coming slow waves, giving a PLEDs-plus morphology. On admission, the patient was loaded with valproate for status epilepticus, and it was continued parenterally with follow-up EEG monitoring till the PLEDS-plus subsided. The second EEG of the patient showed disappearance of the PLEDs-plus morphology. But intermittent photic stimulation at low frequency showed grade III photoparoxysmal response (PPR) from bilateral occipital regions (right > left), although the background activity remained the same []. The third EEG of the patient showed disappearance of the PLEDs-plus morphology and PPR. The patient improved clinically with no further seizures, and visual acuity improved to 6/12. The clinical improvement in vision correlated with the electrical resolution of posterior head region PLEDs-plus, which evolved rapidly over three days with parenteral valproate therapy. Mesalamine, given for Crohn's disease, was thought to be the offending drug causing PRES; this was therefore stopped and replaced by steroids.

[[32.0, 'year']]

F

{'27099860': 1, '19262592': 1, '19762547': 1, '18403560': 1, '31413837': 2, '17724292': 1, '22865991': 1, '18854444': 1, '28932076': 1, '17885064': 1, '18365964': 1, '19650373': 1, '33532511': 1, '507756': 1, '17316891': 1, '24741259': 2}

{'6688734-1': 1, '6688734-2': 1, '6688734-3': 1, '6688734-4': 1, '6688734-5': 1}

3985368-1

noncomm/PMC003xxxxxx/PMC3985368.xml

Neurocysticercosis presenting as pseudobulbar palsy

A 38-year-old female patient presented with progressive dysarthria, dysphagia, nasal regurgitation and hyper nasal speech for 5 months duration. She had 4 episodes of partial seizures involving the right upper and the lower limb for the past 5 months and was not on any medications. There was weakness of the left upper limb for the past 15 days duration but there was no headache, vomiting or blurring of vision. She had emotional instability in the form of inappropriate crying. Neurological examination showed exaggerated jaw jerks and gag reflex with spastic dysarthria. She had both proximal and distal weakness in the left upper limb with power of 3/5. All the deep tendon reflexes were brisk with plantar response mute bilaterally and cortical sensory loss in the left upper limb. There was no atrophy or fasciculation of the affected muscles. The fundus and other system examination were normal.\nLaboratory examination revealed positive neurocysticercosis serology. The peripheral smear was normal. The renal and liver function tests were normal. The MRI brain showed multiple small cysts with scolex in both the cerebral hemispheres and a giant intraparenchymal cyst measuring 5 × 4.3 cms in the right cerebral hemisphere [Figure and ].\nOur patient presented with pseudobulbar palsy, partial seizures and weakness of the left upper limb. Her NCC serology was positive and diagnosis confirmed by MRI, which showed multiple cysts with scolex (in vesicular stage). She received the treatment with albendazole at 15 mg/kg/day along with steroids (for two weeks). She also received phenytoin for seizures. The patient remained seizure free and there were no significant events during her hospital stay. On follow-up six weeks after the completion of albendazole therapy she reported no recurrence of seizures and her right upper limb weakness recovered partially with power of 4/5. There was also improvement in her speech, emotional instability and was able to take food without nasal regurgitation.

[[38.0, 'year']]

F

{'12781380': 1, '3734881': 1, '6390196': 1, '12932389': 1, '16170737': 1, '9445339': 1, '2705902': 1, '24741260': 2}

{}

3985369-1

noncomm/PMC003xxxxxx/PMC3985369.xml

Combined central and peripheral demyelination

A 52-year-old male carpenter, vegetarian by diet, normotensive, non-diabetic and euthyroid presented to neurology department with history of progressive quadriparesis since 4 months. He was diagnosed having chronic active hepatitis 15 months back and was initially started on steroids and was tapered to prednisolone 5 mg/day. He attributed his weakness to hepatic ailment. He attended the neurology department when he developed dysarthria and became drowsy 2 days prior to admission.\nOn examination, patient was drowsy, but arousable, well oriented to time, place and person and would soon drift back to sleep. On general examination, he had no icterus, flaps and sphincter dysfunction or neck stiffness, but had mild pedal edema. Fundus was normal. Cranial nerve examination showed bilateral eye closure and neck flexor weakness. Tone was flaccid in the limbs; with power proximally 2-3/5 and distally 4/5. His liver function test revealed mild elevation of serum bilirubin 1.7 mg/dl. Full blood count, liver enzymes, coagulation screen, electrolytes, serum ammonia and renal function were normal. He had mild thrombocytopenia with a platelet count of 100,000 lakh/cumm.\nSerological testing for hepatitis A, hepatitis B and hepatitis C was negative. Ultrasound abdomen showed shrunken liver with irregular margins and diffusely altered echo texture suggestive of chronic liver disease. Immunological tests demonstrated positive smooth muscle antibody and positive anti-nuclear antibody homogenous staining pattern at a titre of 1 in 6. There was an accompanying hyper-gammaglobulinemia with elevated immunoglobulin G at 2507 (normal range 700-1600) and normal immunoglobulin A levels. Double stranded deoxyribonucleic acid antibodies, anti-mitochondrial antibodies and liver/kidney microsomal antibodies were not detected. Thyroid profile, serum B12, ceruloplasmin, alpha fetoprotein levels, protein electrophoresis was normal; Lupus anticoagulant, P-ANCA, C-ANCA was negative. The positive anti-nuclear and smooth muscle antibody results were strongly suggestive of autoimmune hepatitis and ruled out other autoimmune disorders. Magnetic resonance imaging of brain (T2-weighted) showed hyper intense signals in the basis pontis [] suggestive of CPM which accounted for his drowsiness. Nerve conduction studies showed prolonged distal latencies in median (5.5 ms), posterior tibial (6.6 ms) and peroneal nerves (6 ms); decreased motor conduction velocity in median (25 m/s), posterior tibial (30 m/s) and peroneal nerves (41 m/s). F waves were prolonged in median (56), post tibial nerves (70) and peroneal nerves (69). Sensory conductions were normal. The nerve conduction studies were suggestive of chronic inflammatory demyelinating polyneuropathy (CIDP).\nWith these parameters, patient was diagnosed to have central and peripheral demyelinating disorder. Patient was started on high dose methylprednisolone with meticulous glycemic control. After 10 h of admission, patient sensorium improved and started showing improvement in motor power after 5 days. On discharge, he was able to walk with minimal support on oral corticosteroids. On follow-up after 8 months, he was stable and was maintaining improvement.

[[52.0, 'year']]

M

{'15548509': 1, '12497238': 1, '20148277': 1, '24741263': 1, '8558159': 1, '9328238': 1, '13616772': 1, '7484639': 1, '8469352': 1, '11148672': 1, '22231306': 1, '11559493': 1, '24741261': 2}

{}

3985371-1

noncomm/PMC003xxxxxx/PMC3985371.xml

Chiari Type I malformation yielded to the diagnosis of Crouzon syndrome

A 16-year-old, formerly healthy boy admitted to the outpatient clinic with occasional headache and neck pain. On physical examination it was remarked that he had characteristic features of syndromic craniosynostoses: Hypertelorism, proptosis, midfacial hypoplasia, and abnormal head shape [Figures and ]. However, the patient and his family did not admit to a hospital for this reason before, despite prominent Cruzonoid features. The patients’ neurological examination revealed no abnormalities including pinprick, touch, pain, and temperature sensations in both upper extremities. Anteroposterior (AP) and lateral plain radiographs of head and a cranial computed tomography (CT) demonstrated midfacial and orbital hypoplasia, the fusion of bilateral coronal and lambdoid sutures and sagittal suture, alongside with the increase of AP diameter of the head [Figures and ]. The patient did not have a history of delayed maturation. His psychomotor development was completely normal. The patient did not suffer from any systemic disorders including chronic hypertension. Fundoscopic examination showed no papilledema. Cranial and spinal magnetic resonance imaging (MRI) studies were obtained and it showed a 18 mm cerebellar tonsil herniation into the foramen magnum with accompanying syringomyelia between Th 4 and Th 7 []. Surgery was planned in order to decompress the posterior cranial fossa. Using a median incision, a suboccipital craniectomy, total C1 arcusectomy and partial C2 laminectomy was performed. The dura was opened in Y-form and after arachnoid dissection duraplasty was performed. There were no significant events in the postoperative course and the patient was discharged from the hospital with no neurological deficits. The patient was then referred to the genetics department for the further evaluation of the craniosynostosis. Phenotypical features like the typical dismorphic facies, ocular proptozis and hypertelorism, parrot-like nose, and frontal bossing alongside with the patients’ mothers’ history of four recurrent intrauterine fetal losses supported the diagnosis of Crouzon syndrome in our patient. Regular follow-up examinations were scheduled for the observation of orbital deformities and vision. Control MRI showed complete resolution of the tonsillar herniation and significant reducement of the syringomyelia both in length and thickness [Figures and ]. Four years after the operation the patient is still doing well with no neurological or ocular deficits and with the relief of his symptoms at the admission.

[[16.0, 'year']]

M

{'26572514': 1, '23240845': 1, '12186468': 1, '25245177': 1, '30881832': 1, '22295912': 1, '9442505': 1, '21882907': 1, '29354335': 1, '20013282': 1, '25905085': 1, '7674004': 1, '23139476': 1, '15885794': 1, '24741262': 2}

{}

3985780-1

noncomm/PMC003xxxxxx/PMC3985780.xml

Kimura's Disease of the Orbit Successfully Treated with Radiotherapy Alone: A Case Report

A 28-year-old male presented to the Department of Ophthalmology in February 2006 with a history of blepharoptosis, exophthalmos, a reduction of visual acuity as well as a visual field defect in the right eye. The eyesight of the right eye was 0.07 and that of the left eye was 1.2. Inferior hemianopsia with a scotoma in the center was shown by the Goldmann perimetry. A relative afferent pupillary defect (RAPD) in the right eye was detected. Double vision and disturbance of the lateral gaze in the right eye were also pointed out. A mass on the right side of the neck had been observed 19 years earlier and the patient had been pathologically diagnosed as having Kimura's disease. The diagnosis of a tumor of the right orbit was made based on clinical and MRI findings (fig. ).\nBlood tests showed peripheral blood eosinophilia (15%; normal ∼6%) and elevated serum immunoglobulin E (IgE: 4,470 IU/ml; normal ∼170 IU/ml). The total leukocyte count was 6,300/mm3. A differential white blood cell count performed at that time showed 56% neutrophils, 23% lymphocytes, 15% eosinophils and 6% monocytes.\nA biopsy of the mass of the right orbit was performed by a neurosurgeon. A histological examination of the hematoxylin- and eosin-stained sections of the resected mass revealed a proliferation of the fibrous connective tissue and small vessels with an infiltration of the lymphocytes and eosinophils. There was no evidence of lymphoid follicle growth or malignancy, leading to a pathological diagnosis of Kimura's disease after considering the blood test results (fig. ).\nA neurosurgeon highly recommended radiotherapy and consulted a radiation oncologist. Radiation therapy was started in May 2006. Irradiation with 21.6 Gy was administered to the tumor bed in a single dose of 1.8 Gy in 5 weekly fractions via a high-energy linear accelerator (6-MV X-ray). A single anterior oblique portal was used to avoid radiation exposure of the right lens (fig. ). Lens protection was not used during radiotherapy. Eye drops for radiation-induced conjunctivitis and an ointment to treat radiation-induced dermatitis were also not prescribed. The tumor gradually diminished and ultimately disappeared. Four months after the completion of radiotherapy, the eyesight of the right eye was 1.5, which was the same as that of the left eye, and an improvement of the inferior hemianopsia as well as the disappearance of the scotoma in the center were demonstrated by the Goldmann perimetry. Improvements in the exophthalmos, double vision and a RAPD of the right eye were achieved. The irradiated right eye ball did not develop dry eye syndrome or a cataract. There was no evidence of radiation-induced dermatitis or radiation neuropathy. Neither tumor regrowth nor late complications were detected up to 84 months after radiotherapy (fig. ). Both the elevated serum IgE level and eosinophilia gradually decreased. The serum IgE level was 470 IU/ml 84 months after radiotherapy and the peripheral eosinophil level was 7.9% in June 2013.

[[28.0, 'year']]

M

{'10379615': 1, '9486615': 1, '11926586': 1, '34352903': 1, '24088630': 2, '26889243': 1, '10466591': 1, '32957960': 2, '16750313': 1, '17600884': 1, '17596059': 1, '25120846': 1, '24748872': 2}

{'7507290-1': 1, '5026083-1': 1}

3985782-1

noncomm/PMC003xxxxxx/PMC3985782.xml

Reduced-Intensity Allogeneic Stem Cell Transplantation for Co-Emergence of Chemotherapy-Refractory Follicular Lymphoma and Therapy-Related Myelodysplastic Syndrome

A 54-year-old male was admitted to hospital in September 2003 with systemic lymphadenopathy, fatigue and night sweating. Computed tomography scans confirmed cervical, axillary, mediastinal, para-aortic, mesenteric and inguinal lymphadenopathies. Laboratory tests showed an elevated soluble interleukin-2 receptor (14,800 U/ml) and elevated WBC (113.3 × 109/l), comprised of 89% of abnormal lymphoid cells. The bone marrow (BM) was also massively invaded by abnormal lymphoid cells. Biopsy of the cervical lymph node disclosed the diagnosis of FL grade 3A. In immunohistochemical examinations, lymphoma cells were positive for CD10, Bcl-2, and CD20, and t(14;18)(q32;q21) translocation was detected by fluorescence in situ hybridization. Eight cycles of R-CHOP consisting of rituximab, cyclophosphamide, adriamycin, vincristine and prednisolone and subsequent maintenance therapy with rituximab for 8 months induced complete remission (CR), but the disease relapsed 8 months after the cessation of rituximab. Salvage chemotherapy consisting of rituximab and fludarabine induced a partial response, but the disease relapsed again after 14 months. For the second salvage therapy, the patient was enrolled in a clinical trial for treatment with everolimus, a new inhibitor of mammalian target of rapamycin. The drug induced CR, which sustained for 23 months, but lymphoma eventually relapsed (fig. ). A second biopsy of the cervical lymph node confirmed the diagnosis of relapsed FL without the evidence of transformation into a more aggressive lymphoma. Then, the patient underwent intensified chemotherapy using cyclophosphamide, high-dose Ara-C, dexamethasone, and etoposide (CHASE), radioimmunotherapy with 90Y ibritumomab tiuxetan and myeloablative chemotherapy with melphalan, cyclophosphamide, etoposide, and dexamethasone (LEED) supported by autologous HSCT. The patient achieved CR, which was confirmed by 18F-FDG-PET (PET) examination and BM analysis (no invasion and normal karyotype). However, 7 months after the transplantation, PET examination revealed generalized lymphadenopathy and uptake in the bilateral femoral nerve (suspected to be neurolymphomatosis). BM infiltration with abnormal lymphoid cells was also identified.\nAt this time, 81 months from the initial diagnosis of FL, we planned allogeneic HSCT using reduced-intensity conditioning (RIC). To reduce the tumor burden prior to RIC-HSCT, we administered three cycles of salvage therapy, comprised of rituximab and bendamustine, after which only minor cervical lymphadenopathy was identifiable by PET examination. However, myelosuppression accompanied by grade 4 neutropenia lasted for several weeks after the last dose of bendamustine, and BM analysis revealed hypocellularity with an increase in myeloblasts (5.2% of all nucleated cells) and multilineage dysplastic changes, which was documented in this case for the first time (fig. ). Chromosomal analysis revealed the presence of complex karyotypic abnormalities, including chromosome 7 deletion (fig. ). From these results, the diagnosis of t-MDS, refractory anemia with excess blasts-1, was made []. Regarding the MDS International Prognostic Scoring System, the patient was classified as intermediate-2 risk category []. Furthermore, the patient's condition was complicated by cytomegalovirus retinitis and required antiviral therapy for 4 weeks.\nFor simultaneous treatment of both chemotherapy-resistant FL and t-MDS, we performed RIC-HSCT with peripheral hematopoietic stem cells from his HLA-matched sibling (sister) 4 weeks after the diagnosis of t-MDS. At this time, the FL remained in partial remission. The conditioning regimen consisted of fludarabine (25 mg/m2 × 5 days), melphalan (80 mg/m2 × 1 day) and 4 Gy of total body irradiation (TBI). Cyclosporine A and short-term methotrexate were utilized as prophylaxis against graft-versus-host disease (GVHD). Neutrophil engraftment was confirmed on day 14 and platelet engraftment on day 22. There was no acute GVHD, and infectious complications, such as febrile neutropenia, Clostridium difficile-associated colitis, and reactivated cytomegalovirus retinitis, were treated successfully with antibiotics and antiviral agents. BM analysis on day 30 showed complete donor chimerism with a normal karyotype and without any myelodysplastic changes. The patient was discharged on day 56 and his condition was later complicated by chronic GVHD of the hepatic type that was alleviated successfully by re-dosing with cyclosporine A. PET examination on day 80 also showed no abnormal uptake (fig. ). Since then, CR of both FL and t-MDS has been maintained for 672 days at the timing of writing.

[[54.0, 'year']]

M

{'21918440': 1, '23433739': 1, '23412096': 1, '12623843': 1, '21909142': 1, '20032503': 1, '19357394': 1, '23332452': 1, '20606089': 1, '21740299': 1, '9058730': 1, '23813647': 1, '20962860': 1, '21189387': 1, '19594547': 1, '23001911': 1, '19224851': 1, '19948235': 1, '15812397': 1, '24748869': 2}

{}

3985784-1

noncomm/PMC003xxxxxx/PMC3985784.xml

Giant Adrenal Myelolipoma Masquerading as Heart Failure

A 52-year-old man with a past medical history significant for atrial fibrillation, diabetes type 2 and hypertension for 30 years was admitted with early satiety for the past 3 months and progressive dyspnea on exertion for 3 weeks. He also complained of gradual unintentional weight loss of approximately 100 pounds over the last 10 years. He had been a non-smoker and a moderate alcohol user for the last 30 years. On initial presentation to the hospital, he denied shortness of breath at rest or chest discomfort and was in no acute distress.\nHis blood pressure was 204/93 mm Hg on the left arm and 194/88 mm Hg on the right arm with an irregular heart rate of 54 beats/min and oxygen saturation of 96% on room air. The lungs were clear to auscultation, jugular venous distension was noted at 13 cm above the sternal angle and 3+ bilateral leg edema with scrotal edema. Cardiac auscultation was pertinent for 3/6 systolic ejection murmur over the left sternal border. His abdomen felt firm and lacking in tympanicity, but it was non-tender in all four quadrants. Bowel sounds were audible but faint. Laboratory values were notable for a brain natriuretic peptide of 980 ng/l, creatinine of 1.2 mg/dl, BUN of 20 mg/dl, HCO3 of 31 mEq/l, INR of 1.23, Hb of 12.5 g/dl, Na of 140 mEq/l, K of 3.7 mEq/l and negative cardiac troponins. He was monitored in the Intensive Care Unit for decompensated heart failure with uncontrolled hypertension.\nTo promote diuresis and reduce afterload, he was administered intravenous furosemide 80 mg, oral metolazone 2.5 mg, oral hydralazine 75 mg every 6 h, oral clonidine 0.3 mg, lisinopril 40 mg, isosorbide mononitrate 120 mg and losartan 100 mg. Overnight, he had an episode of moderate self-limited epistaxis with minimal improvement in blood pressure control. He remained in slow atrial fibrillation with a lowest recorded heart rate of 38 beats/min. However, he denied dizziness at any time despite a negative fluid balance of 1.8 liters. Renal function worsened with an increase of creatinine to 1.6 mg/dl.\nAn echocardiogram showed a left ventricular ejection fraction of 30% with four-chamber dilatation, moderately reduced right ventricular systolic function, severe mitral regurgitation and moderate pulmonary hypertension. He underwent right heart catheterization showing a right atrial pressure of 12 mm Hg, right ventricular pressure (systolic/diastolic) of 60/12 mm Hg, pulmonary artery pressure of 60/23 mm Hg and pulmonary capillary wedge pressure of 20 mm Hg and a cardiac index of 2.3 liters/min. A left heart catheterization revealed clean coronaries, and alcohol was thought to be the likely etiology of non-ischemic cardiomyopathy in this patient. Urine catecholamine and vanillylmandelic acid were measured and a magnetic resonance angiography of the renal arteries was performed to evaluate for secondary causes of hypertension. This showed non-obstructed renal arteries bilaterally.\nA minimally enhancing 22 × 16 × 23 cm mass was visualized in the left upper and mid-abdomen displacing the spleen and stomach posterosuperiorly, the pancreas anteriorly and the left kidney inferiorly (fig. ). The left adrenal gland was not visible. A contrast-enhanced CT scan of the abdomen to further characterize the mass showed no infiltration of the surrounding vasculature or organs, and the left adrenal gland was visualized although it could not be confirmed if the mass was arising from the adrenals (fig. ). The suggested radiological differential diagnoses were: liposarcoma, teratoma and myelolipoma. A needle biopsy of this mass showed adipose tissue with foci of extramedullary hematopoiesis consistent with myelolipoma without any evidence of malignancy, confirming this mass to be a benign myelolipoma (fig. ).\nUrinary epinephrine, metanephrine and vanillylmandelic acid were within normal limits. A renal perfusion scan showed a small left kidney with reduced perfusion contributing 22% to the overall tubular function without obstructive uropathy. The lower extremity edema was partly ascribed to be due to inferior vena cava compression, and diuretics were decreased due to worsening renal function. Given the bradycardia and severe congestive heart failure, an electrophysiologist was consulted for evaluation and need for pacemaker implantation. Bradycardia was ascribed to be partly due to the Cushing reflex secondary to elevated blood pressure, and as the patient had no symptoms secondary to a low heart rate, pacemaker implantation was not advised. Despite maximum doses of clonidine, isosorbide, hydralazine, losartan and lisinopril, at best a moderate blood pressure control was achieved preoperatively.\nThe patient was taken for surgical removal of the mass. During surgery, the mass was found to be soft, highly vascular but well encapsulated and attached only to the left adrenal gland via a small portion that was resected along with the mass (fig. ). There was minimal blood loss during the surgery, and the patient had an uneventful recovery in the postoperative period. A renal perfusion scan done 8 days after surgical removal showed 36% contribution to the overall tubular function. Blood pressure control improved after surgery and the patient was gradually titrated off clonidine, hydralazine and lisinopril. Bradycardia resolved with few episodes of atrial fibrillation with rapid ventricular response that were controlled with β-blockers and digoxin. The antihypertensive medications that the patient was discharged on were carvedilol 40 mg, valsartan 320 mg and isosorbide mononitrate 240 mg.

[[52.0, 'year']]

M

{'9646797': 1, '10926199': 1, '23556993': 2, '18366886': 1, '3051964': 1, '19766776': 1, '16890722': 1, '16857113': 1, '7051876': 1, '15989440': 1, '25878407': 1, '17947963': 1, '1987178': 1, '28794862': 2, '11533079': 1, '23161239': 1, '12416010': 1, '7605177': 1, '12709616': 1, '15960364': 1, '20361087': 1, '6730136': 1, '18442597': 1, '15828949': 1, '18020221': 1, '18158060': 1, '16819325': 1, '21740587': 2, '22584001': 2, '11996801': 1, '9120904': 1, '24748868': 2}

{'3407746-1': 1, '3653706-1': 1, '5538031-1': 1, '3142232-1': 1}

3985785-1

noncomm/PMC003xxxxxx/PMC3985785.xml

Primary Anorectal Melanoma

In April 2013, a 71-year-old female with no significant past medical history presented to our institution with painful bowel movements for the last 3 months. The patient also noticed blood-streaked stools and reported a 16-lb unintentional weight loss over a 1-year period. The review of her systems was negative otherwise. On examination: the woman was 5′ 7.5′ (1.715 m) tall, weight was 172 lb (78.019 kg), with a BMI of 26.54, and her vital signs were normal. Digital examination of the rectum revealed two small hemorrhoids at the 6 o'clock position and a firm, nonobstructing mass near the anal verge. The patient underwent a colonoscopy in September 2013 which revealed a nonobstructing, ulcerated anal mass, approximately 1 cm from the anal verge. A biopsy of the mass demonstrated an invasive, poorly differentiated carcinoma (fig. ). Stains for CK5/6 and P63 were positive, likely suggesting a primary squamous cell carcinoma of the anus. Tumor markers including CEA, CA 15–3 and CA 27–29 were negative. A CT of the abdomen and pelvis demonstrated an abnormal mass at the anorectal junction, with no evidence of lymph nodes or liver metastases in September 2013 (fig. ). PET combined with a CT scan demonstrated marked metabolic activity in the primary anal mass and a 1-cm perirectal lymph node near the coccyx, suggesting a node-positive disease in October 2013 (fig. ). An MRI of the pelvis confirmed the PET/CT findings (fig. ). The patient's tumor was sent to an outside institution for a second opinion, and the report was concluded as the tumor may in fact be a malignant melanoma. The patient subsequently underwent an exploratory laparotomy with an APR and left-end colostomy in October 2013. The patient tolerated the surgical procedure without any complications. The pathologic specimen confirmed a malignant melanoma arising in the anal skin and extending into the rectum, involving the anal and perirectal soft tissue and 6 regional lymph nodes (fig. ). The tumor was classified as grade 3, poorly differentiated, stage IIIA, T2N1M0 according to the tumor-node-metastasis classification of colorectal cancer []. Immunohistochemical analysis results were positive for the expression of the S-100 protein, HMB-45 and vimentin, whereas negative for the expression of cytokeratin and SMA (fig. ). The patient agreed to the plan of starting chemotherapy with mitomycin and 5-fluorouracil (for the anorectal melanoma).

[[71.0, 'year']]

F

{'34703388': 1, '1642415': 1, '27422527': 1, '20011314': 1, '20130908': 1, '10792480': 1, '16753594': 1, '12454112': 1, '9005147': 1, '22154054': 1, '29207721': 1, '19430407': 1, '20367986': 1, '26999018': 2, '17944970': 1, '29184917': 2, '33623510': 2, '15651058': 1, '27847790': 2, '32850102': 2, '9781962': 1, '34385788': 2, '9869521': 1, '18058185': 1, '7851168': 1, '21446049': 1, '33519141': 1, '9194459': 1, '29147422': 2, '16811001': 1, '15042682': 1, '19774417': 1, '2306178': 1, '3908491': 1, '34704187': 2, '14647131': 1, '25390611': 1, '31565179': 1, '24748866': 2}

{'7427446-1': 1, '7875022-1': 1, '7875022-2': 1, '5649952-1': 1, '5703688-1': 1, '8548484-1': 1, '4977747-1': 1, '5108666-1': 1, '8320828-1': 1, '8320828-2': 1, '8320828-3': 1}

3985789-1

noncomm/PMC003xxxxxx/PMC3985789.xml

Two Japanese Cases of Birt-Hogg-Dubé Syndrome with Pulmonary Cysts, Fibrofolliculomas, and Renal Cell Carcinomas

The first patient was a 37-year-old female who presented with an asymptomatic left renal tumor that was revealed by ultrasound and computed tomography (CT) examinations (fig. ). The CT examination also revealed the presence of asymptomatic bilateral multiple PCs (fig. ). Since the age of 35, a few firm papules had developed on her face and head (fig. ). The patient had no family history of pulmonary, renal, or cutaneous disease. A laparoscopic left nephrectomy was performed. On gross examination, the resected kidney was a yellowish, solid tumor with partial hemorrhage (fig. ). The tumor was identified as a clear cell renal carcinoma (fig. ) positive for vimentin stain (fig. ) and negative for CK-7. A skin biopsy of the papule on her head revealed it was a fibrofolliculoma (FF; fig. ) positive for factor 13a (fig. ) and c-kit (fig. ), and negative for CD34, α-smooth muscle actin (α-SMA), S100, and CD68. Because the findings for this patient met 1 major criterion and 2 minor criteria [], she was diagnosed with Birt-Hogg-Dubé syndrome (BHD).

[[37.0, 'year']]

F

{'20930443': 1, '26961346': 1, '22148048': 2, '26943385': 2, '12081679': 1, '19687589': 1, '22148047': 2, '33313181': 1, '28151982': 1, '22211584': 1, '19788617': 1, '17323425': 1, '15821464': 1, '11023340': 1, '23356225': 1, '15656814': 1, '18234728': 1, '23223565': 1, '20413710': 1, '19416240': 1, '19659657': 1, '22790147': 1, '28069055': 2, '22687807': 1, '28222720': 2, '22446046': 1, '18437022': 2, '17496196': 1, '11758353': 1, '15826248': 1, '18709329': 1, '19959076': 1, '30360018': 1, '24748863': 2}

{'3985789-2': 2, '5320703-1': 1, '2526433-1': 1, '5220607-1': 1, '5220607-2': 1, '4747967-1': 1, '3229062-1': 1, '3229063-1': 1}

3985789-2

noncomm/PMC003xxxxxx/PMC3985789.xml

Two Japanese Cases of Birt-Hogg-Dubé Syndrome with Pulmonary Cysts, Fibrofolliculomas, and Renal Cell Carcinomas

The second patient was a 35-year-old male who presented with an asymptomatic right renal tumor. The presence of the tumor was revealed by ultrasound and CT examinations (fig. ). A laparoscopic right partial nephrectomy was performed, and the tumor was diagnosed as a chromophobe renal cell carcinoma (RC; fig. ). The carcinoma was negative for CD10, vimentin, and c-kit, and was partially positive for CK-7 (fig. ) and colloidal iron (fig. ). When the patient was 40 years of age, a CT examination revealed the presence of asymptomatic bilateral multiple PCs (fig. ). His mother, aunt, uncle, and grandfather all had histories of recurrent pneumothorax (fig. ). A few firm papules were also present on the patient's face (fig. ). The results of the skin biopsies revealed that the papules were FFs (fig. ) positive for factor 13a (fig. ) and c-kit (fig. ), and negative for CD34, α-SMA, S100, and CD68. Because the findings for this patient met 1 major criterion and 2 minor criteria [], he was diagnosed with BHD.

[[35.0, 'year']]

M

{'20930443': 1, '26961346': 1, '22148048': 2, '26943385': 2, '12081679': 1, '19687589': 1, '22148047': 2, '33313181': 1, '28151982': 1, '22211584': 1, '19788617': 1, '17323425': 1, '15821464': 1, '11023340': 1, '23356225': 1, '15656814': 1, '18234728': 1, '23223565': 1, '20413710': 1, '19416240': 1, '19659657': 1, '22790147': 1, '28069055': 2, '22687807': 1, '28222720': 2, '22446046': 1, '18437022': 2, '17496196': 1, '11758353': 1, '15826248': 1, '18709329': 1, '19959076': 1, '30360018': 1, '24748863': 2}

{'3985789-1': 2, '5320703-1': 1, '2526433-1': 1, '5220607-1': 1, '5220607-2': 1, '4747967-1': 1, '3229062-1': 1, '3229063-1': 1}

3985792-1

noncomm/PMC003xxxxxx/PMC3985792.xml

Cephalic Duodenopancreatectomy for Hyperalgic Duodenal Crohn's Disease Fistulized in the Pancreatic Gland

We report herein the case of a 23-year-old man with a past history of gastric pain in 1999 in relation with an ulcer of the bulb successfully treated by proton pomp inhibitors. Between 1999 and 2008, the patient had no symptoms. In October 2008, the abdominal pain reappeared with anorexia and weight loss (from 67 to 54 kg). Upper digestive endoscopy showed a giant ulcer covering the whole surface of the bulb (fig. ). Histological analysis reported antral gastritis, presence of Helicobacter pylori and non-caseating granulomas composed of epithelioid cells and multinucleated giant cells. Ziehl staining and quantiferon test were negative. Chest X-ray did not show any abnormality. C-reactive protein was 10 mg/l, hemoglobin level 12.2 g/dl with a mean corpuscular volume at 81 fl, and the gastrin blood rate was normal.\nThe diagnosis of duodenal CD was strongly suspected. However, we first decided to treat H. pylori infection with a 7-day regimen of proton pomp inhibitor b.i.d., amoxicillin 1 g b.i.d. and a 500 mg metronidazole b.i.d., without evidence of clinical improvement. A second upper digestive endoscopy confirmed the persistence of a large ulcer with suspicion of a plugged perforation and a stenosis of the bulboduodenal junction. Non-caseating granulomas without H. pylori were still found on biopsies.\nTo assess the extent of CD, ileocolonoscopy with multiple biopsy sampling, abdominal computed tomography and capsule endoscopy were performed. On ileocolonoscopy, the ileum and colon were macroscopically and microscopically healthy. The abdominal computed tomography scan only reported thickening of the pylorus wall and bulb. The capsule endoscopy showed mild bulb stricture with a large inflammatory ulcer with a sclerosus bottom.\nIn January 2009, oral corticosteroid treatment was introduced with a dose of 60 mg/day. The abdominal pain partially improved, but promptly reappeared with identical macroscopic lesions at upper endoscopy. Azathioprine 125 mg/day and infliximab 5 mg/kg (300 mg) scheduled at weeks 0, 2, 6 and every 8 weeks were then introduced. After 8 infliximab infusions, the gastric pain did not disappear, with a significant social impact on the patient's life (work absenteeism a week per month). We decided to optimize the treatment by increasing the azathioprine dose to 150 mg/day and infliximab to 10 mg/kg (600 mg) every 8 weeks. The patient received three new injections of infliximab, but without clinical improvement. Surgery was considered at that point, but gastrojejunostomy was excluded because of evidence of proximal jejunal wall thickening on magnetic resonance enterography. We then switched to another combo therapy with subcutaneous methotrexate injection 25 mg/week and adalimumab 160 mg followed by 80 mg at 2 weeks and by 40 mg every other week. No improvement was noticed after 3 months of this new treatment strategy. The isolated gastric pain became stronger, leading to complete socio-professional inability and requiring daily use of opioid medications. The failure of two lines of combined treatment led us to a salvage surgical option.\nA median laparotomy was performed. Abdominal exploration showed two short inflammatory small bowel stenoses 50 and 70 cm from the angle of Treitz. The stomach was plate with a retracted aspect of the bulb. The bulboduodenal block was inflammatory and thickened. Cephalic duodenopancreatectomy and cholecystectomy were performed. The pancreas was hard at section. The jejunal stenoses were left in place in the absence of tight stricture. Histological analysis reported a large fissuring pylorus ulceration with micro abscesses reaching the pancreas (fig. ).\nRegarding the severity of the disease, adalimumab 40 mg every other week was maintained after surgery to prevent CD recurrence. Six months after the surgery, the patient had stopped antalgic treatment and did not have residual abdominal pain. He had gained 11 kg weight and had no diarrhea with pancreatic enzymes.

[[23.0, 'year']]

M

{'8244104': 1, '8675090': 1, '3721139': 1, '30891327': 1, '11720325': 1, '22350786': 1, '21172284': 1, '21560202': 1, '12870796': 1, '24748861': 2}

{}

3985793-1

noncomm/PMC003xxxxxx/PMC3985793.xml

Intracranial Metastasis in a Patient with Hepatocellular Carcinoma and Gastric Cancer

A 76-year-old man visited our hospital because of visual disturbance, weakness of the left upper and lower limbs, and gait disturbance. The patient had been treated for cirrhosis caused by chronic hepatitis C virus (HCV) infection. Because HCC was detected, approximately 60 mm in diameter, in the right lobe, he had undergone transarterial chemoembolization 3 and 10 years earlier. When radiofrequency ablation was performed for the recurrent HCC 2 years ago, gastric cancer was incidentally found (fig. ). Subsequently, he underwent gastrectomy with D1 lymphadenectomy and the tumor was successfully removed. Pathological examination revealed that the tumor was composed of moderately differentiated tubular adenocarcinoma. The staging of the lesion was T3N0. Additionally, multiple lung tumors were concurrently detected (fig. ). The patient had neither a history of smoking nor an elevation of tumor markers for primary lung cancer (such as squamous cell carcinoma antigen and neuron-specific enolase). Since the resected gastric cancer histologically lacked an involvement of lymph nodes, we considered the possibility that lung tumors were of HCC origin. Subsequently, sorafenib was administered. Because of adverse events such as a hand-foot skin reaction, the dose of sorafenib was reduced from 800 to 200 mg/day.\nOn admission, serum levels of hepatobiliary enzymes and renal function markers such as blood urea nitrogen and creatinine were normal. The serum level of ammonia was 91 μg/dl. Although blood count tests showed slight anemia (hemoglobin: 11.5 g/dl) and thrombocytopenia (8.5 × 104/μl), his white blood cell count was normal (4,000/μl). Anti-HCV antibody was positive, but hepatitis B surface antigen was negative. The level of carcinoembryonic antigen markedly increased to 44.1 ng/ml.\nHowever, the levels of alpha-fetoprotein (AFP), des-gamma-carboxy prothrombin (DCP), and carbohydrate antigen 19–9 (CA19–9) were within the normal range (5.6 ng/ml, 21 U/ml, and 10.2 U/ml, respectively). Although the patient's consciousness level was normal [Glasgow Coma Scale was a full score (E4V5M6)], he exhibited left-sided hemifield visual disturbance and left-sided hemiparesis. Enhanced MRI revealed an intra-axial tumor in the right occipital cerebral lobe (fig. ). Taking into consideration the markedly elevated level of carcinoembryonic antigen, but not AFP or DCP, we made a preoperative diagnosis of intracranial metastasis of gastric cancer, and a craniotomy of the tumor was performed. Macroscopic examination of the resected specimen revealed that the tumor was yellowish-white, solid, and accompanied by necrosis (fig. ). The size of the tumor was 38 × 30 × 32 mm. Pathological examination revealed that the tumor was consistent with metastatic adenocarcinoma of gastric cancer origin (fig. ).\nThe postoperative course was uneventful. The patient's visual disturbance, hemiparesis, and gait disturbance markedly recovered to normal after surgery. Follow-up MRI conducted 1 week after the craniotomy revealed the successful removal of the tumor. Because a small lesion was detected in the left precentral gyrus, the patient received additional gamma-knife treatment (20 Gy). Sorafenib administration was discontinued and S-1 (tegafur/gimeracil/oteracil potassium, 50 mg/day) was administered postoperatively. He was alive for 5 months after the gamma-knife treatment, without any recurrence.

[[76.0, 'year']]

M

{'19486257': 1, '5373627': 1, '10622506': 1, '10448872': 1, '22510321': 1, '23251807': 1, '10883456': 1, '21319152': 1, '3039283': 1, '21351269': 1, '30601858': 1, '5023391': 1, '1309309': 1, '15484315': 1, '24748871': 2}

{}

3985797-1

noncomm/PMC003xxxxxx/PMC3985797.xml

Long-Term Remission of an Aggressive Sebaceous Carcinoma following Chemotherapy

A 69-year-old Caucasian male with a history of multiple premalignant skin lesions presented with a solitary 15-mm erythematous nodular dermal lesion on the vertex. A wide surgical excision was performed and revealed a poorly differentiated SC. In the following months, 2 new dermal lesions consecutively appeared in the right occipital area. As the local resections were microscopically incomplete, a strategy including wide surgical excision with skin graft reconstruction and right posterior cervical lymphadenectomy was adopted. The pathological examination confirmed that the SC had spread to the lymph nodes and that positive tumor margins were still present in the skin and gave rise to multiple new recurrences. More excisions were performed over the next few months, each being followed by more recurrences within a month's time.\nIrradiation in the form of tomotherapy was then proposed. A total of 66 Gy was applied to the occipital and right retroauricular areas, and 52.8 Gy to the cervical lymph nodes. No benefit was observed after radiotherapy and the lesions continued to grow. A physical examination performed at that time revealed an excoriated hemorrhagic nodular dermal lesion (3 × 4 cm) in the central parieto-occipital region and a second nodular lesion (3 × 2 cm) in the right retroauricular area (fig. ). Magnetic resonance imaging of the head showed 3 subcutaneous masses (3 × 2 cm) in the occipital area, the right retroauricular region and the right parietal zone (fig. ). No intracerebral lesions were observed. Further radiographic studies indicated the presence of lymph node metastases in the absence of distant metastases.\nAt this point, chemotherapy was initiated using a combination of 5-fluorouracil (750 mg/m2/day for 4 days), cisplatin (100 mg/m2) and docetaxel (75 mg/m2) every 3 weeks. A significant clinical improvement (>50% reductions in the size of the lesions) was already seen after the first cycle. Due to myelosuppression, the decision was made to remove docetaxel from the regimen. After a total of 4 chemotherapy cycles, all lesions had disappeared. Treatment was subsequently maintained with single-agent capecitabine (1,000 mg/m2/day) on days 1–10 every 21 days. A clinical and radiographic follow-up at >20 months confirmed that complete remission had persisted (fig. , fig. ).

[[69.0, 'year']]

M

{'16699794': 1, '31571090': 1, '29914578': 2, '3864018': 1, '20856079': 1, '15582067': 1, '22367747': 1, '12930349': 1, '30792644': 2, '10826762': 1, '28681210': 1, '11369914': 1, '16052148': 1, '19415798': 1, '11801779': 1, '22267270': 1, '30291222': 1, '1418905': 1, '18289332': 1, '2777652': 1, '26300682': 1, '19076624': 1, '18988294': 1, '24748864': 2}

{'6381883-1': 1, '6006706-1': 1}

3985800-1

noncomm/PMC003xxxxxx/PMC3985800.xml

Vitreous Amyloidosis as the Presenting Symptom of Familial Amyloid Polyneuropathy TTR Val30Met in a Portuguese Patient

An apparently healthy 66-year-old man, born in Santa Maria da Feira and resident in Vila Nova de Gaia, Portugal, was first examined in March 2010 for right blurred vision and floaters. Symptoms were progressing for 2 months. Best-corrected visual acuity was 20/30 in the right eye and 20/20 in the left eye. The anterior segment of both eyes was unremarkable, with no abnormal conjunctival vessels, no change of pupillary shape, and no amyloid deposition at pupillary border or lens surface. Intraocular pressure, ocular movements and pupillary reflexes were normal. Vitreous yellowish-white opacities precluding examination of the fundus were identified in the right eye. The vitreous and retina of the left eye were normal.\nFull clinical evaluation showed an asymptomatic first-degree atrioventricular (AV) block in the absence of other neurologic or cardiac signs of disease. The mutation TTR Val30Met was identified by full sequencing of the gene, and a salivary gland biopsy was done but failed to show amyloid deposition.\nIn November 2010, as the right visual acuity dropped to 20/100 the patient underwent a pars plana vitrectomy. The pathological examination of the surgical specimen which included Congo red stain showed material with yellowish-green birefringence consistent with amyloid. Postoperatively, best-corrected visual acuity was 20/20. In the summer of 2011, the patient had several episodes of dizziness and fainting. A Mobitz 2 second-degree AV block was demonstrated with a Holter register and he was submitted to a pacemaker implantation, with complete recovery of these symptoms. In September 2012, the visual acuity decreased to 20/100 in both eyes. The right eye developed a cataract and the left eye presented vitreous opacities (fig. ). At that time, the light pupillary reflex and the pupil shape were normal. Biomicroscopy of both eyes revealed no amyloid deposits on the lens surface or at the pupillary border. The intraocular pressure was normal. He was submitted to a phacoemulsification of the cataract with intraocular lens implantation in the right eye in September 2012. One month later, pars plana vitrectomy was performed in the left eye without complications (fig. ). In February 2013, his best-correct visual acuity of both eyes was 20/20, and the ophthalmological examination was normal, except for pseudophakia of the right eye.\nThe patient remains free of neurologic symptoms or signs. There is no evidence of FAP in any of the patient's relatives. His parents died very old without FAP manifestations. Nine siblings (1 brother, 1 sister and 7 half-brothers and half-sisters), 3 sons and 7 grandsons had no symptoms suggesting onset of the disease up to the time of reporting (fig. ).

[[66.0, 'year']]

M

{'13054873': 1, '1547960': 1, '8878404': 1, '32823388': 2, '2060679': 1, '8599154': 1, '26437390': 1, '8599155': 1, '22856884': 1, '17554795': 1, '5755734': 1, '14640030': 1, '59590': 1, '12566023': 1, '8825887': 1, '32774294': 2, '27165517': 1, '8063479': 1, '16076612': 1, '12408681': 1, '28904227': 1, '22094129': 1, '12978172': 1, '1268160': 1, '15930086': 1, '28802308': 2, '3032328': 1, '2896079': 1, '16009758': 1, '1690688': 1, '3279959': 1, '3714052': 1, '9215058': 1, '20142544': 1, '21358362': 1, '16129098': 1, '24748873': 2}

{'5554541-1': 1, '7690539-1': 1, '7383199-1': 1}

3985802-1

noncomm/PMC003xxxxxx/PMC3985802.xml

Acinic Cell Carcinoma of the Salivary Gland with Metastatic Spread to the Pancreas

In 2005, a 46-year-old woman presented with several years of progressive left jaw pain and swelling and ultimately developed partial left-sided facial paralysis. In August 2005, she underwent a left total parotidectomy with partial sacrifice of the left facial nerve. Histopathologic examination of the deep left parotid gland showed a thinly encapsulated low-grade salivary gland neoplasm. Tumor cells exhibited round to oval nuclei with inconspicuous nucleoli and basophilic granular cytoplasm that is characteristic of well-differentiated AcCC. Surgical margins were negative. In April 2008, the patient developed a local recurrence in the left neck, confirmed by fine needle aspiration. On May 29, 2008, she underwent surgical excision of the left neck mass with negative margins and one sampled lymph node negative for disease. No other treatment modalities were given. Two years later, the patient developed a second local recurrence, and in June 2010, a 5 × 3-mm mass consistent with recurrent AcCC was removed from the posterior triangle. In October 2010, a surveillance PET/CT scan revealed a 1-cm hypermetabolic nodule between the left styloid process and the tip of the mastoid. Fine-needle aspiration findings were consistent with a third local recurrence of AcCC. In January 2011, the patient had a left posterior neck exploration surgery with left neck dissection. Pathology revealed a single focus of recurrent disease in a lymph node measuring 2.6 cm. Surgical margins were negative but narrow at <0.1 cm. Three other lymph nodes sampled were negative for metastatic disease. The patient did not receive any adjuvant therapy and was placed on expectant observation.\nIn August 2011, the patient presented to our institution for a second opinion regarding management of a fourth local recurrence presenting as an enlarging, asymptomatic neck mass below the left mandible. On physical exam, a single 1-cm non-tender nodule was palpable just below the mandible, overlying the left sternocleidomastoid muscle. She had no other palpable masses or lymphadenopathy present. An MRI scan of the face and neck revealed a 1.3-cm mass in the previous operative bed in addition to a 1.4-cm enhancing mass at the skull base. CT of the chest, abdomen, and pelvis showed no evidence of distant metastatic disease. On August 29, 2011, the patient had a wide local excision of a locally recurrent AcCC measuring 1.5 × 1.3 × 1.1 cm (fig. ). Margins were negative. The second skull base mass seen on imaging was not amenable to surgical resection. The patient subsequently received concurrent chemoradiation therapy to the left neck from October through December 2011 with a total dose of 7,000 cGy in 35 fractions with weekly cisplatin. A surveillance PET/CT scan performed in March 2012 showed no evidence of disease.\nIn August 2012, the patient was admitted to a local hospital for epigastric pain, nausea, and vomiting, and was diagnosed with acute pancreatitis. An outside MRI scan of the abdomen revealed a mass in the head of the pancreas (fig. ). Esophagogastroduodenoscopy and an endoscopic ultrasound with biopsy of the mass were performed, and pathology revealed a well-differentiated neoplasm consistent with metastatic AcCC of salivary gland origin. A PET/CT scan showed minimal fluorodeoxyglucose avidity corresponding with the pancreatic mass but no other areas of active disease and no evidence of local recurrence in the head and neck. On September 21, 2012, the patient underwent a laparoscopic metastasectomy. Microscopic examination revealed a 3.0-cm lobulated neoplasm set within a bed of desmoplastic stroma of the pancreatic neck (fig. ). These tumor cells were morphologically compatible with the excised primary and recurrent tumors resected. Moreover, an immunohistochemical stain for trypsin (Meridian Life Science, Inc., Memphis, Tenn., USA) was negative, essentially ruling out the possibility of acinar cell carcinoma of the pancreas and confirming the diagnosis of metastatic AcCC to the pancreas. Perineural invasion was present. Surgical margins were negative. Multiple (24) regional lymph nodes were negative for metastatic disease. The patient recovered well and resumed routine surveillance. To date, she has had no evidence of disease progression.

[[46.0, 'year']]

F

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{}

3985805-1

noncomm/PMC003xxxxxx/PMC3985805.xml

Endocardial Invasion of Lung Cancer Undiagnosable before Autopsy

A 59-year-old male patient presented with left chest discomfort on admission. His blood pressure was 86/54 mm Hg, with a pulse rate of 107 beats per minute and a body temperature of 35.7°C. His medical history included encephalitis in childhood and his smoking history was 20 cigarettes per day for 40 years.\nA physical examination showed an anemic and edematous face with weak respiratory sounds in the left lung. The patient had elevated C-reactive protein, leukocytes, and calcium levels, and decreased hemoglobin and potassium. Cancer markers such as carcinogenic antigen, neuron-specific enolase, squamous cell carcinoma, and cytokeratin-19 fragment were all elevated. The calcium level was 12.6 mg/dl. His parathyroid hormone-related protein (PTHrP) level was elevated to 20.2 pmol/l (normal range: 0–1.1), and intact parathyroid hormone (PTH) was 2 pg/ml (normal range: 10–65).\nThoracic radiography showed cardiomegaly and computed tomography showed a left lung mass with invasion of the heart and pleural effusion (fig. ). Magnetic resonance imaging (MRI) revealed a large mass surrounding the heart (fig. ), and gallium-68 imaging showed positive accumulation in the region surrounding the heart (fig. ). No malignant diagnoses were possible upon frequent cytology of his sputum and pleural effusion. Bronchoscopy proved impossible due to the critical risk to life. The patient died from congestive heart failure with anoxia 38 days after admission. An autopsy revealed tumoral mass occlusion in the left main bronchus and tumoral invasion of the left atrium, left ventricle, and aorta.

[[59.0, 'year']]

M

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{}

3985806-1

noncomm/PMC003xxxxxx/PMC3985806.xml

Gastric Metastasis of Lung Cancer Mimicking an Adrenal Tumor

A 47-year-old man with a long-term heavy smoking history presented to the emergency room with an one-month history of progressive dyspnea on exertion, productive cough, marked weight loss, profuse diaphoresis at night, neck swelling and dysphagia in early October 2008. A chest film revealed a large soft tissue density in the right upper lobe of the lung and remarkable widening of the upper mediastinum. A subsequent chest computed tomography disclosed a large space-occupying lesion in the right upper lobe of the lung encasing the superior vena cava and the right pulmonary artery (fig. ). Bronchoscopic examination revealed a picture consistent with external compression in the right trachea where the mucosa presented irregularities, narrowing of the orifice of the right upper lobe with suspicious tumor tissue. The pathological report of the tissue biopsy proved it to be small cell carcinoma of the lung. The patient was hospitalized and received radiotherapy to relieve the superior vena cava syndrome, and prophylactic whole brain radiation was undertaken as well. He favorably tolerated six successive courses of chemotherapy with VP-16 and cisplatin later on and had regular follow-ups in the outpatient clinic with a quite satisfactory general performance and relatively good control of the primary lung lesion in the following 4 years.\nIn November 2011, a follow-up chest computed tomography disclosed a small, ill-defined tumor (1.8 × 1.4 cm) in the left adrenal area (fig. ). This lesion was initially interpreted as a non-functioning adrenal incidentaloma with no remarkable clinical relevance and was left for observation. However, the patient, who was free of symptoms, underwent a new chest computed tomography follow-up 6 months later (May 2012) and surprisingly a remarkable enlargement of the previously suspected left adrenal tumor was noted (3.3 × 2.5 cm) (fig. ). A distant metastasis from the lung cancer to the left adrenal gland was then considered and the patient was hospitalized again for surgical intervention by the urologists. Retroperitoneoscopy was initially performed to localize the suspicious metastatic left adrenal tumor. Unexpectedly, the surgeons found an intact left adrenal gland, and the tumor was actually arising from the posterior wall of the gastric body and penetrating into the retroperitoneal space close to the left kidney through a defect in the posterior peritoneum, mimicking an adrenal tumor. Laparotomy was immediately undertaken instead, and wedge resection of the tumor from the stomach was performed accordingly. The pathological analysis of the resected tumor revealed identical pictures as the primary lung lesion (immunohistochemical stain positive both for TTF-1 and CD-56) (fig. ).\nAfter the operation, the patient received further chemotherapy with etoposide and cisplatin and had a relatively good general performance in the meantime. In May 2013, exactly 1 year after the abdominal surgery, a follow-up computed tomography showed several metastatic tumors in the liver and additional chemotherapy with topotecan was instituted. Although the patient underwent an eventful clinical course with several episodes of pancytopenia, the chemotherapy could be finally completed and he currently still has regular follow-ups at the outpatient clinic 15 months after excision of the metastatic tumor in the stomach.

[[47.0, 'year']]

M

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{'4522427-1': 1}

3986008-1

noncomm/PMC003xxxxxx/PMC3986008.xml

Pancreatic Cancer Presenting as New-Onset Diabetes

A 53-year-old African American female with a medical history significant for stage IB, grade 1 endometrial adenocarcinoma status-post total abdominal hysterectomy and bilateral salpingoophorectomy 7 years ago presented to the Henry Ford Hospital Emergency Department upon instruction from her oncologist after her serum glucose was found to be severely elevated. She had no history of diabetes with fasting blood sugars <126 as recent as 6 months prior to presentation. She led a sedentary lifestyle and had a BMI of 31.8. She was experiencing polydipsia and polyuria for 3 weeks with associated blurry vision and distal extremity paresthesias. Six months prior to presentation, she began experiencing persistent, non-exertional, left-sided chest wall pain. Her pain was managed as an outpatient for several months as costochondritis without resolution. She was a former smoker with a 15 pack-year smoking history. Her family history was significant for type 2 diabetes and hypertension, but she denied a family history of any cancers.\nLaboratory findings on admission were significant for serum blood glucose 608 mg/dl, white blood cell count 11.9 K/μl, bicarbonate 27 mmol/l, anion gap 10, and beta hydroxybutyrate 0.13 mmol/l. Serum glycated hemoglobin was 12.7%. Further laboratory studies were significant for an elevated CA 19-9 (349.9 U/ml), normal CA-125 (15 U/ml), and normal C-peptide (1.4 ng/ml). A bone scan for the persistent left-sided chest pain performed shortly after admission was concerning for increased uptake in the left scapula and L5 vertebral body. The patient subsequently underwent a CT scan of the chest, abdomen, and pelvis with IV contrast that showed a 3.6 × 2.5 cm mass extending from the body into the tail of the pancreas and a single 1-cm low attenuation lesion in the liver with minimally enlarged hepatic and portacaval lymph nodes. A biopsy of the hepatic lesion was performed and was suggestive of metastatic pancreatic adenocarcinoma (fig. ). Pathology showed neoplastic glands surrounded by prominent desmoplastic stroma and lined by cuboidal epithelium with marked nuclear pleomorphism, loss of polarity, and frequent apoptotic bodies. The tumor cells stained positive for cytokeratin 7 and 19 and stained negative for estrogen receptor and cytokeratin 20.\nThese findings, along with the newly discovered pancreatic mass, were consistent with stage IV adenocarcinoma of pancreatobiliary origin. After extensive discussion with the patient and her family, she decided to proceed with the FOLFIRINOX chemotherapy regimen for palliative purposes. Her diabetes was treated with a regimen of Lantus 50 units once daily and with Aspart 15 units before meals. She has completed four cycles of chemotherapy and has been experiencing elevated blood sugars despite compliance with her insulin regimen.

[[53.0, 'year']]

F

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{'6558877-1': 1}

3986296-1

noncomm/PMC003xxxxxx/PMC3986296.xml

Incidence rate and occurrence of visually significant cataract formation and corneal decompensation after implantation of Verisyse/Artisan phakic intraocular lens

A 45-year-old woman presented to the Moran Eye Center in 1999, interested in refractive surgery for severe myopia. She had a spherical equivalent (SE) of −6.875 in the right eye and −11.875 in the left eye. At the time of presentation, the Verisyse pIOL was being evaluated by an FDA Phase III clinical trial, and the patient received a pIOL in the left eye through this study. Postoperative CDVA was 20/20 with an SE of −1.75. The patient elected for laser-assisted in situ keratomileusis (LASIK) in the right eye approximately a year later. She subsequently developed a visually significant posterior subcapsular cataract (PSC) in the right eye 5 years after LASIK, and underwent cataract extraction and intraocular lens implantation. Ten years after left pIOL implantation, the patient began to develop a nuclear sclerotic cataract (NSC) in the left eye. Three years later (13 years postimplantation), the left CDVA had decreased to 20/50+2, and it was decided that cataract surgery was necessary. The pIOL was removed, and phacoemulsification with posterior chamber intraocular lens (PCIOL) placement was performed on the left eye. At the most recent follow-up 5 months after removal of the pIOL, CDVA in the left eye was 20/20 and SE was plano.

[[45.0, 'year']]

F

{'27461520': 1, '31211003': 1, '17900695': 1, '33229653': 1, '17516271': 1, '11063268': 1, '16412940': 1, '23664355': 1, '30363928': 1, '19304104': 1, '17686520': 1, '12454028': 1, '18031820': 1, '23036355': 1, '17662430': 1, '18299082': 1, '31659458': 1, '19890209': 1, '17980432': 1, '20362865': 1, '11020614': 1, '18040915': 1, '17662447': 1, '34655334': 1, '24748765': 2}

{'3986296-2': 2, '3986296-3': 2, '3986296-4': 2, '3986296-5': 2, '3986296-6': 2}

3986296-2

noncomm/PMC003xxxxxx/PMC3986296.xml

Incidence rate and occurrence of visually significant cataract formation and corneal decompensation after implantation of Verisyse/Artisan phakic intraocular lens

A 35-year-old man with a history of right retinal detachment, repaired with scleral buckle 20 years ago, presented to the Moran Eye Center in 2000 desiring correction for severe myopia. A Verisyse pIOL was implanted in the left eye as part of the Verisyse FDA clinical trial. Preoperative endothelial cell density in the left eye was 2,146 cells/mm2. Three years later, a Verisyse pIOL was implanted in the right eye for myopia, with preoperative right SE of −15.125 and preoperative endothelial cell density of 2,053 cells/mm2. Postoperative right uncorrected distance visual acuity (UDVA) was 20/20. Ten years later, the patient developed cloudy vision in the right eye with CDVA of 20/30−. Slit-lamp examination identified corneal edema in the right eye. Right endothelial cell density was 1,364 cells/mm2. The patient was medically managed with prednisolone acetate 1% eyedrops, Muro® 128 5% eyedrops (Bausch and Lomb, Rochester, NY, USA) and ointment for 6 months, with improvement of vision. However, after 2 years, the patient’s vision worsened to counting fingers, correctable only to 20/100. Slit-lamp examination identified increasing corneal edema () and early nuclear sclerosis. The patient underwent explantation of the pIOL, cataract extraction with placement of PCIOL, and Descemet’s stripping automated endothelial keratoplasty (DSAEK). At the most recent examination, 4 weeks after surgery, the cornea was clear centrally, in the area of the DSAEK graft, with remaining peripheral corneal edema. The right eye CDVA was 20/25, and SE was +1.125.

[[35.0, 'year']]

M

{'27461520': 1, '31211003': 1, '17900695': 1, '33229653': 1, '17516271': 1, '11063268': 1, '16412940': 1, '23664355': 1, '30363928': 1, '19304104': 1, '17686520': 1, '12454028': 1, '18031820': 1, '23036355': 1, '17662430': 1, '18299082': 1, '31659458': 1, '19890209': 1, '17980432': 1, '20362865': 1, '11020614': 1, '18040915': 1, '17662447': 1, '34655334': 1, '24748765': 2}

{'3986296-1': 2, '3986296-3': 2, '3986296-4': 2, '3986296-5': 2, '3986296-6': 2}

3986296-3

noncomm/PMC003xxxxxx/PMC3986296.xml

Incidence rate and occurrence of visually significant cataract formation and corneal decompensation after implantation of Verisyse/Artisan phakic intraocular lens

A 45-year-old woman presented to the Moran Eye Center in 2002 for correction of high myopia, with SE of −11.75 in the right eye and −7.75 in the left eye. Verisyse pIOLs were implanted in both eyes, 4 months apart, in the FDA Verisyse clinical trial. Postoperative CDVA was 20/20 in the right eye and 20/25+2 in the left. Ten years later, on routine follow-up, the patient reported decreased vision in the right eye, with a CDVA of 20/60. Slit-lamp examination identified nuclear sclerosis in the right eye. The patient subsequently underwent pIOL explantation and cataract extraction, with PCIOL placement in the right eye. At the last examination, 1 year after pIOL removal, CDVA was 20/20+, and SE was −0.75 in the right eye. The patient has reported no problems post-pIOL in the left eye.

[[45.0, 'year']]

F

{'27461520': 1, '31211003': 1, '17900695': 1, '33229653': 1, '17516271': 1, '11063268': 1, '16412940': 1, '23664355': 1, '30363928': 1, '19304104': 1, '17686520': 1, '12454028': 1, '18031820': 1, '23036355': 1, '17662430': 1, '18299082': 1, '31659458': 1, '19890209': 1, '17980432': 1, '20362865': 1, '11020614': 1, '18040915': 1, '17662447': 1, '34655334': 1, '24748765': 2}

{'3986296-1': 2, '3986296-2': 2, '3986296-4': 2, '3986296-5': 2, '3986296-6': 2}

3986296-4

noncomm/PMC003xxxxxx/PMC3986296.xml

Incidence rate and occurrence of visually significant cataract formation and corneal decompensation after implantation of Verisyse/Artisan phakic intraocular lens

A 53-year-old woman was referred in 2003 for correction of high myopia, with SE of −15.75 and −14.375 in the right and left eyes, respectively. The patient underwent uncomplicated pIOL implantation in both eyes, 9 months apart, as part of the Verisyse FDA clinical trial. At 2-year follow-up, the CDVA was 20/20 with SE of 0.125 in the right eye, and 20/20−2 with SE of 0.625 in the left eye. Seven years after implantation of the right pIOL, the patient was found on annual exam to have developed trace nuclear sclerosis in the right eye. Two years later, right CDVA was 20/50−2 and left CDVA was 20/25−2. Slit-lamp examination identified 2+ nuclear sclerosis and PSC in the right eye, and a 1−2+ NSC in the left eye. There were no known comorbidities in this patient. The patient subsequently underwent right pIOL explantation and cataract extraction, with PCIOL placement. At the most recent follow-up, 2 weeks after surgery, the patient’s CDVA was 20/20 in the right eye, and SE was −0.75.

[[53.0, 'year']]

F

{'27461520': 1, '31211003': 1, '17900695': 1, '33229653': 1, '17516271': 1, '11063268': 1, '16412940': 1, '23664355': 1, '30363928': 1, '19304104': 1, '17686520': 1, '12454028': 1, '18031820': 1, '23036355': 1, '17662430': 1, '18299082': 1, '31659458': 1, '19890209': 1, '17980432': 1, '20362865': 1, '11020614': 1, '18040915': 1, '17662447': 1, '34655334': 1, '24748765': 2}

{'3986296-1': 2, '3986296-2': 2, '3986296-3': 2, '3986296-5': 2, '3986296-6': 2}

3986296-5

noncomm/PMC003xxxxxx/PMC3986296.xml

Incidence rate and occurrence of visually significant cataract formation and corneal decompensation after implantation of Verisyse/Artisan phakic intraocular lens

A 23-year-old man with microspherophakia presented in 2006 for correction of high myopia, with SE of −14.375 and −14.25 in the right and left eye, respectively. Preoperative anterior chamber depth (ACD), measured from the epithelium, was 2.87 mm in the right eye and 2.80 mm in the left eye. Preoperative mean endothelial cell density was 3,077 cells/mm2 in the right eye and 2,825 cells/mm2 in the left eye. The patient subsequently underwent pIOL implantation, in the right and left eyes, 2 months apart. At 4-year follow-up, UDVA was 20/25 in both eyes. ACD was 2.46 mm in the right eye and 2.30 mm in the left eye. Mean endothelial cell density was 2,890 cells/mm2 in the right eye and 2,785 cells/mm2 in the left eye.\nIn 2012, on routine follow-up, the patient reported worsening visual acuity in the right eye, associated with irritation and dryness. The patient admitted to rubbing the right eye secondary to localized irritation. UDVA in the right eye was 20/100, correctable to 20/80. Slit-lamp examination showed localized peripheral edema and bullous changes in the superonasal region of the cornea. The nasal enclavation site appeared closer to the corneal endothelium and less securely attached than the temporal site. The patient was treated with prednisolone acetate 1%, Muro 128 5% and Combigan® eyedrops (Allergan, Inc., Irvine, CA, USA) in the right eye for elevated IOP – 24 mmHg. The left eye did not require these treatments. Two weeks later, the corneal edema had only slightly improved, and it was decided to remove the right pIOL. At the most recent follow-up, 10 weeks post-pIOL removal, CDVA was 20/80, with SE of −12.50. The corneal edema was significantly improved. The lower-than-expected visual acuity was attributed to a combination of residual corneal edema, irregular astigmatism, and a secondary glaucoma associated with microspherophakia. The patient has been referred for further glaucoma workup and a fitting of rigid gas-permeable contact lens to see if this will improve his vision.

[[23.0, 'year']]

M

{'27461520': 1, '31211003': 1, '17900695': 1, '33229653': 1, '17516271': 1, '11063268': 1, '16412940': 1, '23664355': 1, '30363928': 1, '19304104': 1, '17686520': 1, '12454028': 1, '18031820': 1, '23036355': 1, '17662430': 1, '18299082': 1, '31659458': 1, '19890209': 1, '17980432': 1, '20362865': 1, '11020614': 1, '18040915': 1, '17662447': 1, '34655334': 1, '24748765': 2}

{'3986296-1': 2, '3986296-2': 2, '3986296-3': 2, '3986296-4': 2, '3986296-6': 2}

3986296-6

noncomm/PMC003xxxxxx/PMC3986296.xml

Incidence rate and occurrence of visually significant cataract formation and corneal decompensation after implantation of Verisyse/Artisan phakic intraocular lens

A 51-year-old woman presented in 2008 for correction of high myopia, with SE of −7.125 in the right eye and −8.5 in the left. The patient underwent pIOL implantation in both eyes, 1 month apart. Postoperative CDVA at 2 months was 20/20−2 with SE of −0.125 in the right eye, and 20/25−2 with SE of −0.25 in the left eye. A year later, on routine follow-up, trace nuclear sclerosis and PSCs were identified in both eyes, worse in the right than the left. The patient was followed at 6-month intervals for 2 years, until it was decided to remove the cataract in the right eye. Preoperative right CDVA was 20/30−. The patient underwent uncomplicated pIOL removal and phacoemulsification with PCIOL insertion. Postoperative right CDVA at 6 weeks was 20/20, with SE of −0.75.

[[51.0, 'year']]

F

{'27461520': 1, '31211003': 1, '17900695': 1, '33229653': 1, '17516271': 1, '11063268': 1, '16412940': 1, '23664355': 1, '30363928': 1, '19304104': 1, '17686520': 1, '12454028': 1, '18031820': 1, '23036355': 1, '17662430': 1, '18299082': 1, '31659458': 1, '19890209': 1, '17980432': 1, '20362865': 1, '11020614': 1, '18040915': 1, '17662447': 1, '34655334': 1, '24748765': 2}

{'3986296-1': 2, '3986296-2': 2, '3986296-3': 2, '3986296-4': 2, '3986296-5': 2}

3986415-1

noncomm/PMC003xxxxxx/PMC3986415.xml

Dopamine transporter changes after unilateral deep brain stimulation in progressive Parkinson’s disease: a case report

A 56-year-old right-handed female PD patient with no family history of PD developed early symptoms of rigidity and mild tremor on the right side in 1995. She accepted left pallidotomy in 1999. After the surgery, pharmacological therapy was started using sustained-release carbidopa-levodopa, adamantanamine, and benzhexol hydrochloride to control her symptoms. By February 2011, her medication was proving ineffective, so the surgeons accepted her as a candidate for DBS to the subthalamic nucleus. In 2011, the motor symptoms in her left limbs were more severe than in the right limb. Her Unified Parkinson’s Disease Rating Scale (UPDRS) score was 19 in the left limb and 11 in the right. After considering the financial circumstances of her family, the surgeons chose to treat the right subthalamic nucleus.\nIn February 2011, 11C-CFT PET was performed after 12 hours off medication to observe dopamine transporter distribution. On the following day, the patient underwent unilateral DBS surgery to the right subthalamic nucleus. In January 2012, a follow-up 11C-CFT PET scan was performed in the “electrodes on” state after 12 hours off medication to assess the longitudinal effect of DBS on the subthalamic nucleus. The patient’s UPDRS and Hoehn and Yahr scores were assessed by the same neurologist on each occasion. The protocol used was approved by the ethics committee at Huashan Hospital, Fudan University, Shanghai, and all examinations were performed with the patient’s informed consent.

[[56.0, 'year']]

F

{'16107354': 1, '19662326': 1, '18446306': 1, '18563467': 1, '17096096': 1, '20089913': 1, '11739831': 1, '24748796': 2}

{}

3986535-1

noncomm/PMC003xxxxxx/PMC3986535.xml

Pleural fluid metastases of salivary duct carcinoma: A case report and review of the literature

The present case report is about a 76-year-old male patient, with a 9-year history of SDC metastatic to the right testicle and brain, who presented at our institution for cryoablation of suspicious lung nodules and subsequently had a recurrent left pleural effusion. He was originally diagnosed at age 67 with a 1.5 cm right submandibular SDC, which showed large polygonal epithelioid cells with prominent nucleoli and abundant granular eosinophilic cytoplasm, arranged in a cribriform pattern with central necrosis []. Perineural and lymphovascular invasion were noted. Immunohistochemical stains showed positivity for human epidermal growth factor receptor-2/neu (HER2/neu) and gross cystic disease fluid protein-15 (GCDFP-15) and negativity for estrogen receptor (ER) and progesterone receptor (PR). The patient was treated with local radiation and chemotherapy. At 4 years later, pulmonary micronodules were noted on positron emission tomography and computed tomography (CT) scan, as well as a recurrence in his right testis. He underwent orchiectomy and received additional chemotherapy. The following year, a right occipital lobe metastasis was irradiated and resected. Serial radiographic imaging showed slow progressive growth of the pulmonary nodules.\nAt the time of current admission, the patient was receiving radiation therapy, but not systemic therapy. The most recent chest CT angiogram showed bilateral pulmonary metastases up to 5.4 cm, pleural implants and a nodular rind of metastatic disease along the left mediastinal reflection. Following cryoablation of the three largest nodules, ultrasound-guided thoracentesis of a left pleural effusion yielded 350 cc of bloody, opaque fluid. Cytological evaluation of cytospin preparations and cell block revealed large, pleomorphic epithelioid cells in small clusters with subtle cribriform features []. The cells displayed large oval nuclei with prominent nucleoli and coarsely granular chromatin. A moderate amount of finely granular apocrine-type cytoplasm was present.\nImmunohistochemical stains [] performed on the cell block were positive for androgen receptor (AR) (panel A), HER2/neu (panel B), Moc31 (panel C) and GCDFP-15 (panel D). These cells were also positive for BerEp4 and were negative for ER and PR. The malignant cells were not present on deeper cuts for evaluation of mammaglobin and B72.3. The morphologic and immunohistochemical profile was similar to the original submandibular pathology and a diagnosis of metastatic SDC was rendered.

[[76.0, 'year']]

M

{'23209336': 1, '23606370': 1, '3469856': 1, '21591276': 1, '9135856': 1, '19582818': 1, '18634961': 1, '15900577': 1, '18414887': 1, '21393874': 1, '17966226': 1, '16783770': 1, '22647549': 1, '10757407': 1, '19886710': 1, '4301301': 1, '16355374': 1, '18412796': 1, '18380570': 1, '25071860': 1, '30655980': 1, '24738005': 2}

{}

3987196-1

noncomm/PMC003xxxxxx/PMC3987196.xml

Docetaxel-induced palmoplantar erythrodysesthesia syndrome and long-lasting multiple nail changes

A 52-year-old female patient had undergone left radical mastectomy with axillary lymph node dissection for invasive ductal breast carcinoma. She had completed the third cycle of docetaxel chemotherapy (CT) with the dose of 100 mg/m2 and a cumulative dose of 480 mg. One week after the cycle, she presented to the out-patient department with palmoplantar redness, pain, tingling and burning sensation which had started 3 weeks back. In her medical history, the patient was on insulin and atorvastatin for diabetes mellitus and hyperlipidemia.\nExamination of the patient revealed palmoplantar erythema, tenderness, desquamation and onycholysis of the second fingernail of the right hand [Figure and ]. The patient had noticed onycholysis after the first cycle; palmoplantar erythema had emerged 1 week after the second cycle of docetaxel CT. Examination of the feet for fungal infection was negative. The laboratory examinations including complete blood count, liver and kidney functions tests were within normal limits except higher total cholesterol and low density lipoprotein levels (270 mg/dl and 199 mg/dl, respectively). Whole-body bone scintigraphy, abdominal ultrasonography and electromyography were normal.\nThe clinical findings of the patient were compatible with a diagnosis of palmoplantar erythrodysesthesia (PPES) and nail toxicity due to docetaxel CT. The severity of PPES was grade 2 according to the National Cancer Institute Common Toxicity Criteria (NCI-CTC). Potent topical steroids, oral pyridoxine (250 mg/day), elevation of extremities during infusion and cold pack application were recommended. PPES regressed completely after 1 week and the patient tolerated the next CT infusions more comfortably. However, the dysesthesia symptoms did not lessen. After completion of CT treatment, the patient was put on radiotherapy of the operated region for 25 days. During the follow ups, the nail changes began to worsen 2 months after docetaxel CT. All fingernails of hands and feet had onycholysis; some of them had subungal hyperkeratosis, nail pain, brown discoloration and four consecutive Beau's lines []. Examination for fungal infection was negative. According to NCI scale, nail changes were compatible with grade 2 nail toxicity. About 6 months after CT, all fingernails of both hands completely recovered while toe nails had still minimal distal subungal hyperkeratosis and brown-yellow discoloration. The severity of dysesthesia symptoms regressed by more than 50%. The relationship between docetaxel and PPES and nail changes was considered ‘certain/definite’ using the WHO-UMC scale[] and Naranjo's algorithm.[]

[[52.0, 'year']]

F

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{'2875744-1': 1}

3987197-1

noncomm/PMC003xxxxxx/PMC3987197.xml

Lorazepam-induced diplopia

The present case is about a 21-year-old male patient who was admitted to the psychiatry unit of a tertiary care teaching hospital in South India. He had no history of similar condition or any significant past medical or family history. Patient presented with the complaints of persistent pre-occupation with sexual and contamination thoughts, insomnia, increased fearfulness, memory impairment and anxiety and repeated hand washing. Based on the symptoms a provisional diagnosis of depression with obsessive compulsive disorder (OCD) was made and subsequently patient was diagnosed as suffering from OCD. Patient was prescribed lorazepam 4 mg intravenous (IV) stat and later as required for the severe anxiety symptoms. Tablet clomipramine 25 mg at night and tablet sertraline 50 mg were prescribed in the morning to treat OCD. The patient received lorazepam 4 mg IV and clomipramine 25 mg at 9 pm on day 1 and woke up next morning at 6 am complaining of giddiness, diplopia and unstable gait. Patient was receiving no other medication, including over the counter medications. He had never experienced similar complaints before. As diplopia was a new symptom the mental health team requested for a neurological and ophthalmic consultation to determine the possible underlying causes. However, diplopia resolved at 12 h of onset. Ophthalmologic and neurologic observations were insignificant. Meanwhile based on literature search and detailed review of the patient's medical history, lorazepam was suspected to be the causal agent for this adverse reaction and discontinued. However, patient continued to receive clomipramine and sertraline during the remaining 4 days of his hospital stay without reoccurrence of diplopia or any other visual problems.\nA causal association between diplopia and lorazepam was assessed by World Health Organization probability scale and Naranjo's algorithm it showed “probable” association between the adverse reaction and lorazepam.

[[21.0, 'year']]

M

{'22193881': 1, '11388882': 1, '15765832': 1, '10701660': 1, '20443647': 1, '24644459': 2, '19643481': 1, '24741200': 2}

{'3939961-1': 1}

3987198-1

noncomm/PMC003xxxxxx/PMC3987198.xml

Delayed onset renal failure in a patient on tenofovir based antiretroviral regimen

The present case report is about a 56-year-old woman was diagnosed to have HIV 1 infection with pulmonary tuberculosis in 2002. Viral load was 127,717 copies/ml with a CD4 cell count of 221 cells/μl. She was started on zidovudine, lamivudine and efavirenz. As she developed zidovudine induced anemia, the drug was replaced with stavudine in 2003. The patient was on regular follow-up since then. During the follow-up, the viral load decreased to less than 20 copies/ml and CD4 cell count improved to 606 cells/μl. However after 5 years of first line ART, viral loads increased to 15548 copies/ml and CD4 count dropped to 286/μl. She was started on ritonavir, lopinavir along with tenofovir and emtricitabine. Subsequently, she wasdiagnosed to have hypertension, type 2 diabetes mellitus and hypothyroidism which were under control with treatment. She was on regular follow-up every 6 months. Complete blood counts, renal function tests were monitored and were found to be normal.\nIn December 2012 that is 6 years after second line antiretroviral therapy (ART) was initiated, she presented with nausea and loss of appetite and a serum creatinine of 4.2 mg/dl. Examination was normal except for obesity, pallor and buffalo hump. Fundus examination did not show evidence of diabetic retinopathy. Investigations showed hemoglobin 9 g/dl, HIV viral load <20 copies/ml and CD4 cell count was 814 cells/μl. Ultrasound abdomen showed grade 1 renal parenchymal changes. Urine culture and blood culture were sterile. ‘M’ spike was absent on serum protein electrophoresis and 24 h urinary protein was 500 mg/day.\nRenal biopsy [] showed normal glomeruli with changes of interstitium showing diffuse infiltrates of lymphocytes and few eosinophils and neutrophils on light microscopy. Many tubules showed simplification of their lining indicating acute injury and a few mildly dilated tubules showed hyaline casts and a few tubules showed leucocyte casts. All these features were suggestive of acute tubulointerstitial nephritis, probably induced by tenofovir.\nTenofovir was stopped and raltegravir was started along with lamivudine, ritonavir and lopinavir. After 1 month of stopping tenofovir serum creatinine improved to 1.4 mg/dl and patient was better thereafter.

[[56.0, 'year']]

F

{'21716719': 1, '21808434': 1, '20811330': 1, '28904656': 2, '20338962': 1, '2770114': 1, '24741201': 2}

{'5567942-1': 1}

3987199-1

noncomm/PMC003xxxxxx/PMC3987199.xml

Acute generalized exanthematous pustulosis induced by piroxicam: A case report

This was a case report of a 61-year-old female patient who was admitted to internal medicine department for renal colic. She had no history of psoriasis or any other skin disorder. The patient had a history of longstanding arterial hypertension for 3 years treated with captopril, indapamide, nifedipine and diabetes mellitus for 3 years treated with glibenclamide, glimepiride and dyslipidemia treated with simvastatin. She was given oral piroxicam 20 mg/day by her primary care physician for treatment of renal colic. There were no other medications prior to starting piroxicam. At 4 days after starting oral piroxicam, she developed a generalized itchy eruption consisting of multiple papules that sometimes coalesced to larger and scaly plaques, on a background of widespread erythema with associated multiple 2-3 mm pustules []. The mucus membranes, palms and soles were spared. Nikolsky's sign was negative. The remaining physical examination was normal. Her white blood cell count was 10.8 × 103/mm3, with a 6.42 × 103/mm3 neutrophil count. The remaining laboratory tests performed were within the normal range: creatinine 61.1 μmol/l, erythrocyte rate sedimentation at 30 mm/h, C-reactive protein 19.48 mg/l and her liver function tests were: Aspartate transaminase 38 U/ml, bilirubin 9 μmol/l and alkaline phosphatase 88 U/ml. A skin biopsy specimen revealed well-developed subcorneal pustules associated with epidermal spongiosis. Scattered neutrophils as well as eosinophils were noted within the dermis (According to the EuroSCAR score, the most of criteria have been met by our patient who had a score of 9). Within a week of piroxicam withdrawal, the patient's lesions gradually began clearing. The patient remained on the same therapies for her arterial hypertension, diabetes mellitus and dyslipidemia.

[[61.0, 'year']]

F

{'30057773': 2, '1832534': 1, '19620579': 1, '22812902': 1, '22111682': 1, '32695700': 1, '20542841': 1, '18783858': 1, '16908368': 1, '11168761': 1, '22257115': 1, '18805845': 1, '18709306': 1, '16919427': 1, '8891829': 1, '21690532': 1, '24741202': 2}

{'6058425-1': 1}

3987200-1

noncomm/PMC003xxxxxx/PMC3987200.xml

Anaphylaxis following intravenous ranitidine: A rare adverse reaction of a common drug

This is case report of a 60-year-old male patient who was brought to the emergency department in drowsy state with skin eruptions over the chest and abdomen. Prior to the present episode the patient had severe epigastric discomfort for which the doctor gave him injection ranitidine 50 mg (Peptac 50 mg/2 ml, containing phenol 0.5% as preservative). Within minutes of the injection, the patient developed above symptoms. There was no history of intake of any other medication. He had no other medical illness. The patient gave positive history of allergy to amoxicillin.\nOn examination, he was found to be drowsy and had edema of the face. Pulse rate was 100 beats/min, blood pressure - 80/40 mmHg, temperature - 36.8°C, respiratory rate - 26/min and oxygen saturation of 83% by pulse oximetry. Wheals were present all over the chest and abdomen suggestive of urticaria. Cardiac and respiratory system examination was unremarkable.\nInvestigations: Hemoglobin: 16.7 g %, total leukocyte count: 11,500, neutrophils - 80%, lymphocytes 14%, monocytes 2%, eosinophil's 4%, random blood sugar: 102 mg/dl, urea: 30 mg/dl, creatinine: 1.5 mg/dl, serum sodium: 141 mEq/l, serum potassium: 3.9 mEq/l, serum chloride: 102 mmol/l, electrocardiogram was suggestive of right bundle branch block with left axis deviation.\nBased on history and findings, the patient was diagnosed as a case of anaphylaxis subsequent to injection ranitidine. He was administered intravenous adrenaline 0.5 mg, hydrocortisone 100 mg and pheniramine 25 mg. He did not require ventilatory support and responded to the treatment. His vitals improved gradually and he was discharged after 3 days. Subsequent test revealed a raised immunoglobulin E (IgE) levels (1658 IU/ml).\nIntradermal test with ranitidine in dilution of 1:1000 was found to be negative. However, patient did not give consent for further testing due to obvious reasons.\nA lucid temporal relationship was observed between the administration of the drug (ranitidine) and the commencement of symptoms. Using Naranjo probability scale the relationship between the drug and the event was categorized as probable.[]

[[60.0, 'year']]

M

{'23441444': 1, '27127327': 2, '14570656': 1, '23633878': 2, '16784015': 1, '29692451': 1, '22059646': 1, '16689191': 1, '22013272': 1, '16409209': 1, '7249508': 1, '18637187': 2, '24741203': 2}

{'4825445-1': 1, '3633294-1': 1, '2488348-1': 1}

3987245-1

noncomm/PMC003xxxxxx/PMC3987245.xml

Myositis in a Child with Murine Typhus

A previously healthy 12-year-old boy was admitted to Driscoll Children’s Hospital in Corpus Christi, TX, USA, with a 9 day history of fever, and 7 day history of pain and weakness in the lower extremities. Three days prior to admission, he was seen by a nurse practitioner and diagnosed with otitis media and pharyngitis. He received intramuscular penicillin and was prescribed cefixime for 3 days without improvement. He progressed and he became unable to walk without assistance. He had no gastrointestinal, respiratory or genitourinary complaints. On admission, his temperature was 36.8°C and the physical examination was significant for antalgic, broad-based gait and tender gastrocnemius – soleus muscles. Biceps, quadriceps and psoas muscle strength was graded at 3/5. Sensation and deep tendon reflexes were normal with absent Romberg’s and Babinski’s sign. The white blood cell count was 8300 cells per cubic mm with 60% neutrophils and 40% lymphocytes, hemoglobin was 13.5 g/dL, and the platelet count was 172,000 cells per cubic mm. His CRP was 1.5 mg/dL. The ESR and urine analysis were normal. Creatinine phosphokinase (CPK) was elevated at 2394 μ/L, aspartate aminotransferase (AST) was 222 μ/L and, alanine aminotransferase (ALT) was 143 μ/L.\nA diagnosis of myositis was made and the patient was given analgesics and oral prednisone as dermatomyositis and polymyositis were amongst the differential diagnosis. Rhabdomyolysis was considered in the differential diagnosis and the patient was started on one and a half maintenance intravenous fluids. He did not have dark urine or hyperkalemia or myoglobinuria or renal failure. Our patient’s clinical course was not severe and did not develop the complications usually associated with rhabdomyolysis. On day 2 of his hospital stay, he was able to stand up with support and CPK levels came down to 1713 U/L. Cerebrospinal fluid analysis showed a protein concentration of 62 mg/dL and white blood cell count of 4. Electromyography and nerve conduction studies did not show evidence of Guillain Barre Syndrome. A multiplex respiratory viral PCR was positive for rhinovirus and negative for Influenza A and B, parainfluenza, metapneumovirus and adenovirus. Lyme disease serology and monospot for Epstein Barr Virus were reported negative. Arboviral titers for West Nile virus was negative and so was the Rocky Mountain spotted fever titers. On the day 3 of his hospitalization, his upper extremity strength significantly improved to 5/5 and lower extremity to 4/5. Hence he was able to sit up and walk down the hallway without support. Rickettsia typhi IgM was elevated at 512 and IgG at 1024. Serum was evaluated by use of an indirect immunofluorescence antibody (IFA) test kit for immunoglobulin G (IgG) to Rickettsia typhi and Rickettsia rickettsii (Focus Diagnostics, Cypress, CA, USA). Reciprocal titers >64 were considered positive. CPK, ALT and AST levels were noted to have a downward trend. Blood and cerebrospinal fluid cultures showed no growth. The complete recovery of the patient took about 48 hours which included 100 mg of doxycycline given twice daily by mouth. He was discharged home on doxycycline to complete a 10 day course and prednisone was discontinued.

[[12.0, 'year']]

M

{'20202415': 1, '10877169': 1, '11247722': 1, '1250660': 1, '17553239': 1, '2742443': 1, '18381500': 1, '24757508': 2}

{}

3987246-1

noncomm/PMC003xxxxxx/PMC3987246.xml

Renal Hemorrhagic Actinomycotic Abscess in Pregnancy

A 20-year-old Puerto Rican woman, G2P0101, was referred to us at 24 weeks gestation for evaluation of an 11 cm right upper quadrant mass and anemia. She reported a history of cholelithiasis, childhood seizure disorder, left upper extremity embolectomy and a laparoscopic appendectomy in prior pregnancy at six weeks gestation, although operative and imaging records were unavailable. Her previous delivery was a Cesarean section. She had no history of poor dentition or intrauterine device (IUD) use. One month before admission to our hospital, she reported fatigue, 25 pound weight loss over six months, and severe right-sided pain. At another hospital, she underwent right upper quadrant and renal ultrasound revealing stones and sludge in the gallbladder. Ultrasound noted an 8×9×11 cm hemorrhagic mass in the right renal subcapsular area extending to the right diaphragm. At this time, differential diagnosis included angiomyolipoma with hemorrhagic rupture, renal carcinoma, lymphoma, metanephric adenoma and renal/pelvic tuberculosis. Chest radiograph was within normal limits. Her hemoglobin was initially 7 g/dL and increased to 12 g/dL after 2 units packed red blood cells. Creatinine was 0.6 mg/dL. Tuberculin skin test was negative. Urology and medical oncology consultations were obtained. She was managed with nil per os (NPO) status, analgesics, and additional two units of packed red blood cells after her hemoglobin decreased to 8.8 g/dL over four days.\nA non-contrast magnetic resonance imaging (MRI) of the abdomen and pelvis was obtained to further characterize the mass and to identify any possible renal vasculature anomalies. MRI showed an 11.2×7.7 cm right renal mass (). She developed preterm contractions and received nifedipine and a betamethasone course for fetal lung maturity. Her cervical exam remained unchanged. An ultrasound-guided right kidney biopsy of medulla and cortex revealed mild to moderate patchy interstitial inflammation with no evidence of malignancy. Immunochemical staining for kappa and lambda light chain and periodic acid Schiff staining demonstrated lymphoplasmacytic infiltrate, indicating acute interstitial nephritis, however renal function was normal. Differential diagnosis based on pathological studies included angiomyolipoma and interstitial inflammation secondary to unbiopsied renal mass with less likely possibility of renal carcinoma, lymphoma and metanephric adenoma. Given the inconclusive biopsy with no indication of malignancy, stable hemodynamic status and advanced gestation, the multi-disciplinary team recommended expectant management with close monitoring for mass size change and hemodynamic status. On hospital day 19, patient was discharged home. Interval MRIs showed stable size of the mass throughout her pregnancy. At 35 weeks gestation, the patient was admitted for preterm labor. She underwent a vacuum assisted vaginal delivery of a 2595-gram male infant. Placenta pathology showed mature third trimester placenta without evidence of inflammation or infection. The presumptive diagnosis of the mass was angiomyolipoma with hematoma as there are many reports of ruptured angiomyolipoma with hemorrhage in the obstetric literature; the plan was to repeat the MRI study six weeks post-partum.\nTwelve days after delivery, the patient returned with fever, right flank pain and leukocytosis of 19.7 K/UL. She was taken to the operating room where she underwent a right renal exploration, resection of retroperitoneal mass and partial nephrectomy. The pathology report revealed xanthogranulomatous pyelonephritis with occasional clusters of actinomyces infection (). Her operation was complicated by an unsuspected duodenal injury necessitating exploratory laparotomy and repair two days later. Pathology from resection of duodenal mass showed abscess, granulation tissue and xanthogranulomatous inflammation without evidence of actinomycotic infection. Multiple pelvic fluid collections were treated with percutaneous drains inserted by interventional radiology. She was started on piperacillin/ tazobactam then switched to amoxicillin/clavulanate for six months. Subsequent computerized tomography (CT) imaging showed complete resolution of mass.

[[20.0, 'year']]

F

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{'3163399-1': 1, '6919534-1': 1, '2576180-1': 1}

3987247-1

noncomm/PMC003xxxxxx/PMC3987247.xml

A Complicated Case of an Immunocompetent Patient with Disseminated Nocardiosis

Forty-two year-old Hispanic male presented with severe and constant bilateral lower extremity pain for 3 weeks, located at the upper thighs with radiation down the legs. He also complained of a non-radiating severe, frontal, throbbing headache for one week, associated with occasional episodes of diplopia, without a stiff neck or photophobia. Four days prior he developed bilateral lower extremity weakness and could not walk or stand on his own. Other complaints included nausea, vomiting and a low-grade fever of 37.7°C. No recent travel abroad or sick contacts. He had no medical problems or previous surgical interventions. He admitted to a 20 pack year history of smoking and chronic alcohol intake of four 8 oz cans of beer every day for the last twenty years. He currently worked as a construction worker. All vital signs were stable on admission and within normal range. Physical examination demonstrated somnolent but arousable patient in no acute distress. The complete neurological and lung examination were unremarkable except hypereflexia of the right brachioradialis and right biceps and a decrease of muscle strength of bilateral lower extremities. All other body systems of physical examination were unremarkable.\nInitial laboratory work up () was remarkable for mild hyponatremia, mild transaminase elevation and hyperbilirubinemia. The ammonia level was in the upper normal range. Urinalysis, urine toxicology screen and alcohol level, hepatitis serology panel and HIV were negative. Chest x-ray on admission was unremarkable. Computer tomography (CT) of the brain () on admission revealed multiple intraaxial hyperdense lesions with surrounding vasogenic edema in the frontal, parietal and left temporal lobes. Hematogenous spread was suggested by the presence of several lesions at the gray-white junction. Chest-CT () on admission demonstrated bilateral cavitary nodules in the lung and right hilar lymphadenopathy. Our differential diagnosis included metastatic versus infectious etiology. We therefore started the patient on empiric antibiotics of vancomycin 1 gram every 12 hours, ceftriaxone 2 grams every 12 hours, and dexamethasone 6mg IV every 8 hours for cerebral edema. We then proceeded to obtain a MRI of the brain () which revealed multiple bilateral supratentorial and infratentorial rim enhancing lesions involving the subcortical gray-white matter interface, superficial and deep white matter tracts, brainstem and cerebellum associated with vasogenic edema. These findings were more likely associated with an infectious etiology causing septic emboli. The initial blood and urine cultures on admission were negative.\nThe pulmonary service was consulted on the second hospital day for bronchoscopy for bronchoalveloar lavage (BAL). Bronchoscopy revealed normal airway anatomy with diffusely erythematous mucosa and clear secretions. BAL was obtained from the left upper lobe and cytology report had no significant findings. The BAL cultures were negative for fungal, bacteria and mycobacteria. AFB stain was performed on the BAL and was also negative. The infectious disease service was also consulted on the second hospital day and recommended a PPD, Quaniferon Gold, coccidiodies serology, aspergillus antigen, toxoplasma IgG antibody, serum crytococcal antigen and a lumbar puncture for cerebrospinal fluid (CSF) analysis. All of the stated lab tests were negative. Cerebrospinal fluid analysis () was elevated WBC count, suggesting an infectious etiology. No evidence of vegetations was noted on echocardiogram. Due to the unclear etiology of the lung and brain lesions, neurosurgery was consulted for a brain biopsy. The neurosurgeon suggested that brain biopsy would not be possible considering the small size and depth of the lesions. By the tenth hospital day the mental status of the patient deteriorated to the point that he was now disoriented to time and place but oriented to person. By the twelfth hospital day the patient developed weakness of the left upper extremity and an unsteady antalgic gait. Then on the next day, he also developed right upper extremity weakness, ptosis and right lower facial weakness. Cardiothoracic surgery was consulted for video-assisted thoracoscopic surgery with biopsy of cavitary lung lesions but the location of the lesion was unsuitable for the surgical access. Eventually, the GCS of the patient decreased to 7, he was bradycardic and had complete right sided paralysis with a positive right side babinski.\nHe was subsequently transferred to the medical intensive care unit (MICU) for further monitoring and cardiopulmonary support. The repeat head-CT with contrast revealed multiple ring enhancing lesions involving both cerebral, basal ganglia and brainstem. There was no evidence for acute intracranial hemorrhage, herniation, mass effect or midline shift. The infectious disease service decided to start the patient on amphotericin B 450 mg (5 mg/kg) IV every 24 hours and advised us to continue the same antibiotics and dexamethasone. On the nineteenth hospital day the patient became tachycardic (HR: 120-130’s) and desaturated to <80%, hence he was intubated and placed on mechanical ventilation support. The infectious disease consult service recommended albendazole 15 mg/kg/day through the naso-gastric-tube every 12 hours for probable neurocysticercosis, and then to initiate toxoplasmosis therapy despite negative test result. This therapy included pyrimethamine 200 mg PO (1 dose) then 75 mg/day plus sulfadiazine 1.5 g PO every 6 hours plus leukovorin 20 mg PO every 24 hours. Despite our best efforts, the patient remained tachycardic and begun to spike fevers ranging from 38.7°C to 39°C. Considering the worsening of his clinical status we continued to advocate the attempt for a tissue biopsy in order to help us guide in the diagnosis and treatment but to no avail. The patient continued to deteriorate, did not respond and subsequently expired on the twentieth hospital day after the family withdrew care.\nAutopsy was subsequently performed two days later. Macroscopic findings of respiratory system included bilateral serosanguineous pleural effusions and a lung abscess at the right hilum. The microscopic examination of the right hilum abscess showed foci of necrosis with acute inflammation and microabscess formation. The macroscopic findings of the brain revealed multiple bilateral cavities present in the white matter throughout the entire cerebrum, and also present throughout the basal ganglia, midbrain, substantia nigra and right lobe of the cerebellum. Microscopic examination findings showed foci of acute inflammation and microabscess formation. Grocott methena mine silver (GMS), grain stain and Fite’s stain of the right hilum abscess and brain abscesses both revealed numerous gram positive branching rods, morphologically consistent with nocardia. Tissue samples from the brain abscess lesions and lung cavitary lesions were sent for cultures and subsequently grew nocardia species. PCR analysis revealed nocardia wallacei species with resistance to ceftriaxone, levofloxacin, aminoglycosides (amikacin) and to sulfonamides (trimethoprim-sulfamethoxazole – TMP-SMX). However, this species of nocardia was sensitive to imipenem. The final autopsy diagnosis revealed nocardia pneumonitis and encephalitis. The cause of death was stated as systemic nocadiosis (nocardia pneumonitis and encephalitis).

[[42.0, 'year']]

M

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{'3610462-1': 1, '3633055-1': 1}

3987279-1

noncomm/PMC003xxxxxx/PMC3987279.xml

A case report of reactive hypoglycemia in a patient with pheochromocytoma and it's review of literature

A 51-year-old female initially presented to the Department of Surgery with complaint of recurrent nonbilious vomiting. USG abdomen revealed cholelithiasisand a right adrenal mass. Patient denied complaints of episodic palpitations, headache, sweating or weight loss. There was no history of early satiety or constipation. There was a history of frequent intake of meals at an interval of 3-4 hrs. She denied any history suggestive of postprandial hypoglycemia. She was diagnosed to be hypertensive around 3 years back, but she was not taking regular medication. She had been taking tablet Amlodipine 10 mg and Olmesartan 40 mg and referred to the Endocrine Unit. There was no family history suggestive of Hypertension, DM, CAD or MEN.\nExamination revealed a thin built female of height 5′3″, weight 43 kg, BMI: 16.79 Kg/m2. Blood pressure was 115/80 mmHg in supine position and 104/80 mmHg in standing position. There was no postural drop in blood pressure. Systemic examination was unremarkable. Biochemical investigations revealed normal hemogram, liver function test and kidney function test. The 24-hour urine catecholamines were elevated [VMA: 36.63 mg/g creatinine (1.6-4.2 mg/g), Epinephrine: 81.42 pg/ml (<67 pg/ml), Norepinephrine: 876.47 ng/ml (95-446 ng/ml), Dopamine: 51.61 pg/ml]. Postprandial glucose levels were reported as 30 mg/dL and 54 mg/dL on two different occasions. An extended oral glucose tolerance test was done which showed reactive hypoglycemia and hyperinsulinemia at 3 hrs []. HbA1C was 6.20%. Thyroid function test and serum cortisol levels were normal. CT abdomen and pelvis showed partially necrotic, otherwise well defined mass in the right adrenal measuring 42 × 39 mm in size. An incidental finding of mural thickening of antrum of stomach was found. Echocardiography revealed severe concentric Left ventricular hypertrophy, mild MR, AR and LV diastolic dysfunction with left ventricular ejection fraction of 60%.\nPatient underwent surgery after appropriate hypertensive management with α and β-blockers. Histopathology revealed tumor cells with abundant amphophilic granular cytoplasm, vesicular nuclei and few cells showed nucleoli with occasional mitotic figures suggestive of pheochromocytoma [].

[[51.0, 'year']]

F

{'1525976': 1, '19269923': 1, '20963572': 1, '2991734': 1, '7092541': 1, '31275775': 1, '6018752': 1, '4184216': 1, '31911981': 2, '16034010': 1, '2195784': 1, '3573413': 1, '8968691': 1, '31777577': 1, '11114627': 1, '844019': 1, '3359794': 1, '7208288': 1, '3913722': 1, '10855527': 1, '34170845': 1, '24741525': 2}

{'6939798-1': 1}

3987280-1

noncomm/PMC003xxxxxx/PMC3987280.xml

A rare case of triple thyroid ectopia

A 42-year-old woman was examined by CT as a client of health check-up to study neck and brain vessels. Her history revealed that she was investigated and counseled by a physician for a nodule over the midline in the neck a few years ago. She was subjected to thyroid function tests, which were normal and excluded hypo or hyper thyroidism. She was correctly advised not to do any further investigation, worry about it or get rid of it surgically.\nCT revealed etopic thyroid nodules over the surface of posterior tongue, anterosuperior and close to body of hyoid bone and in sub-hyoid region as an enlarged pyramidal lobe. The normal thyroid lobes and isthmus were absent and as a result common carotid and internal jugular veins were closely applied to trachea without the interposing thyroid lobes []. All these were un-connected and separated by 5-8 mms in craniocaudal direction in the midline. These were hyperdense and showed enhancement (post contrast CT value measuring more than 200. A nuclear scan was performed using 3 millicuries of Technetium 99m pertechnetate administered intravenously. The static images were acquired at 20 minutes. The frontal projection showed two hot spots, a smaller and upper one between submandibular glands due to lingual ectopia and the lower larger one due to combined activity from pre-hyoid (sublingual) and pyramidal ectopic gland [].\nAs she was now asymptomatic and nuclear scan had ruled out any abnormal thyroid function, repeat thyroid function tests were also not recommended.

[[42.0, 'year']]

F

{'21713222': 1, '31886006': 2, '22281882': 1, '21765986': 1, '33344620': 2, '31929881': 1, '15205845': 1, '18583899': 2, '12973493': 1, '11954930': 1, '30294586': 1, '24741526': 2}

{'2526509-1': 1, '6915127-1': 1, '6915127-2': 1, '7723730-1': 1}

3987281-1

noncomm/PMC003xxxxxx/PMC3987281.xml

Effect of octreotide on endometriosis in acromegaly: Case report with review of literature

A 34-year-old female presented in the gynaecology outpatient department with complaints of menorrhagia and passage of clots along with abdominal pain which she had been experiencing for the last 13 years. Periods had been regular otherwise, lasting for about 5-6 days each month. USG pelvis revealed bilateral complex cystic adnexal masses with diffuse low level internal echoes. The left adnexal cyst was larger (6.5 × 6.0 cm) and multiloculated. The right adnexal cyst was unilocular and of size 3.5 × 2.8 cm []. MRI pelvis was done subsequently which revealed bilateral cysts, hyperintense on T1 and T1 fat suppressed images and hypointense with few hyperintense areas (shading) on T2WI and a diagnosis of endometriotic cysts was made [Figure and ]. She was advised to take oral contraceptives and NSAIDS. There was however no change in either the menstrual flow or clots with this therapy. She discontinued the therapy after two months.\nThree months later, she approached the doctor with additional complaints of diplopia and left sided temporal hemianopia. MRI brain was done, this revealed a pituitary macroadenoma. She was then referred to the department of Endocrinology for further assessment and management of macroadenoma. History and clinical features were suggestive of acromegaly. Post glucose load Growth Hormone levels were high (39.8 ng/ml). Prolactin levels were 70 ng/ml and freeT4 levels were low (freeT4-0.60 ug/dl (0.6-2.2), TSH-4.410 mIU/ml). Thyroxine supplementation was initiated. The patient underwent pituitary surgery, five months following which she underwent 25 sessions of radiotherapy (SRT). Menstrual problems persisted and she underwent dilatation and curettage followed by biopsy of the endometrium which was suggestive of endometrial hyperplasia.\nAs her IGF-1 levels were high even nine months post operatively, the patient was put on Injection Octreotide. (IGF1-710:Nomalrange 117-329 μg/L). Six months from the introduction of octreotide, the patient developed gallstones. During this period, the patient's menstrual flow had decreased from 5 to 3 days and there was a reduction in the amount of clots. Follow up ultrasound scans revealed a significant decrease in the size of the lesions over a period of one year with bilateral normal ovaries in the scans done at three years and subsequently []. She was continued on monthly octreotide injections. There was a gradual decline and normalisation of IGF-1 levels over a period of three years with this treatment []. Octreotide therapy was stopped after four years. Concurrently, there was a gradual improvement and normalisation of menstrual flow and pattern. Ultrasonography revealed bilateral normal ovaries. Presently, the patient is amenorrhoeic for the past 3 years. Hormonal profile was suggestive of hypogonadotropichypogonadism (LH-1.84 mIU/ml normal value range 0.8-15.5 mIU/ml in fertile females age group, FSH-7.03 mIU/ml normal value range 1.3-23.4 mIU/ml, E2-3.00 pmol/L (97.5-592 pmol/L), Progesterone -0.052 (0.44-6.47 nmol/L), Prl-15.2 ng/ml, normal value range 3-18.6 ng/ml.

[[34.0, 'year']]

F

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{}

3987316-1

noncomm/PMC003xxxxxx/PMC3987316.xml

Sildenafil for Noncompaction Cardiomyopathy Treatment in a Child: Case\nReport

The patient is a 6-year-old male, previously healthy, admitted with clinical findings\ncompatible with CHF. The clinical investigation ruled out causes of CHF secondary to\ninfectious, arrhythmogenic, infiltrative, toxic and ischemic processes and neuromuscular\ndisorders. The serum level of type B natriuretic peptide (BNP) was 641 pg/mL. The\nechocardiographic findings were as follows: left ventricular (LV) ejection fraction of\n19.1%; significant biventricular systolic dysfunction; LV diastolic dysfunction;\nsignificant LV dilation; and mild left atrial dilation. In addition, deep myocardial\ntrabeculae were observed, communicating with the free LV cavity, with a noncompaction to\ncompaction ratio of 3.2:1 and no structural malformation, establishing the diagnosis of\nbilateral cardiomyopathy of the noncompaction myocardial type (). Drug treatment with angiotensin-converting-enzyme\ninhibitor (ACEI), diuretics and carvedilol was initiated.\nAfter one year of clinical follow-up and optimized pharmacological treatment (diuretics,\nACEI and beta blocker), his symptoms and functional class worsened, a new hospital\nadmission being necessary. Echocardiography showed persistent dilated cardiomyopathy of\nsignificant hemodynamic repercussion, with moderate tricuspid and mild mitral\nregurgitations. Because of the unfavorable diagnosis and clinical course, the patient\nwas assessed aiming at heart transplantation. The hemodynamic evaluation showed\ncardiomyopathy with noncompaction of the ventricles and spongy myocardium, normal\ncapillary angiography and mean capillary pressure of 25 mm Hg.\nRescue therapy with sildenafil at the dose of 2 mg/kg/day was indicated while awaiting a\ndonor. The clinical and imaging follow-up every three months showed progressive\nimprovement, with normalization of the ventricular function, of the BNP serum levels and\nof the symptoms (). The patient was then\nremoved from the heart transplantation list, maintaining good quality of life.

[[6.0, 'year']]

M

{'22898992': 1, '10400016': 1, '22131856': 1, '25317942': 1, '22192662': 1, '12196335': 1, '21894393': 1, '11850525': 1, '10933363': 1, '20048034': 1, '15302010': 1, '24714790': 2}

{}

3987339-1

noncomm/PMC003xxxxxx/PMC3987339.xml

Clinically Manifested Myocarditis in Acute Rheumatic Fever\nJosé

The patient was a 23-year-old Caucasian female, born and raised in São Paulo, who came\nto the emergency department complaining of dyspnea at rest (functional class IV of the\nNew York Heart Association), palpitations, nausea, unmeasured fever and increased\nabdominal volume for six days. She reported a personal history of rheumatic fever, with\ntwo mitral and tricuspid valve plastic surgeries, in 1996 and 2011, and subsequent\nmitral valve replacement with a biological prosthesis four months before, in 2012. She\nalso had chronic atrial fibrillation on anticoagulation. She denied other symptoms and\ncomorbidities. She was an irregular user of warfarin, furosemide 40 mg / day,\nspironolactone 50 mg/day, captopril 37.5 mg/day, diltiazem 180 mg/day and sulfadiazine 1\ng/day (due to allergy to penicillin).\nIn February 2012, the patient started to have dyspnea at rest due to symptomatic mitral\nvalve regurgitation and remained hospitalized until heart surgery for mitral valve\nreplacement with a biological prosthesis. At this time she was submitted to preoperative\nmyocardial scintigraphy with gallium-67, which was negative for myocardial inflammatory\nprocess. The surgery had no complications and the postoperative transthoracic\nechocardiography showed left atrium (LA) with 50 mm in diameter, left ventricle (LV) of\n56 x 39 mm, ejection fraction (EF) of 57% and unchanged mitral bioprosthesis structure.\nShe was discharged receiving the medications listed above.\nOn physical examination, the patient was in good general health status, afebrile,\ntachycardic (heart rate = 180 beats per minute), blood pressure of 90 x 60 mmHg,\ntachydyspneic (respiratory rate = 25 breaths per minute), arterial oxygen saturation in\nambient air was 93% and she had intercostal retraction. Apex beat was visible and\npalpable in the fifth intercostal space on the left midclavicular line; presence of\narrhythmic heart sounds with a loud B2 sound, holosystolic mitral regurgitation murmur\nof 2 +/6+ intensity, breath sounds present with fine rales in the lung bases\nbilaterally, hardened liver that was palpable about 7 cm from the right costal margin\nand bilateral and symmetric 2+/ 4+ lower limb edema.\nAt this time, a diagnosis of heart failure due to probable infective endocarditis or\nactive rheumatic fever was attained, considering the presence of fever and clinical\nsigns of pulmonary and systemic congestion, after which three pairs of blood cultures\nwere collected, an echocardiogram was requested and empirical antibiotic therapy with\nintravenous ceftriaxone and oxacillin was initiated.\nThe electrocardiogram initially showed atrial fibrillation with high ventricular\nresponse. Chest X-ray showed interstitial infiltrates in the lower two-thirds of both\nhemithoraxes, as well as cardiomegaly.\nTransesophageal echocardiography showed LA = 56 mm, LV = 71 x 62 mm, EF 20% with diffuse\nhypokinesis of LV and bioprosthetic mitral valve with no signs dysfunction or evidence\nof vegetation. Blood cultures were negative. At this time, we chose to maintain adequate\ncontrol of heart rate and administration of intravenous furosemide. To confirm the\nrheumatic myocarditis, myocardial scintigraphy with gallium-67 was requested, which\nshowed positive for ongoing inflammatory process (). Cardiac magnetic resonance imaging was performed, which showed significant\ndiffuse biventricular dysfunction and presence of myocardial inflammatory process (). Laboratory assessment showed C-reactive\nprotein of 89.3 mg/L, brain natriuretic peptide (BNP) of 2,553 pg/mL, ASLO = 693 IU/mL,\nerythrocyte sedimentation rate of 50 mm and alpha-1-acid glycoprotein = 136 mg/dL.\nDue to the diagnosis of myocarditis, Prednisone 2 mg/kg/day was started. Two hypotheses\nwere then considered: postoperative myocarditis (procedure-related) and acute attack of\nrheumatic fever. The patient showed significant symptom improvement and was discharged\non the 14th day after admission using prednisone 1 mg/kg/day, captopril,\nfurosemide, spironolactone, carvedilol, digoxin and warfarin. In addition, she was\nreferred to immunology for desensitization to penicillin and started to receive a dose\nof benzathine penicillin of 1.200.000 IU every 15 days without complications.

[[23.0, 'year']]

F

{'15936613': 1, '21953302': 1, '7596370': 1, '15936612': 1, '12727153': 1, '22219153': 1, '25478552': 2, '22617826': 1, '12813196': 1, '28327870': 1, '22185868': 1, '24676379': 2}

{'4238348-1': 1}

3987357-1

noncomm/PMC003xxxxxx/PMC3987357.xml

Delayed diagnosis of an Ewing sarcoma of the knee during pregnancy

A 37-year-old woman, gravida 6 para 3 abortion 2, was admitted to our maternity ward at a gestational age of 41 weeks for induction of labour. She had received antenatal care from an obstetrician in a University hospital clinic and from a midwife at home. She presented to the emergency department of the university hospital with an intense pain in the right knee and lower leg since 4 months.. A deep vein thrombosis, one of the most current pregnancy-related problems, was excluded by a negative Doppler examination and the patient was sent home. Over the last two weeks an increased loss of function occurred inducing difficulties with standing up and walking. She was referred again by her midwife to the same emergency ward but no further examinations were performed and she was sent home without a diagnosis. At admission to our maternity ward clinical examination of the painful area revealed a swollen knee, painful and warm at palpation. Because her delivery was imminent, only a blood analysis and an ultrasound of the knee and lower leg were performed. The ultrasound showed the presence of a necrotic/inflammatory collection at the superior part of the tibia with an irregular aspect of the periost and external cortical layer. Underlying bone pathology was therefore suspected, possibly related to osteomyelitis of the superior part of the tibia. Laboratory investigation showed signs of infection (CRP 44, white blood count 11300 cells/µL, neutrophilia 8803 cells/µL). Given the suspicion of osteomyelitis, an antibiotic treatment (Floxacilline) was started. Labour and delivery were uneventful and she gave birth to a healthy boy.\nThe next day an additional work up was performed. Clinical head-to-toe examination showed the already described findings regarding the right knee and leg, but additionally the astonishing presence of several lumps in both breasts, the largest being a mass of 4 centimetres in the right breast. Blood tests showed normal kidney function tests, slightly elevated hepatic tests, a normal CA 15.3 (14 IU/ml) but an elevated CA 125 (121 IU/ml). Further radiologic examinations, including X-Rays and an MRI of the knee and leg confirmed the presence of a massive destruction of the proximal part of the tibia seen as an infiltrating lesion of the metaphysis of the tibia with signs of resorption (). RX thorax revealed the presence of lung metastases in both pulmonary fields. Computer Tomography (CT) of thorax and abdomen confirmed the presence of lung metastases, but showed also peritoneal and multiple bone metastases. Mammography and ultrasound of both breasts not only confirmed the presence of two large lumps, but in addition it showed 12 neoplastic lesions in the right and 7 neoplastic lesions in the left breast. Finally, a whole bone scan and positron emission tomography (PET) scan confirmed all sites of neoplastic lesions ().\nIn view of these findings the differential diagnosis of a metastatic breast cancer or metastases of a primary bone tumour was withheld. The microscopic examination of a biopsy of one of the large breast nodules revealed the presence of a small blue round cell tumour, suggesting a primary bone tumour, which was confirmed by immunohistochemistry (CD99 expression) (). Additional FISH analysis revealed rearrangement of the EWS gene, and not of the WT1 gene, indicating the diagnosis of Ewing sarcoma (). Four days postpartum, chemotherapy was initiated. A 3-week alternating treatment of vincristine/adriamycin/cyclophosphamide (VAC) and etoposide/iphosphamide (IFO-VP16) was given, which was well tolerated apart from slight anaemia and constipation. After one cycle of chemotherapy the patient reported less pain and a reduction of the volume, redness and inflammation around the knee was observed.\nAfter five cycles of chemotherapy, subjective and objective response was excellent and the patient was able to stand up again and walk small distances after a long period of suffering from an intense pain and inability to walk. After the total of nine cycles, the PET-scan showed complete response ().\nSince the last studies on Ewing sarcoma showed that additional 5 cycles of chemotherapy increase the durability of the remission, her treatment was extended with 5 extra cycles. Unfortunately, three months after the total of 14 cycles, a solitary brain metastasis was discovered. While writing this case report she just completed one month of stereotactic radiotherapy with complete response.

[[37.0, 'year']]

F

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{}

3987383-1

noncomm/PMC003xxxxxx/PMC3987383.xml

Atypical Clinical Presentation of Arrhythmogenic Biventricular\nCardiomyopathy

A 57-year-old hypertensive woman presented with a 6-month history of atypical chest\npain. In addition, ongoing maintenance therapy with azathioprine for Crohn's disease and\na nonfunctional adrenal adenoma were observed. Family history was unremarkable, and\nphysical examination results were normal.\nElectrocardiography revealed a normal sinus rhythm, left axis deviation, and T-wave\ninversion in precordial leads from V2 to V6. Further, an epsilon wave in leads V1-V3\n() led to the suspicion of ARVC.\nMonitoring using a 24-h Holter electrocardiogram documented only occasional ventricular\nextrasystoles with left bundle branch block morphology and no significant cardiac\narrhythmia. Further evaluation included cardiac magnetic resonance (CMR) imaging, which\nrevealed right ventricular (RV) enlargement with an indexed end-diastolic volume of 110\nml/m2 and mild dysfunction (ejection fraction = 44%). No signs of fatty\ntissue infiltration were observed, but regional RV dyskinesia in the free wall and\noutflow tract was identified (). LV was\nmildly enlarged (90 ml/m2), and systolic function was at the lower limit of\nnormal. Flow analysis revealed no shunts in the aorta and pulmonary artery.\nSubepicardial delayed enhancement was observed the lateral basal and middle segments of\nLV as well as a small focal area of the RV free wall (). These findings suggested a diagnosis of ARVC with LV\ninvolvement.\nIn this case involving a patient with atypical symptoms, no clinical arrhythmia, and a\nnegative family history, three major criteria led to the definite diagnosis of ARVC:\ninverted T waves in the precordial leads in the absence of complete right bundle branch\nblock; epsilon wave in the right precordial leads; and regional RV dyskinesia with\nindexed end-diastolic volume ≥ 100 ml/m2.\nLV involvement in ARVC has been recognized in several studies and can occur in > 75%\npatients with disease progression.\nCMR is an ideal technique to aid in the diagnosis of this condition. Particularly, in asymptomatic patients,\nthe differential diagnosis of ARVC should be considered. Future investigations should\nclarify the clinical relevance of these findings and the prognosis of patients with\nbiventricular arrhythmogenic cardiomyopathy.

[[57.0, 'year']]

F

{'20172911': 1, '18281826': 1, '22030343': 1, '24652094': 2}

{}

3987397-1

noncomm/PMC003xxxxxx/PMC3987397.xml

Coronary Obstruction Following Transcatheter Aortic Valve\nImplantation

A 83-year-old female, hypertensive, diabetic, with coronary artery disease and heart\nfailure functional class III (NYHA). In clinical evaluation, it was noted severe\naortic stenosis (mean gradient: 77 mmHg; valve area: 0.50 cm2) of high\nrisk (logistic EuroSCORE: 9.5%; STS PROM: 7.9%) being referred to TAVI. On\nangiotomography it was verified the sinus of Valsalva with mean diameter of 26 mm,\nvalve annulus of 24 mm and height of right coronary artery (RCA) and left main (LM)\nof 10.4 mm and 9.6 mm, respectively ().\nThe procedure was performed by transfemoral approach, with implantation of a 26 mm\nballoon-expandable Sapien XT prosthesis. Immediately after valve implantation, the\npatient evolved with severe and maintained hypotension, in addition to ST-segment\nelevation detected on cardiac monitoring. Transesophageal echocardiogram (TEE) showed\nappropriate bioprosthesis positioning, with mild perivalvular regurgitation. On\naortography it was detected complete obstruction of RCA ostium (). A condition of shock and cardiac arrest had quickly\nbegun, so that cardiopulmonary resuscitation and angioplasty with implantation of 2\ndrug-eluting stent of the RCA were successfully performed (). As a further complication, due to resuscitation\nprocedures, there was a perforation on right ventricle by temporary pacemaker and\ntamponade, and despite the treatment of the complications, there was another cardiac\narrest and subsequent death.

[[83.0, 'year']]

F

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{'3987397-2': 2, '3987397-3': 2}

3987397-2

noncomm/PMC003xxxxxx/PMC3987397.xml

Coronary Obstruction Following Transcatheter Aortic Valve\nImplantation

A 82-year-old female, hypertensive and diabetic, in clinical evaluation due to\nfunctional class II (NYHA) heart failure, was diagnosed with significant aortic\nstenosis (mean gradient: 68 mmHg; valve area: 0.60 cm2). Based on her age\nand high risk (logistic EuroSCORE: 13.3%; STS-PROM: 14.8%), the patient was referred\nto transfemoral TAVI, with implantation of a 23 mm Sapien XT prosthesis. Immediately\nafter valve implantation, the patient developed severe and maintained hypotension,\nwithout electrocardiographic changes. Control aortography showed complete obstruction\nof LM ostium (). Drug-eluting stent\nimplantation in the LM was performed with restoration of coronary flow and immediate\nreversal of shock condition (). After\nthe procedure, however, a severe stroke was detected, with development of pneumonia\nand death after 78 days of hospitalization.

[[82.0, 'year']]

F

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{'3987397-1': 2, '3987397-3': 2}

3987397-3

noncomm/PMC003xxxxxx/PMC3987397.xml

Coronary Obstruction Following Transcatheter Aortic Valve\nImplantation

A 89-year-old female, with history of hypertension, dyslipidemia and ischemic\ncardiomyopathy with previous percutaneous coronary intervention, was developing heart\nfailure functional class III (NYHA), being diagnosed with significant aortic stenosis\n(mean gradient: 83 mmHg; valve area: 0.60 cm2). Based on her age and high\nrisk (logistic EuroSCORE: 23.2%; STS-PROM: 5.4%), the patient was referred to TAVI,\nthat was performed by the transfemoral approach, with implantation of a 23 mm Sapien\nXT. Due to the presence of moderate periprosthetic aortic regurgitation,\npost-dilation was carried out. Control aortography and TEE revealed a decrease in\naortic regurgiration and the absence of other complications. However, 50 minutes\nafter procedure, the patient suddenly developed severe and maintained hypotension,\nand aortography showed obstruction of the LM ostium. Despite successful implantation\nof a bare-metal stent, the patient persisted in refractory cardiogenic shock, leading\nto death.

[[89.0, 'year']]

F

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{'3987397-1': 2, '3987397-2': 2}

3987487-1

noncomm/PMC003xxxxxx/PMC3987487.xml

Unicornuate uterus and ectopic (undescended) ovary

A 31-year-old woman was referred to our infertility clinic with a history of primary infertility for more than two years. During the routine infertility exploration a hysterosalpingography (HSG) showed a left sided unicornuate uterus with a patent tube (). On vaginal ultrasound only one ovary could be detected at the normal position, with a normal size and a normal number of antral follicles. On the right hand side no ovary could be visualized.\nA 3D ultrasound was performed confirming the presence of a unicornuate uterus and a normal leftsided ovary with normal blood supply ().\nDue to our previous experience with ectopic ovaries associated with a unicornuate uterus (Ombelet et al., 2003b; Ombelet et al., 2003c) an MRI after mild ovarian clomiphene citrate (CC)-stimulation was carried out. MRI was performed using an extended phased array body coil on a 1.5 Tesla (Siemens, Germany) scanner. Axial, coronal and sagittal T1 (TurboFlash) and T2 weighted (HASTE) images were acquired, without intravenous contrast. The images through the level of the pelvis demonstrated a left sided unicornuate uterus with a single vagina and a single cervix. The left ovary was located anteriorly in the fossa adjacent to the uterus and contained several tiny cysts. Furthermore, small cysts were found posterior from the hepatic flexure of the colon, interpreted as follicles in the right ovary (). The right kidney was absent (). Numerous subcentimetric tiny cysts vertically oriented posterior of the ascending part of the colon, like a string of beads could be demonstrated (), interpreted as small isovolumetric follicles in a ‘stretched’ right sided ovarian structure. According to the MRI images it was not sure whether the rightsided ectopic ovary was located intra- or extraperitoneally.\nA laparoscopy confirmed the diagnosis of a unicornuate uterus with one normal patent tube and one normal ovary on the left side. On the right side no rudimentary horn could be seen. High up in the abdomen, just below the liver, an ectopic ovary could be visualized with a rudimentary tube. The distal, fimbriated end of the fallopian tube was developed adjacent to the ectopic ovary.\nAn infertility work-up of the male partner revealed an isolated teratozoospermia with 2% ideal forms using strict criteria of sperm morphology (Ombelet et al., 1997; Cooper et al., 2010). It was decided to start with a first-line treatment with intrauterine inseminations.

[[31.0, 'year']]

F

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{'7360228-1': 1, '6260671-1': 1}

3988348-1

noncomm/PMC003xxxxxx/PMC3988348.xml

Polyostotic Fibrous Dysplasia Mimicking Multiple Bone Metastases in a Patient with Ductal Carcinoma In Situ

A 42-year-old woman was admitted to the breast clinic of a university hospital with a palpable mass in the right breast originally detected in a local clinic. According to her medical records, there were no signs of nipple retraction or skin abnormalities. Breast ultrasonography showed a 1.2-cm microlobulated heterogeneously hypoechoic mass in the lower inner quadrant of the right breast. A core needle biopsy was performed, and ductal carcinoma in situ (DCIS) was diagnosed. The patient had no past medical or family history of breast disease and had no bone pain symptoms.\nShe underwent chest radiography as a baseline study for general anesthesia, which showed osteolytic lesions of the right second, third, eighth ribs, and the left fourth rib (). A chest CT was performed and revealed multiple asymmetric osteolytic lesions in the previously enumerated ribs suggesting multiple bone metastases. She was indicated for a whole-body bone scan to identify distant metastases. The scan revealed lesions of the right parietal and occipital bones, cervical, thoracic, lumbar, sacral (CTLS) spine, bilateral scapulae, multiple ribs, bilateral pelvic bones, right femur, tibia, fibula, right tarsal bone, sternum, and right humerus (). 18F-FDG PET/CT revealed an increased uptake in the right femur, right ninth and left fourth ribs, and T-L spine consistent with multiple bone metastases. Serum laboratory test results and tumor markers were not increased as follows: calcium, 8.9 mg/dL; phosphorus, 3.2 mg/dL; alkaline phosphatase, 85 IU/L; carcinoembryonic antigen, 0.807 ng/mL; carbohydrate antigen 15-3, 3.87 U/mL.\nThe patient's medical history included a modified radical mastectomy of the right breast out of concern for a possible hidden malignancy. Histopathological examination showed a 2.0×1.6-cm DCIS with nuclear grade 2, and no metastatic lymph nodes detected out of the 24 dissected axillary lymph nodes. Immunohistochemistry studies showed positive staining for estrogen receptor protein and progesterone receptor protein, and negative staining for human epidermal growth factor receptor 2 (score 1). The patient underwent a postoperative pelvic bone biopsy given the histopathological stage, which was nondiagnostic.\nThe patient visited another hospital for a second opinion, and we conducted a multidisciplinary review. The final histopathological report by the pathologist confirmed the previous diagnosis of DCIS (). Radiological evaluation demonstrated the aforementioned results and was not able to exclude the possibility of multiple bone metastases. We recommended a repeat bone biopsy based on the knowledge that distant metastasis after a diagnosis of pure DCIS is rare. The patient underwent right ilium CT-guided biopsy, which revealed fibro-osseous lesions consistent with fibrous dysplasia (). She only received tamoxifen (20 mg daily) endocrine therapy. At 1-year follow-up, a whole-body bone scan was performed (). At 1.5 years, a 18F-FDG PET/CT scan revealed only persistent increased uptake () without evidence of recurrence.

[[42.0, 'year']]

F

{'23346174': 1, '9779715': 1, '11587606': 1, '9529287': 1, '11043717': 1, '16024960': 1, '6261910': 1, '1999061': 1, '23847214': 1, '19372108': 1, '28533645': 2, '1944469': 1, '16166837': 1, '22505821': 1, '21476105': 1, '27330519': 1, '10227522': 1, '24744802': 2}

{'5439207-1': 1}

3988349-1

noncomm/PMC003xxxxxx/PMC3988349.xml

Metastatic Breast Cancer Presenting as a Subconjunctival Mass

A 41-year-old woman visited our clinic complaining of conjunctival injection and a foreign body sensation in the left eye, with no other systemic symptoms. She was treated with antibiotics and steroid eye solutions at a local eye hospital, and was later referred to our clinic because of disease progression. She had a history of breast cancer and had been treated 2 years previously with modified radical mastectomy followed by adjuvant radiotherapy (50.4 Gy, 28 cycles; 1,411.2 Gy in total) and six cycles of chemotherapy (cyclolphosphamide, methotrexate, and 5-fluorouracil). Pathological examination revealed an invasive ductal carcinoma (stage T2N1M0) that was moderately differentiated, negative for estrogen receptor/progesterone receptor expression, cytokeratin 5/6, and c-erb-B2, and positive for p53 (positive reaction in more than 51% of tumor cells) and Ki-67 expression (labeling index of 31% in tumor cells). Axillary lymph node metastasis was found in 1 out of 18 resected nodes.\nThe best-corrected visual acuity was 20/20 in the right eye and 16/20 in the left eye, with an intraocular pressure of 9 mm Hg and 7 mm Hg in the right and left eyes, respectively. A slit lamp bi-microscopic examination showed a cystic mass under the temporal bulbar conjunctiva, associated with dilated overlying conjunctival vessels (). The anterior chamber, lens, and media were clear, no signs of choroid or retina involvement were observed, and extraocular muscle movement was not limited. Informed consent was obtained from the patient before the surgery. An excisional biopsy revealed a poorly differentiated adenocarcinoma positive for carcinoembryonic antigen and p53, and negative for gross cystic disease fluid protein 15, thyroid transcription factor-1, and estrogen receptor (). Positron emission tomography examination for systemic malignancy revealed multiple bony metastasis with bone marrow infiltration, multiple muscular and subcutaneous metastasis, multiple lung metastasis with metastatic subcarinal and left hilar lymph nodes, mesenteric metastasis, and pancreatic metastasis.

[[41.0, 'year']]

F

{'572142': 1, '15951117': 1, '3307718': 1, '953971': 1, '4412321': 1, '6022244': 1, '30275864': 2, '14707963': 1, '17305726': 1, '12782697': 1, '24155753': 1, '7070786': 1, '14717761': 1, '1427135': 1, '24744803': 2}

{'6158159-1': 1}

3988350-1

noncomm/PMC003xxxxxx/PMC3988350.xml

Concurrent Invasive Ductal Carcinoma of the Breast and Malignant Follicular Lymphoma, Initially Suspected to Be Metastatic Breast Cancer: A Case Report

A 40-year-old woman presented with a large palpable lump in the right breast. Mammography revealed a large mass involving the entire breast with nipple retraction and multiple bilateral axillary lymphadenopathies (). Ultrasonography (US) images showed an 8×6×3 cm irregular hypoechoic mass in the right breast without any suspicious lesion in the left breast. US of the regional lymph nodes showed multiple enlarged lymph nodes in the axillae on both sides and in the left supraclavicular area (). US-guided core needle biopsy (CNB) of the right breast mass indicated invasive ductal carcinoma. Immunohistochemical (IHC) staining showed that the biopsy specimen was positive for estrogen receptor (ER) and progesterone receptor (PR) (4+, 4+, respectively), and fluorescence in situ hybridization (FISH) revealed that the specimen was negative for human epidermal growth factor receptor 2 (HER2) expression. ER and PR expressions were quantified using the Allred score, a semiquantitative system based on the proportion of positive cells (scored from 0 to 5) and staining intensity (scored from 0 to 3) []. The proportion and intensity scores were added to yield a total score of 0 to 8. An Allred score >2 was considered positive for ER or PR. HER2 IHC staining was quantified using the HercepTest scoring system (0 and 1+, negative; 2+, equivocal; and 3+, positive). Specimens with an IHC staining score 2+ results were subjected to a second test and were tested with FISH. A HER2-positive tumor was defined as one with an intensity score of 3+ on IHC staining or as a HER2/CEP17 (centromeric probe for chromosome 17) ratio of more than 2.2 on double-probe FISH assays [].\nOn contrast-enhanced magnetic resonance imaging (CE-MRI), the right breast mass appeared as an irregular mass with initial rapid and late washout enhancement and diffusion restriction. Multiple enlarged lymph nodes were observed in the axillae on both sides, without any suspicious lesion in the left breast. Positron emission tomography/computed tomography (PET/CT) with 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) revealed multiple lymphadenopathies with increased FDG uptake in the axillae on both sides, in the neck, and in the left external iliac and inguinal areas ().\nWe initially considered disseminated metastatic disease from breast cancer, but other pathologies with multiple lymph node involvement such as lymphoproliferative disease and metastasis from another primary malignancy could not be ruled out. US-guided fine needle aspiration (FNA) of an enlarged cervical lymph node and CNB of a left axillary lymph node revealed reactive hyperplasia.\nClinically, metastatic breast cancer was strongly suggested (clinical stage IV, T3N3M1), and therefore initial hormone therapy with zoladex (3.6 mg) and tamoxifen (20 mg) was administered according to the current guidelines for metastatic ER+ breast cancer in a premenopausal woman. One month later, the patient visited another hospital for a second opinion. During the following 8 months, she was enrolled in a clinical trial at another hospital and underwent 8 cycles of maintenance chemotherapy. The regimen comprised 175 mg/m2 paclitaxel, administered intravenously on day 1 and every 21 days thereafter, and 1,250 mg/m2 gemcitabine administered as a 30-minute intravenous infusion on days 1 and 8 and every 21 days thereafter. Postchemotherapy response evaluation showed stable disease, but she refused further chemotherapy because of a poor performance status. Eight months after the discontinuation of chemotherapy, a PET/CT scan at our hospital showed that the primary breast malignancy was stable but that the multiple lymphadenopathies were aggravated, and a new bone metastasis was detected in one thoracic vertebral body (). Therefore, hormone therapy with tamoxifen was initiated. After 1 year of hormone therapy, bilateral neck and right leg swelling developed. A PET/CT scan showed aggravated lymphadenopathies throughout the torso and splenomegaly (), strongly suggesting a lymphoproliferative disease such as lymphoma. Excisional biopsy of a left neck lymph node revealed malignant follicular lymphoma ().\nThe lymphoma was diagnosed as clinical stage IV and the patient was administered chemotherapy with rituximab, cyclophosphamide, vincristine, and prednisolone. Four months after chemotherapy, the clinical symptoms had improved and a PET/CT scan showed complete remission of the lymphoma.\nPalliative surgery for the breast cancer was planned and mammography, US and MRI were performed. During the evaluation, a new suspicious lesion was found in the upper outer region of the left breast. This lesion showed a 3.5×1.5 cm heterogeneous hypoechoic area on US () and a 4 cm focal area with initial rapid and late plateau enhancement on CE-MRI. US-guided CNB revealed invasive ductal carcinoma. Radical mastectomy with axillary lymph node dissection and a pedicled transverse rectus abdominis muscle flap for chest wall reconstruction was performed for the right-sided breast cancer, and a simple total mastectomy with ipsilateral lymph node sampling was performed for the left-sided breast cancer. Pathology results demonstrated invasive ductal carcinoma (both, modified Bloom and Richardson grade II: tubule and gland formation 3, nuclear grade of pleomorphism 2, mitotic count 1) in both breasts and axillary lymph nodes. On IHC staining, both breast carcinomas was positive for ER and PR (right: 7+ and 7+, respectively; left: 8+ and 5+, respectively) and Ki-67 (right: 2%; left: 5%), and negative for HER2 and epidermal growth factor receptor. Pathologically, the left breast cancer was suspected to have arisen due to metastasis from the right-sided breast cancer ( and ). The postsurgical pathological staging was stage IV (T3N3M1). Maintenance chemotherapy including rituximab for lymphoma was scheduled for 2 years and hormone therapy and palliative radiotherapy were considered for breast cancer.

[[40.0, 'year']]

F

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{}

3988442-1

noncomm/PMC003xxxxxx/PMC3988442.xml

Infant Robotic Bilateral Upper Urinary Tract Surgery

The patient was a 4-month-old female with a history of prenatal bilateral hydroureteronephrosis. On day 1 of life, the renal ultrasound showed severe bilateral upper pole urinary tract dilation and a large right-sided ureterocele. There was no vesicoureteral reflux (VUR) on a cyclical voiding cystourethrogram (VCUG). The patient was started on antibiotic prophylaxis. At 8 weeks of age, a diuretic renal scan demonstrated the following relative function: right upper pole (RUP), 16%; right lower pole (RLP), 31%; left upper pole (LUP), 24%; and left lower pole (LLP), 29%. However, the formal radiologist interpretation reported that the RUP function was exaggerated because the renal parenchyma could not be easily separated from liver activity. The LUP drained with a postdiuretic T ½ of 16 minutes and the RUP with a T ½ of 71 minutes. The patient was initially scheduled for an upper urinary tract approach due to the absence of VUR. The initial plan was to perform a left upper to lower ureteroureterostomy (UU) because the LUP renal moiety function remained preserved. However, prior to the scheduled surgical date, the patient presented with fever. Urinalysis was consistent with infection. Leukocytosis was noted. Renal ultrasound revealed a large amount of debris throughout the urinary tract (). Incision of the ureterocele and percutaneous LUP nephrostomy tube placement were performed. An ectopic LUP ureteral orifice in the urethra was confirmed. Postoperative VCUG revealed RUP grade 5, RLP grade 3, and LLP grade 2 VUR. Staged upper and lower urinary tract procedures were planned. The surgical plan was determined on the basis of shared decision making with the parents. A robot-assisted laparoscopic left upper to left lower UU and RUP partial nephroureterectomy were scheduled, with plans for lower urinary tract reconstruction at a later date.\nCystoscopy was performed to place a double-pigtail indwelling ureteral stent into the LLP ureter and an open-ended ureteral catheter into the RLP ureter. The patient was repositioned on her flank for a left upper urinary tract procedure. Access was obtained through a midline umbilical incision. One 8.5-mm robotic camera umbilical trocar, one 8-mm trocar below the xiphoid, and one 8-mm trocar in the left lower quadrant were placed (). Our pediatric institution routinely utilizes an 8.5-mm camera because it is smaller. We have noticed that the optics of the 8.5-mm camera are not equivalent to those of the 12-mm robotic camera, but it does not compromise the surgical procedure. The robot was docked ipsilaterally to the side of surgery. The left retroperitoneum was exposed, including reflecting the colon. The lower pole ureter was left in situ, with minimal dissection to preserve the blood supply. Using robotic Potts scissors, a longitudinal ureterotomy was made in the midureter of the lower pole system, matching the diameter of the obstructed upper pole ureter. The upper pole ureter was divided transversely. The upper to lower UU anastomosis was performed by using running 6-0 PDS with a double-armed needle, which was made by tying two sutures together. The suture length was 4 and 6 cm from the needle to the knot for the two arms (). Redundant obstructed midureter was excised. The distal ureters were left undisturbed in the pelvis. The stump of the ectopic upper pole ureter was left open. The trocars were removed and sterile dressings were applied.\nThe patient was repositioned on her flank for a right upper urinary tract procedure. The umbilical camera and subxiphoid trocars were replaced. A new 8-mm trocar was placed in the right lower quadrant (). The robot was docked ipsilaterally to the side of surgery. The upper pole vessels were identified and divided with a 5-mm LigaSure Blunt (). A percutaneous Prolene suture was placed in the upper pole parenchyma to provide traction and exposure. The upper pole ureter was opened. The floor of the collecting system was identified. The upper pole parenchyma was excised after identifying the avascular plane between the upper and lower pole moieties. The dilated upper pole ureter was mobilized and transected below the level of the lower pole renal hilum. The upper pole ureter was then mobilized from above the hilum, until it was completely delivered, without passing instruments behind the lower pole vessels. The refluxing stump of the upper pole ureter was controlled with two 0-PDS Endoloops. Surgicel and FloSeal were placed on the bed of the resection. Trocar site fascial incisions were closed with 4-0 Vicryl. The RLP ureteral catheter was removed. There were no intraoperative complications or significant blood loss. The total operative time from initial cystoscopy to skin closure was 458 minutes. The console time for UU was 115 minutes and that for partial nephroureterectomy was 145 minutes. A 6-Fr urethral catheter was left indwelling and removed on postoperative day 1. The patient tolerated clamping of the LUP nephrostomy tube on postoperative day 1. No other drains were used. Scheduled postoperative acetaminophen was used for pain management, initially intravenously and subsequently transitioned to oral. Postoperative narcotics or ketorolac were not administered. The patient was discharged on postoperative day 1.\nThe nephrostomy tube was removed 2 weeks after surgery. The left ureteral stent was removed 6 weeks after surgery (). Postoperative renal ultrasound showed decompression of the left upper system without ipsilateral lower pole hydronephrosis and a well-perfused RLP renal moiety without any significant perinephric fluid collection (). The patient will remain on antibiotic prophylaxis until the lower urinary tract reconstruction is performed after infancy during the toddler years.

[[4.0, 'month']]

F

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{}

3988443-1

noncomm/PMC003xxxxxx/PMC3988443.xml

Testicular Adrenal Rest Tumor in 11-Beta-Hydroxylase Deficiency Driven Congenital Adrenal Hyperplasia

A 16-year-old male patient was referred from the pediatrics clinic to our clinic with a diagnosis of 11β-hydroxylase deficiency-driven CAH after the determination of bilateral testicular masses. The patient's history revealed a diagnosis of 11β-hydroxylase deficiency-driven CAH at a young age. Although the patient's laboratory data from an early age were not available, the patient had been using dexamethasone 1×0.75 mg and spironolactone 1×100 mg irregularly.\nThe physical examination revealed multiple bilateral solid nodules in the testes of approximately 0.5 to 1.5 cm. The results of routine hematologic and biochemical tests and the levels of prolactin, luteinizing hormone, and follicle-stimulating hormone were normal. The testosterone level was at the lower limit (231.6 ng/dL). The values of serum markers for testis tumors, such as alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (βhCG), and lactate dehydrogenase (LDH), were within normal ranges. Cortisol, ACTH, and dehydroepiandrosterone sulfate levels were likewise normal, unlike the elevated levels of 17-hydroxyprogesterone and 11-deoxycortisol, which were 23 ng/mL (<2 ng/mL) and 238 ng/mL (<8 ng/mL), respectively.\nScrotal ultrasonography revealed the following testicular sizes: right, 41 mm×21 mm, and left, 43 mm×22 mm. Both testes contained multiple solid heterogenic hypoechoic nodules of different sizes ranging from approximately 21 mm×15 mm to 14 mm×10 mm with well-drawn borders and increased vascularity as indicated by the arrows (). Scrotal magnetic resonance imaging revealed multiple solid nodules with the largest diameter being 18 mm in the right testis and 11 mm in the left. In T1A the nodules were hyperintense and in T2A they were hypointense. After intravenous gadolinium injection, intense homogeneous contrast accumulation was seen in the nodular lesions with contoured lobes and well-drawn borders (). No pathological findings were visible in the computerized tomography of the abdomen.\nSemen analysis showed oligoasthenoteratozoospermia. The patient's sperms were cryopreserved in case he underwent bilateral orchiectomy on the basis of malignant pathological findings. Because the testicular tumor could not be differentiated as malignant or benign on the basis of the laboratory and imaging findings, the patient underwent a right high inguinal testicular exploration. A 1.8-cm nodule was totally excised for frozen section analysis. Because the report of the frozen section analysis was benign, orchiectomy was not performed. After the tunica albuginea was sutured, the testis was placed back into the scrotum.\nHistopathological analysis revealed that the cells forming the mass were similar to Leydig cells with separated fibrous tissue; significant, nucleolus, eosinophilic cytoplasm; and polygonal shapes forming in some areas nests and at other areas layers. Mitosis was rare and necrosis was not seen. The cell cytoplasmic fluid contained lipofuscin but no Reinke crystals. Immunohistochemical analysis revealed that the tumor cells totally diffused with vimentin and Melan-A but were focally immunopositive to inhibin and creatine. Placental alkaline phosphatase and Ae1/Ae3 were immunonegative and the tissue was defined as TART (). The patient was diagnosed with TART, glucocorticoid treatment was initiated, and the patient was followed up.

[[16.0, 'year']]

M

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{}

3988493-1

noncomm/PMC003xxxxxx/PMC3988493.xml

Acute Hematogenous Infection of Revision Total Hip Arthroplasty by Oral\nBacteria in a Patient without a History of Dental Procedures: Case Report

A 53-year old female underwent cup and ball revision of a right THA due to loosening and osteolysis 17 years after primary surgery using a cementless THA (Fig. ). She did not take any corticosteroids and had no history of disease associated with a possibility of infection, such as diabetic mellitus, rheumatoid arthritis, liver cirrhosis, etc.\nNo clinical signs of infection were observed prior to the revision surgery.\nThe laboratory findings included a C-reactive protein (CRP) level of 0.06 mg/dl and a white blood cell (WBC) count of 6,600 cells/μl. The normal value for CRP in the hospital laboratory is a CRP level below 0.3 mg/dl. During the revision surgery, after removing the ball, liner and shell, a cementless porous HA-coated acetabular component and polyethylene liner (AMS-HA acetabular shell and AMS liner; Kyocera, Kyoto, Japan) were implanted. In addition, a new metal ball (C-taper; Stryker, Mahwah, New Jersey, USA) was implanted (Fig. ).\nWith respect to the intraoperative findings, no signs of infection were observed and no specimens obtained intraoperatively for culture at the time of the revision surgery.\nFollowing the revision surgery, the patient was given intravenous cefazolin at the time of induction of anesthesia and for 24 hours postoperatively. She exhibited a routine recovery and showed no symptoms of infection until 18 months after the revision surgery.\nHowever, the patient reported gradually worsening right hip pain. Two weeks later, she visited our institution using a wheelchair. She was febrile (38.7 °C) and had a swollen right thigh with severe pain on motion of the hip joint; however, no fistulas were evidenced. The laboratory findings included a CRP level of 22.3 mg/dl and a WBC count of 5,500 cells/μl. The patient underwent aspiration of the right hip joint for culture; however, no aspirate was obtained.\nTwo-stage revision surgery was planned to treat the infected THA.\nThe patient underwent removal of the entire THA implant. There was pus in the capsule, and cup loosening was found. The patient underwent debridement of the area around the abscess in an effort to prevent progression of the infection. The area was thoroughly irrigated using pulsed lavage with 30 liters of saline. Finally, a cement mold was inserted into the femur (Fig. ). The cement mold consisted of 120 g bone cement and 6 g of vancomycin. The patient was administered 1,200 mg of linezolid for 14 days. Streptococcus mutans, a Gram-positive coccus was identified in all four of the intraoperative specimens (Table ). The antibiotics were subsequently changed to a combination of 900 mg of clindamycin and 1000 mg of ampicillin.\nThe patient was referred to the department of dental surgery at our institution for an assessment of her dental problems. The dentist diagnosed her with caries.\nHowever, Streptococcus parasanguinis, a resident of the flora of the oral cavity was identified only in specimens obtained from the patient’s mouth. The laboratory findings related to infection were all within the normal ranges, and the patient underwent revision total hip arthroplasty eight weeks after the implant removal.\nThe operation was performed using an HA-coated cementless femoral component, an HA-coated cementless acetabular shell, a polyethylene liner and a zirconia ball (Kyocera, Kyoto, Japan).\nA morselized allogenic bone graft was packed on the floor of the acetabulum (Fig. ).\nFollowing completion of the total revision surgery, the patient continuously received oral antibiotics consisting of 900 mg of clindamycin and 1000 mg of ampicillin for six months.\nThe last follow-up occurred approximately 23 months after the total revision surgery, at which time, all laboratory findings indicative of infection remained well within the normal limits, no clinical signs of infection were noted and the prosthesis appeared to be well fixed radiographically. The patient is currently able to walk without a cane.

[[53.0, 'year']]

F

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{'6142345-1': 1}

3988588-1

noncomm/PMC003xxxxxx/PMC3988588.xml

Establishing a Chest MRI Practice and its Clinical Applications: Our Insight and Protocols

A 32-year-old male with biopsy-proven sarcomatoid carcinoma involving the right middle lobe was evaluated by MRI.[] shows an example of the right middle lobe malignant mass suspicious of pericardial invasion, a finding confirmed at surgery. In this case, T2-weighted images using a BLADE TSE/PROPELLER FSE technique and ECG-gated double inversion-recovery FSE images were particularly useful in characterizing disease extent.

[[32.0, 'year']]

M

{'21785057': 1, '12704035': 1, '27200162': 1, '27386267': 1, '22695952': 1, '22434450': 1, '22695944': 1, '19885311': 1, '17900843': 1, '22695943': 1, '24744974': 2}

{'3988588-2': 2, '3988588-3': 2, '3988588-4': 2, '3988588-5': 2}

3988588-2

noncomm/PMC003xxxxxx/PMC3988588.xml

Establishing a Chest MRI Practice and its Clinical Applications: Our Insight and Protocols

A 25-year-old female with chromosomal abnormality, and severe combined pectus excavatum and carinatum deformity presented with a large mediastinal mass. T2-weighted and contrast-enhanced T1-weighted images illustrate the exquisite soft tissue contrast, detail, and extent of a complicated cystic mass consistent with lymphatic malformation [].

[[25.0, 'year']]

F

{'21785057': 1, '12704035': 1, '27200162': 1, '27386267': 1, '22695952': 1, '22434450': 1, '22695944': 1, '19885311': 1, '17900843': 1, '22695943': 1, '24744974': 2}

{'3988588-1': 2, '3988588-3': 2, '3988588-4': 2, '3988588-5': 2}

3988588-3

noncomm/PMC003xxxxxx/PMC3988588.xml

Establishing a Chest MRI Practice and its Clinical Applications: Our Insight and Protocols

A 45-year-old female with chronic upper respiratory symptoms and dry cough had an MRI as part of her imaging work-up. Contrasting soft tissue signaling features in the mediastinum can be particularly improved with some MRI techniques such as DWI [] as shown in this case. Based on the imaging features differential considerations included thymoma and left phrenic nerve sheath tumor. Surgery followed with pathology indicating a thymoma with extensive cystic change.

[[45.0, 'year']]

F

{'21785057': 1, '12704035': 1, '27200162': 1, '27386267': 1, '22695952': 1, '22434450': 1, '22695944': 1, '19885311': 1, '17900843': 1, '22695943': 1, '24744974': 2}

{'3988588-1': 2, '3988588-2': 2, '3988588-4': 2, '3988588-5': 2}

3988588-4

noncomm/PMC003xxxxxx/PMC3988588.xml

Establishing a Chest MRI Practice and its Clinical Applications: Our Insight and Protocols

A 53-year-old male with a large left hemithorax mass could not tolerate lying supine in the MRI scanner, and the entire study was performed with the patient in the left lateral decubitus position. For patients who cannot lie supine or who are severely short of breath, noncontrast-enhanced fast imaging techniques such as bSSFP can provide helpful information []. Differential considerations included sarcoma or fibrous tumor of the pleura. The mass was surgically excised with pathology indicating solitary fibrous tumor with focal tumoral necrosis.

[[53.0, 'year']]

M

{'21785057': 1, '12704035': 1, '27200162': 1, '27386267': 1, '22695952': 1, '22434450': 1, '22695944': 1, '19885311': 1, '17900843': 1, '22695943': 1, '24744974': 2}

{'3988588-1': 2, '3988588-2': 2, '3988588-3': 2, '3988588-5': 2}

3988588-5

noncomm/PMC003xxxxxx/PMC3988588.xml

Establishing a Chest MRI Practice and its Clinical Applications: Our Insight and Protocols

An 85-year-old male with malignant mesothelioma presented with focal right-sided anterior pain. Staging of mesothelioma by CT and PET/CT may benefit from improved soft tissue contrast provided by MRI particularly along the mediastinal pleura []. The region of focal pain corresponded to a mass, which demonstrated restricted diffusion.

[[85.0, 'year']]

M

{'21785057': 1, '12704035': 1, '27200162': 1, '27386267': 1, '22695952': 1, '22434450': 1, '22695944': 1, '19885311': 1, '17900843': 1, '22695943': 1, '24744974': 2}

{'3988588-1': 2, '3988588-2': 2, '3988588-3': 2, '3988588-4': 2}