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zhengyun21

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PMC-Patients

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3975723-1

noncomm/PMC003xxxxxx/PMC3975723.xml

Bilateral Internal Carotid Artery Occlusion Associated with the Antiphospholipid Antibody Syndrome

A 39-year-old woman was transferred to our hospital after being found unconscious at home. She was confused, but was able to give a history of left-sided weakness with decreased use of her left hand and difficulty bearing weight on her left leg that had begun abruptly 3 days prior to presentation.\nShe had had one prior outside hospital admission 1 year earlier for a left middle cerebral artery stroke that presented with expressive aphasia and right arm and leg weakness. Limited MRI at that time revealed 2 areas of restricted diffusion in the left parietal lobe with increased FLAIR signal and associated cortical/subcortical enhancement. Axial T1-weighted images showed the absence of a flow void in the left internal carotid artery, while the right internal carotid artery appeared patent based on the presence of a normal flow void. Imaging showed no evidence of dissection. The patient underwent stereotactic biopsy of the left parietal lesion to rule out a neoplasm. The results showed nonspecific necrotic changes and no evidence of a neoplasm. She was discharged to inpatient rehabilitation, and over the subsequent months her speech and motor function completely recovered.\nThree years prior to her current presentation, the patient had had a miscarriage at 12 weeks’ gestation. Her history was also significant for intravenous methamphetamine use, ending 13 years prior to presentation, and an 18 pack-year smoking history. She had no history of head or neck trauma. She did not have hypertension, diabetes, or hyperlipidemia. She did not use birth control pills and did not have a history of deep venous thrombosis or pulmonary embolism. Her family history was remarkable for systemic lupus erythematosus in her father and a brother who was diagnosed with thrombotic thrombocytopenia purpura.\nOn examination, her blood pressure was 126/80 mm Hg, and her heart rate was 91 beats/min and regular. There was no cardiac murmur. She was alert and oriented to person, but not place, time, or situation. She was able to follow simple commands, but was slow to respond. Her speech was fluent, with intact repetition and naming and without aphasia or dysarthria. Cranial nerve examination was significant for a left homonymous hemianopsia and left lower facial weakness. Her motor exam revealed left hemiparesis, left hyperreflexia, and a left Babinski sign. She had intact sensation of light touch bilaterally, but extinction on the left with double simultaneous stimuli. Movements were slow on the left side, but there was no ataxia. Gait was not assessed.\nAbnormal coagulation studies included a prolonged activated partial thromboplastin time at 42.6 s (normal range 25.1–37.6 s) which did not correct with a 1:1 mix with normal plasma, a thromboplastin inhibition test that was strongly positive for lupus anticoagulant, and a dilute Russell's viper venom test that was prolonged at 64.3 s (normal 29–46 s) which corrected with the addition of phospholipids. Other coagulation studies, which included anticardiolipin and anti-β2 glycoprotein antibodies, were within normal limits. Erythrocyte sedimentation rate (55 mm/h) and C-reactive protein (5.7 mg/l) were moderately elevated, and the antinuclear antibody assay was elevated at 1:160. Anti-dsDNA was negative. Other studies were normal or negative, including complete blood count, platelet count, renal, liver, and thyroid functions, hemoglobin A1c, and LDL cholesterol. Electrocardiogram and transthoracic echocardiogram were normal.\nA CT scan showed areas of evolving infarction in the right anterior and middle cerebral artery distributions. CT angiography showed bilateral internal carotid artery occlusions extending from the level of the bifurcation to the supraclinoid segments. MRI showed areas of acute infarction within the right middle cerebral artery-anterior cerebral artery watershed territory and chronic infarcts in the left middle cerebral artery-anterior cerebral artery watershed territory (fig. ).\nConventional angiography confirmed bilateral internal carotid artery occlusions in the proximal cervical segments, with reconstitution of the carotid arteries at the supraclinoid segments via the ethmoidal branches of the distal internal maxillary arteries and the ophthalmic arteries (fig. ). Posterior communicating arteries were present bilaterally. The posterior circulation was normal, with extensive collaterals to the anterior circulation via the posterior communicating arteries. No abnormalities concerning for vasculopathy or dissection were noted in the aortic arch or in the carotid, vertebral, subclavian, renal, or femoral arteries.

[[39.0, 'year']]

F

{'11953980': 1, '9576644': 1, '16420554': 1, '8956600': 1, '12595612': 1, '31281662': 2, '2124737': 1, '24707268': 2}

{'6600127-1': 1}

3975747-1

noncomm/PMC003xxxxxx/PMC3975747.xml

IgA Nephropathy with Pathologic Features of Membranoproliferative Glomerulonephritis following Burn Injury

A 46-year-old male patient with scrotal and pedal edema was admitted to our department in August 2012. He had been burned in a gas leakage accident 2 weeks ago. Laboratory examination showed proteinuria (4+) and more than 775 red blood cells in the urine without casts. This patient had been treated for his 2nd- to 3rd-degree burn injuries in a local burn center. He had no inhalation injury or sepsis during the whole treatment process. At the admission time, he had a body temperature of 36.6°C, a pulse rate of 75 beats/min, a respiratory rate of 16/min, and a blood pressure of 118/80 mm Hg. Physical examination revealed cutaneous convalescence after full-thickness burns of both hands, the coronal plane of the body and both legs. The skin showed fuscous, slight exudation, bleeding cracks, mild scaling and itch during the treatment process (fig. ). Severe edema in the bilateral lower extremities and scrotums were also observed.\nNo lymphadenopathy, hepatosplenomegaly, or neurological abnormalities were shown. Electrocardiogram and chest X-ray were normal. Abdominal ultrasonography showed bilateral normal-sized kidneys. No antineutrophil cytoplasmic antibodies, antiglomerular basement membrane antibodies and antinuclear antibodies were detected. The laboratory test results of the urine and blood for this patient are listed in table . He was diagnosed as having nephrotic syndrome on the basis of a diminished serum albumin level of 23 g/l and an increased proteinuria excretion of 10.0 g/24 h. During the treatment course, microbiological examination of wound secretion was performed twice a week and no infection was observed.\nA percutaneous renal biopsy was performed on September 11, 2012 (day 57 after burn injury) to explore the cause of proteinuria. The examination under light microscopy revealed a diffuse and moderate proliferation of mesangial cells and endothelial cells without observable crescents in 20 glomeruli. Hyaline droplets containing proteins and lipids in tubules were observed. Meanwhile, red blood cells in some tubules were also observed. The interstitium showed diffuse edema and scattered infiltration of mononuclear cells. Arterioles presented as normal status. Neither tubular atrophy nor interstitial fibrosis was found, as shown in figure .\nIgA and C3 are predominant immunoreactants for the diagnosis of IgAN. Immunofluorescence revealed IgA (3+), trace IgM, C3 (3+), IgG (–), C4 (–) and C1q (–) in a coarse granular pattern with mesangial and capillary distribution (fig. ), and inconspicuous staining for IgM along the glomerular capillary walls in a granular pattern. In addition, this patient showed negative staining of HBsAg and HBcAg.\nUltrastructural studies showed high-density deposits of mesangial and subendothelial cells. The mesangial hypercellularity and increased mesangial matrix were present between the glomerular basement membrane and glomerular endothelium. The thickened capillary wall was composed of basement membrane-like materials, interposed mesangial cells, and electron-dense immune-type deposits (fig. ).\nBased on the proliferative properties of glomerular lesions, the patient was started on therapy with oral prednisone at a dose of 1 mg/kg/day. After treatment, the excretion of urinary protein revealed a significant decrease from 10.0 to 5.20 g/24 h in 2 weeks. Then, the patient was discharged and treatment was continued at the outpatient section. The patient had been followed up to date and showed normal renal function and mild proteinuria.

[[46.0, 'year']]

M

{'23000373': 1, '22819700': 1, '10851994': 1, '19473624': 1, '22871574': 1, '28117341': 1, '14690266': 1, '20547000': 1, '20061841': 1, '22226222': 1, '24707281': 2}

{}

3975748-1

noncomm/PMC003xxxxxx/PMC3975748.xml

A Novel Mutation of the GNE Gene in Distal Myopathy with Rimmed Vacuoles: A Case with Inflammation

A 40-year-old Thai man had developed gradual but progressive left leg and left arm weakness over 7 years. He could not flex his left foot upward and had difficulty using the left hand. He also noticed weakness on his right leg and right hand for the last 4 years. Physical examination revealed muscle atrophy in both arms and legs. The muscle volume and strength of distal muscles on both sides of the extremities were markedly decreased, especially in the forearms, hands, and feet. Motor power of both sides of the body rated by the Medical Research Council Scale was as follows: tibialis anterior 2/5, quadriceps 4/5, gastrocnemius and soleus 5/5, forearm flexors and intrinsic hand muscles 3/5, and triceps and biceps 5/5. The muscle strength of deltoid and supraspinatus on the left side was 4/5 but 5/5 on the right side. The deep tendon reflexes at the ankle were diminished. There was no other neurologic abnormality. There was no clinical or laboratory evidence of systemic or connective tissue diseases. Serum creatine kinase (CK) was mildly increased to 293 IU/l. He was initially treated with corticosteroids but there was no significant clinical improvement. A nerve conduction study and electromyogram were consistent with chronic myopathy predominantly involving the intrinsic hand muscles and tibialis anterior muscles. Whole-spine magnetic resonance imaging was within normal limits. Magnetic resonance imaging of the muscles was not performed. There was no history of muscle disease or consanguineous marriage in his family. The patient was partially wheelchair-bound but could walk with assistance.

[[40.0, 'year']]

M

{'22507750': 1, '31938415': 1, '12913203': 1, '12473753': 1, '21868336': 1, '27858732': 1, '14678807': 1, '11528398': 1, '15676110': 1, '23287327': 1, '20354512': 1, '25976366': 1, '22196754': 1, '12743242': 1, '19596068': 1, '21294420': 1, '16810679': 1, '24707269': 2}

{}

3975749-1

noncomm/PMC003xxxxxx/PMC3975749.xml

Trabectedin in Advanced High-Grade Uterine Leiomyosarcoma: A Case Report Illustrating the Value of 18FDG-PET-CT in Assessing Treatment Response

A 60-year-old woman presented following 2 episodes of postmenopausal bleeding, several months apart. The patient had no significant medical, surgical or family history, was on no medication and with all previous screening investigations reported as normal. Initial trans-abdominal and trans-vaginal ultrasound scans demonstrated appearances which were felt to be consistent with uterine fibroids. A subsequent CT scan confirmed a large (80 μ 60 mm) heterogeneously enhancing but predominantly hypo-dense mass within the uterus, extending deeply, with only a very thin layer of normal myometrium. There were no enlarged lymph nodes and no evidence of local or distant disease spread. Endometrial chippings obtained by Pipelle biopsy demonstrated a high-grade sarcoma, with a mitotic count of 15 per 10 high-powered fields. Cells were positive for vimentin, strongly positive for oestrogen receptors and moderately positive for progesterone receptors. Staining for cytokeratin, actin, myoD1 and CD10 was negative. A total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed, following which histology confirmed a high-grade, undifferentiated sarcoma of the uterine corpus extending deeply into the myometrium and reaching up to the serosa.\nLymphovascular invasion was present and the mitotic count was high, at 42 per 10 high-powered fields. There was no evidence of malignancy affecting the fallopian tubes, ovaries, cervix or the single pelvic lymph node removed. Peritoneal washings were negative for malignancy. This was reported as an International Federation of Gynaecology and Obstetrics (FIGO) stage 3a high-grade uterine sarcoma []. Following surgery, the patient commenced a course of adjuvant chemotherapy, receiving five 3-weekly cycles of the combination of doxorubicin (50 mg/m2) and ifosfamide 5 g/m2 (1,700 mg/m2 on days 1, 2 and 3). Repeat CT imaging of the chest, abdomen and pelvis was performed on completion of adjuvant chemotherapy and, again, 26 months after surgery. On neither scan was there any evidence of metastatic disease. At a routine review 31 months after surgery, the patient described a short history of new pelvic discomfort although she remained well, with an Eastern Cooperative Oncology Group (ECOG) performance status of 0. Magnetic resonance imaging (MRI) of the pelvis confirmed a large (7.5 μ 5 cm) heterogeneous mass in the anterior pelvis, indenting the bladder, with 2 soft tissues nodules (3 μ 2.3 and 1.6 μ 1.4 cm) in the pelvis. A subsequent CT scan demonstrated new pulmonary metastases and a bone metastasis in the T7 pedicle.\nOn confirmation of metastatic disease, and in view of the strongly positive staining for oestrogen receptors on the original histology, the treatment selected was a trial of the aromatase inhibitor letrozole (2.5 mg). However, CT reassessment after 8 weeks of therapy demonstrated a marked increase in the size of the pelvic masses, along with minor increases in the sizes of both the pulmonary and T7 metastases. There was new metastatic involvement of the L3 pedicle. An 18FDG-PET-CT scan confirmed the disease was moderately FDG avid and revealed multiple additional sites of skeletal involvement, including the right scapula, left sixth rib and right acetabulum. The multiple pelvic masses were described as being confluent and part solid, part cystic, with a maximum axial dimension of 13 cm. The cystic components were FDG negative, whilst the most FDG-avid soft tissue component was located medial to the right external iliac vessels, with a maximum standardized uptake value (SUVmax) of 9.4.\nConsidering disease progression with letrozole, trabectedin was commenced at an initial dose of 1.5 mg/m2 administered as a 24-hour intravenous infusion every 3 weeks. Each infusion was preceded by 500 ml 0.9% sodium chloride and 20 mg dexamethasone intravenously. Treatment was tolerated well with grade 2 fatigue and grade 1 nausea, responding to oral cyclizine, being the worst trabectedin-related adverse events. The patient's ECOG performance status continued to be 0 for at least half of every cycle and was never greater than 1. After 3 cycles of trabectedin, a further 18FDG-PET-CT scan was performed to assess initial response to therapy (fig. , right panel). The pulmonary disease was stable and the skeletal deposits had marginally increased in avidity. There was a marked increase in the size of the pelvic mass, with expansion of the cystic component, such that the maximum diameter was now 20.1 cm. However, there was an associated reduction in the SUVmax of the solid component of the pelvic mass, indicating a cystic or necrotic response in the tumour to trabectedin, with the site of most active disease displaying reduced FDG uptake. No new lesions were identified. Taking into consideration the response detected by PET-CT, treatment continued with trabectedin.\nFollowing 3 cycles, the frequency of administration was reduced to 4-weekly, and after 6 cycles the dose was reduced to 1.3 mg/m2. Each change was made in response to escalating fatigue (>grade 2). A pelvic ultrasound scan after the sixth cycle of trabectedin suggested a subjective interval decrease in the solid peripheral component of the pelvic tumour. Yet, before the patient could proceed to cycle 7 she was admitted for acute abdominal pain and vomiting. At this stage a repeat pelvic ultrasound scan revealed that the complex pelvic mass had collapsed, with crenation of the peripheral margin and new moderate-volume generalized ascites. A total of 3.7 litres of sero-sanguinous fluid was drained with marked symptomatic relief, and the patient was discharged home after 48 h with no treatment delays. A further 2 cycles of trabectedin 1.3 mg/m2 were administered at 4-weekly intervals, following which reassessment of the extent of disease was made. Interpretation was complicated by the pelvic cystic collapse and subsequent drainage, altering tumour size and by implication any response measure as per RECIST. However, on 18FDG-PET-CT there was clear evidence of ongoing disease improvement after 7 months of treatment with trabectedin (fig. ). The lingular pulmonary metastasis had reduced in size and become FDG negative, and there was further reduction in the size of a second left upper lobe pulmonary metastasis. The bony metastases were stable. The solid pelvic components were at worst stable, with an unchanged SUVmax, and possibly marginally reduced in size. The patient continued on trabectedin 1.3 mg/m2, 4-weekly, finally showing signs of progression on an 18FDG-PET-CT scan performed after a total of 13 cycles of treatment, administered over 13 months. The safety profile of trabectedin remained manageable, showing no evidence of cumulative toxicity, maintaining quality of life. Fatigue resulted in an ECOG performance status that fluctuated between 0 and 1 during the treatment.\nAll procedures were conducted in accordance with the Declaration of Helsinki, guidelines for good clinical practice and local regulations, and were approved by the institutional review board. Signed informed consent was obtained from the patient.

[[60.0, 'year']]

F

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{}

3975750-1

noncomm/PMC003xxxxxx/PMC3975750.xml

Primary Pulmonary Synovial Sarcoma during Pregnancy: A Diagnostic and Therapeutic Dilemma

A 26-year-old Caucasian female, G2P1, at 21 weeks’ gestation with no other significant medical history presented to a community hospital with a dry cough and right-sided pleuritic chest pain, which radiated to her right shoulder. She reported no family history of unusual or early-onset malignancies, she never smoked and she worked as a receptionist at a wastewater management company. Her previous pregnancy 2 years ago was uncomplicated and resulted in a healthy baby boy.\nOn presentation, the patient was afebrile, tachypneic, and tachycardic with normal pulse oximetry. Physical examination was remarkable for diminished lung sounds at the right base. Her complete blood count was remarkable only for a low-grade normocytic anemia and her comprehensive metabolic panel was normal. Her symptoms and pregnancy-associated risk were suggestive of a pulmonary embolus, which prompted a CT of the chest with IV contrast. The CT scan revealed a smooth, lobulated 6.5-cm mass in the right hilum (fig. ). No parenchymal disease or pulmonary emboli were appreciated. She was referred to our academic center for further evaluation and treatment considerations.\nOne week after her initial presentation, the patient underwent bronchoscopy, which disclosed a mass arising in the airway. Multiple transbronchial needle aspirations and forceps biopsies were performed.\nH&E staining of the biopsied specimens revealed malignant spindle cells infiltrating endobronchial tissue (fig. ). Immunohistochemistry was positive for CD99 and Bcl-2, but negative for CD34 (fig. ). Additional stains for epithelial membrane antigen pancy-tokeratin AE1/3, Cam5.2, desmin, smooth muscle actin, S-100, and HMB45 were all negative.\nFluorescence in situ hybridization performed on the formalin-fixed paraffin embedded tissue revealed two populations: a predominant population (>90%) of polypoid cells with multiple copies of SYT probe of which >80% had the break-apart signal and a small population (10%) of diploid cells showing the break-apart signal for SYT probe. The combined histopathology, immunohistochemistry, and fluorescence in situ hybridization studies confirmed the diagnosis of monophasic spindle cell synovial sarcoma.\nIt was unclear at presentation if this represented a metastatic or primary pulmonary synovial sarcoma. Due to her pregnancy and possible fetal risk, the patient declined whole body imaging (i.e., PET-CT) to survey for a possible primary source. A repeat comprehensive physical exam failed to reveal any soft tissue masses. Based on these clinical observations and testing, it was assumed that the lung mass was a primary pulmonary synovial sarcoma.\nSurgical resection, the only possible immediate cure, was deferred due to pregnancy as well as the size and proximity of the mass to vital structures. Neoadjuvant chemotherapy would necessarily focus on containing the growth of the mass, with hopes of inducing tumor necrosis, without causing undue harm to the fetus. A literature review yielded data supporting clinical benefit and acceptable third-trimester fetal risk associated with ifosfamide [, , ]. She was given 2 cycles of ifosfamide as follows: 2 g/m2 IV bolus over 4 h followed by 2 g/m2/day as continuous IV infusions for 6 days (the total dose given was 14 g/m2/cycle) each along with mesna. These were initiated at 26 and 29 weeks’ gestation.\nAt 31 weeks’ gestation, the patient reported deceased fetal movements. Her obstetrician discovered oligohydramnios and a non-reassuring fetal tracing. The patient was then rushed to the operating room for an emergency C-section. She delivered a baby boy, who, aside from typical prematurity-associated concerns, was healthy. The patient's follow-up chest CT after delivery showed approximately 30% decrease in the size of the primary mass (fig. ).\nAfter delivery, the patient was treated with two more cycles of standard neoadjuvant chemotherapy with mesna, adriamycin, and ifosfamide. She also underwent a PET-CT, which showed increased metabolic activity solely at the site of the known lung malignancy and an estimated 30% decrease in the size of the primary mass. She was then scheduled for right total pneumonectomy and mediastinal lymphadenectomy approximately 8 weeks after the birth of her son. Gross pathology revealed a large, white-tan, necrotic tumor mass in the right upper lobe extending inferiorly down into the interlobar fissure. Histology confirmed the primary diagnosis of synovial sarcoma, with evidence of necrosis. All 5 resected lymph nodes as well as the bronchial and vascular margins were free of tumor. Adjuvant mesna, adriamycin, and ifosfamide were offered, but the patient declined due to concerns about toxicity.\nA PET-CT scan performed 5 months later revealed recurrent sarcoma and a 4.7-cm right hilar and hypermetabolic mass compressing the right main pulmonary artery and indenting the left atrium. There was no evidence of metastatic disease. Bronchoscopy with endobronchial ultrasound delineated a right hilar/paratracheal mass 3–4 cm in size, causing extrinsic compression of the left mainstem bronchus. Palliative radiation therapy was then given (3,750 cGY over 15 days). The patient developed fistulae involving the trachea, bronchus, pleura, and esophagus, followed by cardiomyopathy and pneumonia. She eventually succumbed to her disease and passed away approximately 13 months after her diagnosis.

[[26.0, 'year']]

F

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{'8313357-1': 1}

3975751-1

noncomm/PMC003xxxxxx/PMC3975751.xml

Anti-N-Methyl-D-Aspartate Receptor Encephalitis Causing a Prolonged Depressive Disorder Evolving to Inflammatory Brain Disease

In June 2012, a 32-year-old woman was referred to our clinic to investigate a progressive cognitive dysfunction, cerebellar ataxia, abnormal movements and a reduced word output. She had a 9-month history of slowly progressing mood changes and ‘brain fog’. The patient was a high school teacher, with an unremarkable medical history, who lived with her husband and 20-month-old son. Five months earlier, she had attended a psychiatric clinic where she received a tentative diagnosis of postpartum depression. Antidepressants and benzodiazepines left her clinical condition unchanged. Thereafter, while under psychiatric care, the patient slowly began to experience hypersexuality, dysarthria, imbalance, decreased word output and episodes of unexplained crying. EEG tracings at that time showed diffuse slowing without epileptiform activity. Upon referral to our clinic, a brain MRI disclosed widespread multifocal lesions, hyperintense on T2-weighted images, involving the brainstem, the thalamus, the caudate and lenticular nuclei, the insula and the corona radiata. Two periventricular lesions and several small spots in the insula and pyramidal tract showed a contrast enhancement. Given the clinical and MRI findings, the patient was admitted for further investigation.\nOn examination, the patient was alert. Her speech was dysarthric, hypophonic and she answered in short phrases. Cognitive testing disclosed a markedly impaired executive function. Color vision testing detected dyschromatopsia and visual field testing found full visual fields on confrontation. Saccades were hypometric and slow with upward palsy. She had postural instability, an ataxic gait, dysmetria, oro-lingual facial dyskinesias, choreoathetosis, hand dystonia and mild muscle rigidity. Deep tendon reflexes were brisk with bilateral ankle clonus. Hematologic and serum chemical tests, including a screening for rheumatologic diseases and a comprehensive panel for infectious, metabolic and paraneoplastic disorders yielded negative findings. The whole-body PET scan was unremarkable. Upper and lower limb somatosensory and motor evoked potentials elicited slightly reduced amplitudes on the left side; conversely, flash-evoked visual potentials showed prolonged N2 and P2 latencies (fig. ). Cerebrospinal fluid (CSF) analysis, including tau protein level and a 14-3-3 protein assay yielded normal findings, except for an elevated IgG index and oligoclonal IgG bands; we detected anti-NMDAR IgG antibodies. CSF cell count showed 1 white cell per milliliter and nucleic acid testing for HSV, VZV and enteroviruses was negative. In addition, testing of serum and CSF for water channel protein aquaporin-4-IgG-Ab by indirect immunofluorescence was negative. The positive CSF anti-NMDAR and negative serum findings were also confirmed elsewhere using human embryonic kidney cells expressing the NR1 subunits (Dr. Josep Dalmau, Hospital Clinic, Universitat de Barcelona, Spain). In July 2012, a brain scan using a 3T MR scanner detected multiple and partially confluent punctate foci of T2/FLAIR hyperintensity, unenhanced after gadolinium, bilaterally in the basal telencephalon, diencephalon, external capsulae, subcortical insula, periventricular white matter, temporal horns, corpus callosum, and optic nerves as well as the ventral cerebral peduncles, pontine-mesencephalic junction and dorsal pons (fig. ). Spectroscopy of the left basal ganglia region and the right midbrain tegmentum, acquired with the single-slice multi-voxel chemical-shift technique (TE = 30 and 135 ms), showed a reduced N-acetyl aspartate (NAA) peak and a slightly increased choline (Cho) peak, resulting in an inverted Cho/NAA ratio, in addition to lipid traces and an absence of lactate within a high signal-intensity foci.\nThese brain metabolic findings were consistent with widespread encephalitis, characterized by confluent bilateral demyelination areas and focal optic nerve involvement in a late subacute stage. The patient was treated with oral corticosteroids followed by two IVIg cycles, given at 2-week intervals, in August 2012. After treatment, the gait ataxia improved and her mood improved, but the EEG tracings were unchanged. At neuropsychological evaluation, working memory, attention, and the logical-deductive capacities remained altered; the Mini-Mental State Examination score was 26/30. Between August and November 2012, the patient received 4 IVIg cycles given at 4-week intervals.\nIn November, a repeat MRI scan showed a reduction in the number and the extension of lesions previously described, with a new, non-enhancing lesion in the left basal ganglia. Thereafter, therapy was switched to cyclophosphamide. In December 2012, neurological evaluation showed a slight improvement of speech, ataxia and cognitive function; dystonic posturing of the left hand, slight postural tremor of the left limbs, brisk reflexes, muscle rigidity in the lower limbs and oro-lingual dyskinesias were observed. In March 2013, brain MRI showed that most alterations had disappeared and residual lesions were no longer contrast enhanced (fig. ). A PET brain scan showed a reduced glucose metabolism in the temporal lobes and the left striatum, relative to other cortical areas (fig. ).\nAt the last visit in August 2013, cognitive function, speech and balance had improved, but emotional liability and her attention deficit persisted.

[[32.0, 'year']]

F

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{'3673874-1': 1, '7383012-1': 1}

3975752-1

noncomm/PMC003xxxxxx/PMC3975752.xml

Complete Remission of Brain Metastases in Non-Small Cell Lung Cancer Patients Harboring an EGFR Mutation Treated with Tyrosine Kinase Inhibitor without Radiotherapy: A Report of 3 Cases

A 60-year-old man with a history of smoking presented at our hospital due to back pain and a chest X-ray abnormality. Lung adenocarcinoma was diagnosed with a bronchoscopic biopsy, and whole body positron emission tomography-computed tomography (PET-CT) showed multiple metastases on the lumbar spine and pelvic bone. The tumor was found to have an EGFR mutation (exon 19 deletion) and sequential brain magnetic resonance imaging (MRI) revealed multiple tiny enhancing nodules in the left occipital lobe and cerebellum. Gefitinib (250 mg/day) was administered and radiotherapy was performed on the lumbar vertebra. WBRT was deferred due to the absence of symptoms. One month after gefitinib treatment was initiated, interval regression of BM was identified on a follow-up brain MRI. After another 3 months, metastatic lesions were not discernible on a follow-up brain MRI (fig. ).

[[60.0, 'year']]

M

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{'3975752-2': 2, '3975752-3': 2}

3975752-2

noncomm/PMC003xxxxxx/PMC3975752.xml

Complete Remission of Brain Metastases in Non-Small Cell Lung Cancer Patients Harboring an EGFR Mutation Treated with Tyrosine Kinase Inhibitor without Radiotherapy: A Report of 3 Cases

A 72-year-old woman without a history of smoking presented with supraclavicular lymphadenopathy. An incisional biopsy of the lymph node was performed, and the pathologic result was adenocarcinoma with cytokeratin-7 (CK-7) and thyroid transcription factor-1 (TTF-1) positivity on immunohistochemical staining. The tumor was harboring an EGFR mutation (exon 19 deletion). Whole body PET-CT showed multiple bone metastases with mediastinal lymphadenopathy. Brain MRI identified well-defined enhancing round nodules on the right frontal and left parietal lobes. She received gefitinib (250 mg/day) and palliative radiotherapy for the painful pelvic bone metastases. WBRT was put off because she did not complain of neurologic symptoms. A brain MRI performed 6 months later showed interval regression of multiple BM. The metastatic nodules disappeared after another 3 months (fig. ).

[[72.0, 'year']]

F

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{'3975752-1': 2, '3975752-3': 2}

3975752-3

noncomm/PMC003xxxxxx/PMC3975752.xml

Complete Remission of Brain Metastases in Non-Small Cell Lung Cancer Patients Harboring an EGFR Mutation Treated with Tyrosine Kinase Inhibitor without Radiotherapy: A Report of 3 Cases

A 74-year-old woman without a history of smoking presented with a scalp mass. An incisional biopsy performed on the scalp mass revealed adenocarcinoma with CK-7 and TTF-1 positivity on immunohistochemical staining. An EGFR mutation analysis found an exon 21 L858R point mutation. Whole body PET-CT detected a lung mass and multiple bone metastases. Brain MRI identified several tiny enhancing nodules on both cerebral hemispheres. After 5 months of gefitinib treatment (250 mg/day), a follow-up brain MRI showed no brain parenchymal metastatic lesions (fig. ).

[[74.0, 'year']]

F

{'23453646': 1, '24048959': 1, '25548673': 1, '23715918': 1, '27446584': 1, '24021541': 1, '24133369': 1, '22631670': 1, '22127359': 1, '22846582': 1, '23564810': 1, '23341526': 1, '31815659': 1, '29354805': 1, '17239293': 1, '22677429': 1, '21135267': 1, '19692934': 1, '19157632': 1, '23407558': 1, '24707263': 2}

{'3975752-1': 2, '3975752-2': 2}

3975753-1

noncomm/PMC003xxxxxx/PMC3975753.xml

Discrepancy between the Clinical Image and Pathological Findings of Non-Small Cell Lung Cancer Harboring an Epidermal Growth Factor Receptor Gene Mutation That Was Surgically Resected after Gefitinib Treatment

A 66-year-old female never-smoker with no significant medical history was referred to our hospital for the evaluation of an abnormal shadow observed on a chest X-ray film. Chest computed tomography (CT) revealed a 4.4-cm primary mass in the left upper lobe beside the main pulmonary artery and the growth of mediastinal lymph nodes (cT2aN2M0 stage IIIA) (fig. ). Fluorodeoxyglucose positron emission tomography (FDG-PET) showed FDG uptake in the mass with a maximal standardized uptake value (SUV) of 12.2, and in mediastinal lymph nodes with an SUV of 6.6 (fig. ). She was diagnosed with lung adenocarcinoma (fig. ) by a transbronchial lung biopsy. The L858R mutation in exon 21 of the EGFR gene was identified in the primary lung tumor. We gave the patient and her family three possible treatment options: concurrent CRTx (using standard platinum-based doublet chemotherapy), induction chemotherapy followed by surgery, or gefitinib therapy. They selected gefitinib therapy. Therefore, systemic chemotherapy with gefitinib (250 mg/body) was performed.\nAfter 3 months of gefitinib treatment, a radiological CT evaluation revealed that there was a PR to gefitinib (regression rate was 35%) (fig. ), and a PET scan image showed positive accumulation of FDG (SUV max. 4.0) in the tumor (fig. ). Because of the good response, the patient wanted to undergo surgery. The gefitinib administration was stopped 2 weeks prior to surgery so that the drug would not interfere with tissue repair. We performed a left upper lobectomy and a combined resection of S6, which was involved by the tumor, and a systematic lymphadenectomy. Because the initially swollen lymph nodes had become thickened fibrous scars owing to the response to gefitinib, it was difficult to expose the superior trunk of the pulmonary artery. Finally, complete resection was achieved. The postoperative course was uneventful. The pathological examination revealed adenocarcinoma in the primary site, hilar lymph node (#12u) and mediastinal lymph node (#5), which also involved extra nodal disease. The tumor size was 37 × 32 × 30 mm, and the left S6 was considered to have higher than interlobar involvement (pT2aN2M0 stage IIIA). The pathologically therapeutic effect was considered to be slight or of no response (fig. ). EGFR T790M mutation and MET amplification, which are often acquired following gefitinib treatment, were not observed [].\nRadiation therapy was performed for the mediastinal lymph nodes because of the extranodal invasion. Ten months after the operation, the patient developed recurrence in the cervical lymph nodes and multiple pulmonary metastases. Gefitinib therapy was tried again, and the effect was a PR of the lymph nodes and complete response of the pulmonary metastases. She is doing well and is still being treated with gefitinib, 16 months after surgery.

[[66.0, 'year']]

F

{'23456778': 1, '21315472': 1, '22753915': 1, '15738541': 1, '19884551': 1, '21558399': 1, '22688581': 1, '30370131': 1, '22481232': 1, '20573926': 1, '20881637': 1, '17548126': 1, '22722786': 1, '20674944': 1, '24707260': 2}

{}

3975754-1

noncomm/PMC003xxxxxx/PMC3975754.xml

High-Dose Lanreotide in the Treatment of Poorly Differentiated Pancreatic Neuroendocrine Carcinoma: A Case Report

In February 2009, a 55-year-old woman presented with complaints of loss of appetite and a painful sensation in the gastric region after meals. In the past 30 days, she had also experienced episodes of diarrhea (mean <1/day) and flushing (1–2/day). Because of her age and irregular menstrual cycles, these episodes of flushing were interpreted as a menopausal sign. The patient suffered from arterial hypertension, controlled with bisoprolol 10 mg per day. Clinical examination did not reveal any significant findings, except for a dull pain in the epigastric region. An abdominal computed tomography (CT) scan revealed a mass of about 8 × 5 cm in the hilar region of the liver, involving the head of the pancreas and encasing regional blood vessels (fig. ). Dilated bile ducts were also observed, but there was no evidence of metastases. Dosing of serum chromogranin A (CgA) and neuron-specific enolase was performed. Potential diagnoses included pancreatic adenocarcinoma, cholangiocarcinoma, functional NET or NEC, colon cancer, lymphoma, metastases from melanoma or pheochromocytoma, and chronic pancreatitis.\nPositron-emission tomography-CT (PET-CT) scan using 18F-fluorodeoxyglucose (18F-FDG) confirmed a metabolically active mass in the hilar region of the liver extending to the head of the pancreas. Even though a colonoscopy could have excluded colon cancer from the list of differential diagnoses, it was not performed because the oncologist estimated that another pathology was more likely. CT-guided biopsy was performed; histopathology results revealed a neuroendocrine carcinoma with mitotic count based on 10 high-power fields of >20, and a Ki-67 proliferative index of 22%. Immunohistochemistry showed presence of chromogranin A (+++) and synaptophysin (+). According to the World Health Organization (WHO) 2010 classification, the tumor was graded as a poorly differentiated NEC (G3), small cell type [], and staged as T4NxM0 []. An elevated CgA level of 385 µg/l (reference range: 40–170 µg/l) was noted; neuron-specific enolase level was normal. Somatostatin receptor scintigraphy confirmed that the tumor expressed somatostatin receptors, indicating that treatment with SSAs could be beneficial, despite the poorly differentiated nature of the tumor.\nSurgical resection of the tumor was not an option due to the involvement of the celiac axis. Chemotherapy with carboplatin (target area under the curve = 5 mg/ml/min, administered intravenously on day 1) and etoposide (100 mg/m2, administered intravenously on days 1, 2 and 3) was initiated and repeated every 3 weeks. In addition, treatment with lanreotide Autogel (120 mg/4 weeks), injected deep subcutaneously, was initiated to control symptoms elicited by the secretion of hormones. After 6 cycles of chemotherapy, a partial response was observed: the size of the mass decreased to 2.3 cm, and was then interpreted as locally advanced, involving the epigastric and aortic area; no further lesions or PET activity were noticeable (fig. ). However, the patient experienced important side effects (nausea and vomiting) during the chemotherapy administration.\nAs the tumor size had decreased, surgery became feasible. After consultation with the tumor board and based on minilaparotomy results showing no peritoneal lesions, resection of the PET-positive lesion was performed with maximal debulking. An additional lesion in segment 3 of the liver was also removed. Pathological examination revealed an R1 resection in the distal margin of the resected mass, but no viable tissue in the liver lesion. Intensity-modulated radiotherapy was proposed because of the R1 resection and aggressive histological appearance of the tumor, but the patient refused it due to fear of gastrointestinal toxicity. Biotherapy using lanreotide Autogel (120 mg/4 weeks) was continued by the general practitioner (GP).\nAlthough monitoring of the disease progression using PET-CT and CgA dosing every 3 months was proposed, the patient was lost to follow-up for 10 months. During this time, lanreotide Autogel therapy was administered monthly by the GP. In August 2010, the GP referred the patient to the hospital with loss of appetite, 3–4 episodes of diarrhea per day since 1.5 months and up to 10 episodes of flushes per day since 3.5 months. Clinical examination revealed dull pain in the right hypochondrial and epigastric area and hepatomegaly. Laboratory results revealed CgA levels of 3,568 µg/l; bilirubin was elevated and hepatobiliary enzyme levels (ALT, AST, LDH, GGT) were 3–4 times over the upper limit of normal. A PET-CT scan showed that despite no local recurrence, the right liver lobe was extensively affected by a complex pattern of metastases (fig. ), making surgical resection impossible.\nAt that time, adequate symptom control could no longer be maintained by once per month administration of lanreotide Autogel; thus, biotherapy was continued at a double dose (120 mg/14 days). Fearing gastrointestinal toxicity, the patient refused to undergo chemotherapy with carboplatin and etoposide. An echocardiography was performed because the patient had signs of exercise-induced dyspnea and peripheral edema. The echocardiography revealed dilated right heart cavities, tricuspid valve insufficiency 4/4 (retracted valves, retrograde flow into dilated inferior vena cava and liver veins) and a normal left heart system. Based on these results, carcinoid heart disease was diagnosed, limiting further chemotherapeutic options (e.g. anthracyclines, fluid administration associated with cisplatinum). Treatment with diuretics, angiotensin-converting enzyme inhibitors and low molecular weight heparin was initiated. Right portal vein embolization (RPVE) was performed to ensure fast reduction of the hormone levels causing carcinoid heart disease and the severe burden from flushing and diarrhea. No resection was performed after RPVE, as it had no curative purpose; in addition, the patient refused another abdominal surgery (table ).\nValve replacement surgery was proposed, but was also refused. In September 2010, the patient asked for a pause in active therapy and only supportive treatments were continued. Adequate symptom control was achieved solely by administration of the double dose of lanreotide Autogel. Imaging showed a stable disease after 1.5 months. Three months after RVPE (December 2010), the liver metastases had progressed and bone metastases were also present. Molecular treatment with everolimus was administered at a dose of 10 mg per day. Biotherapy with double-dose lanreotide Autogel was continued and treatment with zoledronic acid at a dose of 4 mg for 4 weeks was initiated. After 6 months, the disease was documented as stable on imaging, but 1 month later the patient showed signs of hepatic failure and clinical disease progression became evident. The patient was switched to best supportive care and died in June 2011.

[[55.0, 'year']]

F

{'19713711': 1, '17312381': 1, '19402369': 1, '22261872': 1, '28860831': 1, '19077417': 1, '18097129': 1, '15477324': 1, '15627802': 1, '19845567': 1, '15888809': 1, '16967267': 1, '32010361': 1, '21907552': 1, '24707264': 2}

{}

3975755-1

noncomm/PMC003xxxxxx/PMC3975755.xml

Benefit of a Second Opinion for Lung Cancer: No Metastasis to the Kidney but a Synchronous Primary Renal Neoplasm

A 48-year-old female received palliative radiotherapy (30 Gy) directed to vertebrae Th9-Th12 and 4 cycles of chemotherapy [gemcitabin 1,200 mg/m2 (on days 1 and 8), carboplatin 80 mg/m2] for an 18-FDG-PET avid, thyroid transcription factor-1 (TTF-1) positive adenocarcinoma of the right lower lobe invading the thoracic vertebrae 10, and an additional 18-FDG-PET negative lesion in the right kidney, cytology-confirmed adenocarcinoma, considered as a distant metastasis (cT4NxM1). Therapy resulted in a slight reduction of both lesions. Due to the determined stage (IV), an expectative approach was opted. The patient initiated a second opinion.\nThe patient's data were reviewed and additional 18-FDG-PET and CT scans were performed. Except for the presence of the lesion in the kidney, no signs of metastases were found. Therefore, the initial diagnosis was reconsidered as two primary tumors: an adenocarcinoma of the lung, stage IIIB (cT4N0M0) and an adenocarcinoma of the right kidney (cT1a). Two cycles of neo-adjuvant chemotherapy (cisplatinum 80 mg/m2, pemetrexed 500 mg/m2 on days 1 and 21) were administered prior to lung surgery. Surprisingly, no tumor was found in the right lower lobe perioperatively. A hemicorporectomy of Th10 and a resection of the processus transversus of Th10 and Th11 were performed, followed by spine stabilization.\nWith regard to the lesion of the right kidney, an expectative approach was agreed because of stable disease (no growth), its localization (in the mid pole of the kidney) and small size (2.3 cm). Eleven months later, cryoablation was ultimately performed because the patient insisted on removal of the tumor, which revealed a papillary renal cell carcinoma. The postoperative course was uneventful. The patient is doing well more than 6 years after the initial diagnosis.

[[48.0, 'year']]

F

{'19740516': 1, '22977986': 1, '15470708': 1, '21940540': 1, '32637169': 1, '16485580': 1, '23649447': 1, '24707259': 2}

{}

3975756-1

noncomm/PMC003xxxxxx/PMC3975756.xml

Desmoplastic Small Round Cell Tumor: Report of 2 Cases Treated with Chemotherapy Alone or in Combination with Bevacizumab

A 22-year-old male presented with a 3-month history of intensive backaches and weight loss. Later, he noticed a mass in the hypogastrium region and lower limb lymphedema. It evolved into intestinal semiocclusion.\nOn computed tomography (CT), performed on August 18, 2009, the mass was confirmed to be a retrovesical tumor (fig. ), extending to the umbilical region, with peritoneal implants and the liver capsule (7.0 cm). A laparoscopy with biopsy was done, confirming an unresectable retroperitoneal mass. Histology and IH studies (table ) confirmed the diagnosis of DSRCT.\nOn September 19, 2009, with a performance status (PS) of 3, the patient began chemotherapy [doxorubicin 60 mg/m2 and cisplatin 60 mg/m2 on day (D)1], as available from the public service. On D15, resolution of the bowel obstruction was noted. After the 3rd cycle of chemotherapy, abdominal CT still showed a solid heterogeneous mass, but with a reduction of 42%. After the 8th cycle of chemotherapy, on May 3, 2010, a new CT scan showed stabilization of the lesions; however, they remained inoperable. The patient was referred for outpatient palliative care. On September 30, 2010, he unfortunately progressed to death due to neoplastic cachexia. Since the initial diagnosis, he had had a survival time of 13 months.

[[22.0, 'year']]

M

{'8375856': 1, '21301996': 1, '26566481': 1, '33126354': 1, '9738572': 1, '8622067': 1, '22096758': 1, '30652419': 1, '2473463': 1, '34604040': 1, '33192158': 1, '22162435': 1, '22550424': 1, '15557784': 1, '8689345': 1, '26893693': 1, '22643247': 1, '18573782': 1, '24707256': 2}

{'3975756-2': 2}

3975756-2

noncomm/PMC003xxxxxx/PMC3975756.xml

Desmoplastic Small Round Cell Tumor: Report of 2 Cases Treated with Chemotherapy Alone or in Combination with Bevacizumab

A 37-year-old male presented with a 2-month history of poor digestion and weight loss of 7 kg. On clinical examination, a right abdominal tumor mass was found. Magnetic resonance imaging (MRI) confirmed an abdominal lesion, measuring 18.9 × 16.6 cm, on the periphery of the liver segment VI. A chest CT scan was normal. At exploratory laparotomy, on October 7, 2008, a tumor attached to the liver, invading the splenic hilum, omentum, and mesenteric region was found. Partial resection was possible. Histology and IH studies (table ) were compatible with DSRCT.\nHe started chemotherapy (carboplatin AUC5, paclitaxel 180 mg/m2, and bevacizumab 7.5 mg/kg) on November 18, 2008, for 21/21 days, with a covenant provided by private health insurance. He had PS 3 (73 kg) and changes in liver function. After the 3rd round of chemotherapy, on January 16, 2009, MRI already showed partial remission (78.6% reduction). After the 8th cycle, on May 12, 2009, a presurgical positron emission tomography (PET) reassessment was performed. Interestingly, PET showed physiological distribution of F-18-fluorodeoxyglucose (FDG) without identifying any uptake (fig. , fig. ). A concomitant CT scan showed tumor infiltration of the hilum, hepatic parenchyma, and peritoneal implants (fig. ).\nA new surgical approach was contraindicated. On June 16, 2009, chemotherapy was stopped at the patient's request. Two months after that, there was a clinical and liver function worsening due to tumor progression and compression of the biliary tract. A retrograde endoscopic cholangiopancreatography was done and a stent was successfully placed.\nChemotherapy was restarted on August 26, 2009. He already had new partial remission. This scheme was discontinued after the 10th cycle on March 30, 2010 (4.9-cm tumor) due to more frequent occurrences of neutropenia. Chemotherapy was then initiated with cyclophosphamide 50 mg/day, oral, and bevacizumab; this regimen was maintained until November 16, 2010, when it was suspended because of worsening of the patient's clinical state and laboratory findings. He remained in hospice care until his death on July 22, 2011, due to neoplastic cachexia and hepatic encephalopathy. He had had a survival time of 34 months after the initial diagnosis.

[[37.0, 'year']]

M

{'8375856': 1, '21301996': 1, '26566481': 1, '33126354': 1, '9738572': 1, '8622067': 1, '22096758': 1, '30652419': 1, '2473463': 1, '34604040': 1, '33192158': 1, '22162435': 1, '22550424': 1, '15557784': 1, '8689345': 1, '26893693': 1, '22643247': 1, '18573782': 1, '24707256': 2}

{'3975756-1': 2}

3975757-1

noncomm/PMC003xxxxxx/PMC3975757.xml

Efficacy of XELOX plus Bevacizumab in Brain Metastasis from Rectal Cancer

A 62-year-old man was referred to our hospital with abdominal fullness and gait disturbance. Barium enema revealed a nearly obstructing tumor in the rectum. Stenosis prevented the endoscope from passing through. The patient needed a fasting because of stenosis of the rectum. Abdominal computed tomography (CT) revealed more than 10 hepatic metastases. Head CT and MRI showed two cerebellar metastases (fig. ). The patient underwent a resection of BM and loop transverse colostomy. We started XELOX + BV [BV (7.5 mg/kg) and oxaliplatin (130 mg/m2) on day 1 plus capecitabine (1,000 mg/m2) twice daily on days 1–14, every 3 weeks] which was administered on postoperative day 28 []. After 4 cycles of XELOX + BV, CT and MRI showed a reduction in tumor size (fig. ). Laboratory studies revealed a serum carcinoembryonic antigen (CEA) level of 3,460 ng/ml, which improved to 936 ng/ml after 4 cycles of chemotherapy. Observed adverse events that had appeared before were only a peripheral neuropathy in the acute stage (grade 1) and hand-foot syndrome (grade 1). Hematological toxicity, surgical site infection and incisional hernia were not noted.\nAfter 8 months, tumor progression has not occurred, and the patient is still undergoing therapy with XELOX + BV.

[[62.0, 'year']]

M

{'15867200': 1, '22287384': 1, '19738122': 1, '12778165': 1, '12888888': 1, '12173339': 1, '2273405': 1, '20332478': 1, '17596102': 1, '18725212': 1, '20028762': 1, '25417044': 1, '17470858': 1, '23388092': 1, '18279580': 1, '15269313': 1, '17538177': 1, '19720927': 1, '24811333': 1, '28167569': 1, '16098251': 1, '19433393': 1, '10223560': 1, '23049262': 1, '24707258': 2}

{}

3975758-1

noncomm/PMC003xxxxxx/PMC3975758.xml

Oncocytoma of the Parotid Gland: A Case Report and Review of the Literature

A 67-year-old male presented to the ENT service with left facial swelling of 5 months duration. His medical history was unremarkable, he had no pain or cutaneous inflammatory reaction. An intraoral exam revealed swelling of the soft tissue palate, and CT and MRI imaging studies were performed to identify the nature of the swelling.\nCT revealed an isodense expansive mass of 7.3 cm in diameter, partially confined to the inside of the left deep parotid lobule with moderate enhancement observed after intravenous contrast media injection. Hypodense areas were present.\nThe mass encompassed the anterior lateral and retromandibular vein, the anterior and medial pterygoid muscle, the pharyngeal mucous space, the posterior carotid space and obliteration of ipsilateral parapharyngeal fat resulting in a decrease of airway volume. The morphology of the right parotid gland and bilateral submaxillary glands was intact. The bilateral submaxillary, jugulodigastric, and left periparotid nonspecific lymph nodes were also intact (fig. , fig. ).\nMRI showed a large solid expansive process in the deep lobule of the left parotid gland. An isodense area was seen on T1 sequence and a mildly hyperintense on T2 (fig. , fig. ). After intravenous injection of paramegnetic contrast, a moderate enhancement was observed. The mass crosses the stylomandibular space, the parapharyngeal space involving the oropharyngeal posterior wall decreasing the airway. Furthermore, it involves the anterior base of the tongue and reaches the prevertebral space (fig. ).\nA biopsy was performed on oropharyngeal submucous samples resulting in the following diagnosis: ‘fragment of benign epithelial tumor consistent with oncocytoma’ (fig. ).\nFollowing the results of the tests, it was decided that surgical excision was the best treatment with total parotidectomy, complete tumor resection and facial nerve preservation (fig. ). At present, the patient has remained disease free with no signs of recurrence.

[[67.0, 'year']]

M

{'1730113': 1, '27335603': 2, '14759120': 1, '17921228': 1, '17761983': 1, '21454151': 1, '20181155': 2, '18544445': 1, '29971177': 1, '32710434': 1, '18272563': 1, '33842232': 1, '20395389': 1, '22215326': 1, '31737142': 1, '29599620': 1, '15041058': 1, '15659505': 1, '20652885': 1, '23120423': 1, '30034902': 2, '14697153': 1, '24707257': 2}

{'2827107-1': 1, '4908748-1': 1, '6032967-1': 1}

3976210-1

noncomm/PMC003xxxxxx/PMC3976210.xml

Progressive dysphagia and neck pain due to diffuse idiopathic skeletal hyperostosis of the cervical spine: a case report and literature review

The study has been approved by the Committee for Human Research at Navy General Hospital, and written informed consent was collected from the patient.\nA 71-year-old Asian man was referred to the orthopedic clinic of Navy General Hospital with the main complaint of chronic neck pain for 5 years and increased difficulty in swallowing solid food over the past 3 years. The neck pain was dull and progressive but generally tolerated by the patient. Sometimes neck pain would become sharp with certain body movements such as twisting or bending over. Over the past year he had altered his diet to include only soft foods and liquids, and he had an approximately 5 kg weight loss over that period of time.\nEsophagogastroduodenoscopy had been done 2 years before, and the results were unremarkable. He denied difficulty in breathing and any symptoms suggestive of cervical radiculopathy or myelopathy. The patient had had type 2 diabetes for 12 years and had been admitted to the local hospital on two previous occasions for control of his disease.\nOn physical examination, the patient was alert, afebrile, and well oriented, with stable vital signs. Cervical range of motion was significantly decreased, and a hard lump could be felt deep in the anterolateral cervical region. The neurological exam and the patient’s reflexes were normal. The patient did not show clinical, radiological, or serological evidence of rheumatoid arthritis or of ankylosing spondylitis. His neck disability index score was 62% and the visual analogue scale score for neck pain was 7 while hospitalized in our clinic.\nLaboratory tests including blood cell count, C-reactive protein, erythrocyte sedimentation rate, and autoimmune panel were normal. The lateral radiograph of his cervical spine showed characteristic flowing ossification along the anterior aspect of the cervical vertebrae from C2–C5, with relative preservation of the disc spaces (). The facet joints and spinous processes did not appear ankylosed. The bony mass compressed the esophagus anteriorly and resulted in marked swallowing tube stenosis. The computed tomography scan of the cervical spine revealed continuous but irregular flowing hyperostosis alongside the anterior aspect of all the cervical vertebrae as well as local ossification of the posterior longitudinal ligament (). There were especially striking osteophyte outgrowths covering the anterior side of the vertebrae and projecting into the soft tissues of the neck from the level of C2 to C5 (). The largest bony excrescences measured 16.32 mm thick. The anterior edge of the body of the vertebrae was clearly visible at the posterior limit of the outgrowth except at C4. Sagittal T2-weighted magnetic resonance imaging showed bone marrow signal abnormality (high signal intensity) in C5–C7 as well as in the outgrowth hyperostosis (). Magnetic resonance imaging did not show obvious spinal stenosis and cord compression. The features were characteristic of DISH or Forestier’s disease.

[[71.0, 'year']]

M

{'12606604': 1, '33728307': 2, '341323': 1, '31723619': 2, '30852868': 1, '15682880': 1, '32875895': 1, '31440668': 1, '24189840': 1, '1153976': 1, '19669655': 1, '26240723': 2, '21033027': 1, '28664003': 1, '14800245': 1, '3899489': 1, '25267806': 1, '15103260': 1, '29930166': 1, '2525941': 1, '33824560': 1, '24729695': 2}

{'6786737-1': 1, '4522454-1': 1, '7942043-1': 1}

3977155-1

noncomm/PMC003xxxxxx/PMC3977155.xml

Isolated Hemolytic Anemia: An Unusual Manifestation of Occult Malignancy

A 75-year-old female presented complaining of progressive fatigue and dyspnea over several months. Physical examination was significant only for pallor. Palpable splenomegaly was absent. Laboratory studies showed macrocytic anemia with a hemoglobin of 8.2 g/dL, hematocrit of 25.3%, and mean corpuscular volume of 103.7 fL; these values had been within normal limits one year prior. Her platelet count was 188,000/mL and white blood cell count was 10,000/mL, both normal, as were tests of renal and hepatic function, coagulation, and micronutrient levels including iron, folate, and vitamin B-12. The reticulocyte index was 2.4, but only 1.6 after correction for maturation factor, showing a suboptimal response to anemia. Erythrocyte sedimentation rate was elevated at 94 mm/h. Lactate dehydrogenase was elevated at 549 IU/L (normal range 90-250) and haptoglobin was undetectable, consistent with a hemolytic process. D-dimer was mildly elevated at 1.04 µg/mL, and fibrinogen was within normal limits at 363 mg/dL. A peripheral blood smear contained schistocytes and spherocytes, suggesting hemolysis, and also showed leukoerythroblastosis, with polychromasia, nucleated red blood cells, and immature granulocytes (). DAT was negative on two separate occasions, a cold agglutinin assay was negative, and hemoglobin electrophoresis and serum protein electrophoresis were normal. Flow cytometry found no evidence of paroxysmal nocturnal hemoglobinuria. Abdominal ultrasound showed a sonographically normal spleen. As part of the patient’s workup for anemia, upper endoscopy was performed and found no source of bleeding, but did recover a sessile 10 mm polyp from the gastric fundus, which was found to contain a microscopic focus of adenocarcinoma. A bone marrow biopsy revealed poorly differentiated signet ring adenocarcinoma, raising concern for a metastatic gastric cancer (). At this point cytotoxic therapy with capecitabine was initiated. The patient’s anemia continued to worsen, requiring several red blood cell transfusions, and she was given darbepoetin alfa to promote erythropoiesis. She developed an indirect hyperbilirubinemia of 2.7 mg/dL, while maintaining normal platelet counts and appropriate reticulocytosis, with a corrected reticulocyte index as high as 8.4. However, her anemia did not improve. A six-week trial of corticosteroids, given as empiric treatment for possible DAT-negative AIHA, similarly produced no improvement in anemia or in laboratory markers of hemolysis.\nAfter starting treatment for presumed gastric cancer, a palpable breast mass was discovered. Biopsy revealed signet ring adenocarcinoma that was histologically similar to both bone marrow and gastric polyp findings, with strong estrogen receptor positivity (). Additional immunohistochemical staining of the initial bone marrow sample was performed at this time, and was positive for estrogen receptor, E-cadherin, and GATA-3, consistent with primary breast cancer. PET-CT imaging showed diffusely mottled osseous structures consistent with an infiltrative process, but no other metastatic foci. In light of these findings, corticosteroids and chemotherapy were stopped and aromatase inhibition with anastrozole was initiated. This was followed by a rapid improvement in anemia, allowing blood transfusions and darbepoetin alfa treatments to be stopped. The patient survived 28 months from initial presentation with no evidence of recurrent hemolysis, before succumbing to progression of breast cancer.

[[75.0, 'year']]

F

{'17034030': 1, '20331741': 1, '23738188': 2, '22184535': 1, '22732949': 1, '11549777': 1, '20503022': 1, '19183189': 1, '22419897': 1, '23169533': 1, '17227897': 1, '21534942': 1, '228553': 1, '12478015': 1, '12897334': 1, '20820945': 1, '21779188': 2, '17986749': 1, '20736453': 1, '24711918': 2}

{'3657421-1': 1, '3129345-1': 1}

3977156-1

noncomm/PMC003xxxxxx/PMC3977156.xml

Glucose-6-Phosphate Dehydrogenase Deficiency Presented with Convulsion: A Rare Case

A 70-year-old female patient presented to the emergency department of Akdeniz University Medical Faculty Hospital (Turkey) with a complaint of fatigue. The patient had generalized tonicclonic seizures while she was in the emergency department; but spontaneously regressed in the follow-up. In the physical examination, the patient had no hepatosplenomegaly, peripheral lymphadenopathy, and there were no signs of jaundice.\nDuring the follow-up, she was oriented and cooperative. Her body temperature was 36.8 degrees Celsius. The patient’s brain MRI (magnetic resonance imaging) and diffusion MRI of the brain showed normal findings. The patient’s laboratory findings were as follows: hemoglobin: 8.5 g/dL (12-16 g/dL), number of red blood cells: 2.5 million/mm3 (4-6), LDH: 685 U/L (135-214 U/L), direct bilirubin: 0.45 mg/dL (0-0.2 mg/dL), total bilirubin: 6.67 mg/dL (0.1-1.2 mg/dL), reticulocytes 4.5% (0.5-1.5), creatinine: 0.7 mg/dL (0.7-1.2 mg/dL), platelets: 344,000/microliter (150,000-450,000/microliter), sodium: 140 mEq/L (136-145 mEq/L), potassium: 4.2 mEq/L 3.5-5.1 mEq/L), albumin 4.2 g/dL (3.9-4.9 g/dL), and calcium: 9.8 mg/dL (8.4-10.2 mg/dL). Normochromic-normocytic erythrocytes were present in the peripheral blood smear, while no atypical cells and blasts were present. There was no visible schistocytes and fragmentation. Negative direct Coombs and negative indirect Coombs tests were noted. The patient’s other laboratory findings were within normal ranges. The patient was hospitalized to find the etiology of her symptoms and 2 units erythrocyte suspension was given to the patient. The clinical electroencephalography was evaluated as normal, and as the patient had no seizure recurrence, her convulsion episodes were associated with acute symptomatic anemia by the department of neurology.\nThe hemoglobin electrophoresis test of the patient showed normal results. The patient’s hemoglobin level increased to 11.6 g/dL after transfusion but decreased again to 7.5 g/dL immediately in two days. The patient’s history revealed recent ingestion of broad beans two days prior to attending the emergency service. The blood test results showed low levels of glucose-6-phosphate dehydrogenase (G6PD), which was 1.7 IU/g Hb (4-10) and which was measured after transfusion. After 72 hours (the third day), 2 units of erythrocyte suspension was given again to the patient and the patient’s hemoglobin level increased to 10.9 with decreased bilirubin levels (direct bilirubin: 0.19 mg/dL; total bilirubin: 0.48 mg/dL); therefore, the patient was discharged with improved symptoms. She was followed-up in hematology outpatient clinic. The patient’s glucose-6-phosphate dehydrogenase level was checked during her hematology outpatient follow-up and the level was found 3.4 IU/g Hb (4-10) with a normal reticulocyte count of 1.37% (0.5-1.5).

[[70.0, 'year']]

F

{'33143705': 2, '24665272': 2, '18177777': 1, '24711919': 2}

{'3943025-1': 1, '7640440-1': 1}

3977157-1

noncomm/PMC003xxxxxx/PMC3977157.xml

Intracranial Hemorrhage in Patient Treated with Rivaroxaban

This is an 84 year-old right-handed female with a past medical history of atrial fibrillation on rivaroxaban 20 mg daily, Alzheimer’s dementia, hypertension, diabetes, and chronic obstructive pulmonary disease. The patient had fallen down 6 steps at home as witnessed by her husband. Her last rivaroxaban dose was about 8 hours prior to the fall. She became unresponsive 2 hours after the fall without tonic or clonic activity and was intubated in the field for airway protection. In addition she received 1 gram of levatiracetam and 1 mg of lorazepam.\nPhysical examination was significant for left forehead and right lower extremity ecchymoses. On computed tomography (CT) scan at time of presentation in the emergency room, she was found to have diffuse scattered acute subarachnoid hemorrhage and intraventricular hemorrhage (). Repeat head CT less than 24 hours after initial event showed stable acute subarachnoid hemorrhage and intraventricular hemorrhage. Laboratory evaluation at admission showed prothrombin time of 11.7 seconds, activated partial thromboplastin time of 24.7 seconds, and platelet count of 157,000 per mm3. At 3 hours post event, she received four units of fresh frozen plasma and 10 mg of Vitamin K slow intravenous push. The patient’s hospitalization was complicated by intubation, pneumonia, and gastrostomy tube placement. Rivaroxaban was held during the hospitalization. Levetiracetam was initiated for seizure prophylaxis and was tapered off after two weeks. She was able to recover to her prior neurological baseline. Warfarin anti-coagulation was started 2-3 weeks after onset of the hemorrhage.

[[84.0, 'year']]

F

{'26929637': 1, '23810130': 1, '22042412': 1, '24711920': 2}

{}

3977160-1

noncomm/PMC003xxxxxx/PMC3977160.xml

Decreasing Adhesions and Avoiding Further Surgery in a Pediatric Patient Involved in a Severe Pedestrian Versus Motor Vehicle Accident

The patient was an 11 year old boy who had been involved in a MVA versus pedestrian accident in which a large vehicle rolled over his pelvis, resulting in an open book pelvic fracture, splitting the osseous structure of his pelvis. He sustained life-threatening injuries for which he underwent 19 surgeries over the course of one year in order to repair damage that resulted from the accident (). Because of healing from both the number of surgeries and trauma from the accident, the patient developed extensive scarring and abdominal adhesions as well as post traumatic stress disorder (PTSD). He had traditional physical therapy for three months to facilitate his ability to walk and perform daily functions. However, the patient experienced recurrent partial small bowel obstructions (SBO) that were treated non-surgically, and he required a laxative, polyethylene glycol (PEG) 3350 – oral, for maintenance of bowel function. The use of laxatives caused the patient distress and reportedly impacted his life significantly, causing rectal fecal leakage and thus furthered emotional distress in a pediatric patient medicated for PTSD.\nUpon initial physical therapy evaluation at a specialized manual therapy clinic, 19 months following the accident, the patient reported frequent constipation, pain of up to 7/10 during bowel movements, weakness and tingling in his left lower extremity and general pain that increased throughout the day. He expressed numerous goals, including the ability to participate in more athletic activities, to run a marathon, and to eliminate the requirement for pharmaceutical maintenance of bowel function. Findings from the initial evaluation, which included visual, palpatory, postural and movement exams were correlated with patient medical history, previous surgical reports, and physician diagnosis to determine adhered and dysfunctional areas requiring treatment. Restrictions, scars or adhesions were palpated by the therapists, major organs were identified, and decreased mobility of specific organs was determined. The patient was ambulatory, but exhibited a shuffling gait and a wide base of support with both hips held in external rotation. He presented with decreased range of motion in several areas that impacted his activities of daily living (), decreased strength, postural deviations, and biomechanical dysfunction, as well as myofascial, visceral and osseous restrictions due to scarring and adhesion formation after the original trauma, and from the 19 required surgical interventions. The extensive adhesions in his pelvis had also caused his left testicle to ascend into the inguinal canal where it was unable to be palpated, but was visible by diagnostic ultrasound.\nThe patient was treated with an intensive site-specific manual physical therapy called the Clear Passage Approach (CPA) or Wurn Technique for 4 hours a day for 5 consecutive days (a total of 20 hours). In accordance with the American Physical Therapy Association guidelines, detailed clinical treatment records were maintained on the patient throughout the course of therapy. These included symptomatic complaints, areas treated, duration and techniques performed. Unlike traditional physical therapy that often consists of exercise and modalities, the CPA utilizes a variety of techniques focused on creating microfailures of the adhesions by a variety of site-specific sustained pressures across restricted fascial bands of adhered tissues and organs. The amount and time of force that was applied to cause these microfailures was often significant, but varied with the tolerance of the patient and according to the location and delicacy of the tissues that were being treated. In previously published clinical trials and studies, these techniques increased range of motion, reversed infertility, prevented SBO and decreased pain in patients with histories indicating significant adhesion formation.\nTherapy focused on decreasing adhesions in order to decrease pain, and to increase function and range of motion. The patient’s response to treatment was significant and readily apparent to him, the therapists and his physicians. Following the initial 20 hours of treatment, the patient demonstrated an apparent decrease of adhesions evidenced by increased range of motion () of by at least 5 degrees for abnormal tests, and by improved myofascial, visceral and ligamentous mobility accessed via palpation. He reported decreased abdominal pain, increased frequency of normal bowel movements, and decreased use of laxatives by 50%.\nUpon urologic re-evaluation, his physician reported that the scar adhesions in his scrotum had decreased significantly. The urologist was optimistic that additional treatment would continue to decrease the scarring in his left inguinal region in order to aid in the increased mobility of the testis, possibly negating the need for surgical intervention for the ascending testicle. He recommended an additional 20 hour regime of the manual physical therapy.\nSeven months after the first CPA therapy (26 months following the trauma), the patient returned for an additional 20 hours of treatment focused on further decreasing adhesions. Following that therapeutic series, the patient again showed an apparent decrease of adhesions evidenced by improvement in range of motion (); improved myofascial, visceral and ligamentous mobility; decreases in pelvic and abdomen pain; decreases in left lower extremity pain and edema; and an improved gait. Pain and functional levels improved to the point that he reported no pain with bowel movements, increased frequency of bowel movements, and further decrease in the laxatives previously required for proper elimination. Upon further urologic examination, the physician noted that the patient demonstrated additional decreases in the scarring and adhesions in the inguinal area (, ) and the previously ascending left testicle was able to be reduced manually into the upper scrotum (, ). Ten months following the second treatment, his parents reported no surgical intervention for the ascending testicle and no further partial SBOs. Moreover, he was able to return to a normal diet, improving not only his health but also his return to normal daily activities after the accident. They reported that improvements in the patient’s physical ability to participate in normal activities also improved his mental status; he no longer required medication for PTSD associated with the MVA.

[[11.0, 'year']]

M

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{'3474405-1': 1, '3474405-2': 1, '3474405-3': 1}

3977163-1

noncomm/PMC003xxxxxx/PMC3977163.xml

Early Complete Remission of Osteoid Osteoma with Conservative Medical Management

A previously healthy 10-year-old boy visited a nearby hospital because of increasing pain and swelling in the area of his left leg that was first experienced a month ago. He had no history of previous trauma to the area of concern. His condition was diagnosed as osteomyelitis of the tibia and antibiotics were administrated. The patient showed no response to initial treatment for 2 months and was subsequently referred to our hospital. At his first visit to our hospital, he complained of severe nocturnal pain. Physical examination revealed mild swelling with tenderness in the middle part of his leg. Results of laboratory examinations indicated a normal white blood cell count, C-reactive protein level, and erythrocyte sedimentation rate. Radiographs showed a lucent zone and a surrounding sclerotic zone in the middle third of the tibia (). Computed tomography (CT) revealed a 10-mm circumscribed osteolytic area in the cortex of the tibia with surrounding sclerosis (). This radiographic appearance of a radiolucent nidus with surrounding sclerosis was consistent with the typical appearance of an osteoid osteoma. Moreover, a bone scan revealed the double-density sign, which is quite specific for diagnosis of osteoid osteoma (). Magnetic resonance (MR) images showed a 10-mm circumscribed abnormality located in the cortex of the tibia with surrounding soft tissue edema. The circumscribed signal abnormality was isointense in comparison with bone marrow on fat-suppressed T1-weighted images and was moderately enhanced by gadolinium (, ). Axial CT images of the lesion clearly demonstrated an osteolytic lesion corresponding to the abnormality seen on MR images. The patient’s symptoms markedly improved with NSAIDs and his parents did not provide consent for surgical treatment. He was therefore treated with a usual dose of ibuprofen (300 mg/day, 3 times daily) for 3 weeks. Within 3 weeks, his symptoms were almost completely resolved; he no longer needed NSAIDs and returned to normal life. Serial images including radiographs, CT scans and MR images revealed complete radiological resolution of the nidus 2.5 years after initial presentation (). An early complete remission of osteoid osteoma with conservative medical treatment was confirmed in this patient.\nAt the 5-year follow-up visit, patient was free of pain and there was no evidence of recurrence.

[[10.0, 'year']]

M

{'1112841': 1, '20737157': 1, '2317978': 1, '24093694': 1, '28123536': 1, '1541612': 1, '13670322': 1, '11603890': 1, '1061564': 1, '31970263': 1, '10631904': 1, '26837513': 1, '11764357': 1, '24337349': 1, '28884296': 1, '10212612': 1, '16967288': 1, '11504296': 1, '12944597': 1, '24711915': 2}

{}

3977164-1

noncomm/PMC003xxxxxx/PMC3977164.xml

Atypical Choroid Plexus Papilloma Treated With Single Agent Bevacizumab

A 40-year-old woman was referred to us for salvage treatment. She was diagnosed in February 2005 with a 6.5 cm right occipital tumor with small millimetric parenchymal metastases and drop metastases throughout the neuraxis. She presented with clinical evidence of increased intra-crania pressure (ICP), mass effect with extensive vasogenic edema requiring urgent surgery. She underwent gross tumor resection and pathology reported an atypical choroid plexus papilloma. Her staging work up was obtained following her recovery including brain and full spine contrast enhanced magnetic resonance imaging (MRI) scans. This revealed small drop metastases in the posterior fossa and along the spinal cord. The patient received radiation therapy to the neuraxis (the CSI dose was 36 Gy and the total dose to the primary tumor bed or surgical cavity was 54 Gy). She remained clinically stable for two years, and was able to perform activities of daily living. Repeated contrast enhanced MRI scans of the brain and full spine reported stable appearance in size and enhancement of all drop metastases in the posterior fossa and the spinal canal.\nAt relapse, she presented with continuous headaches, neck stiffness, altered mental status, and severe ataxia. Imaging revealed metastasis to bilateral cerebello-pontine (CP) angles and intraparenchymal supratentorial lesions (left frontal, right thalamic, and right temporal). She received 2 cycles of nitrosourea without response and worsening symptoms. Hence this was changed to ifosfamide, carboplatin and etoposide based combination. Radiological and clinical stabilization were attained following three cycles, but second progression was documented after the fifth cycle. Further surgeries and performed for rapidly growing and symptomatic right CP angle metastasis and dorsal brain stem metastasis. Post-operative imaging revealed decrease size of the tumor. With remaining residual disease, the patient was referred to us for salvage treatment.\nIn this setting of previous craniospinal irradiation, significant chemotherapy toxicity, and only short-lived stabilization of the disease, bevacizumab was offered as single agent treatment in an attempt to spare the patient further toxicities. The first treatment was injected after 8 weeks from last surgery.\nThe patient received bevacizumab, 5 mg/kg on day 1 and day 15 of each cycle. Cycles were repeated every 4 weeks. Contrast enhanced MRI scans were obtained after the initial two treatments and every 2 cycles thereafter or sooner if required to assess new or worsening symptoms.\nThe patient was taken off steroids, which was started at first relapse, shortly after starting bevacizumab and did not receive steroids later during the course of her disease. Her symptoms immediately stabilized following the first cycle of bevacizumab and progressively improved. The headaches resolved, the mental status returned to normal, and the ataxia improved very slowly but her cervical pain and stiffness did not. She achieved radiological stabilization with significant decrease of the vasogenic edema, and minimal decrease in the size and enhancement of all metastatic lesions ( and ). This response continued for over 5 months of therapy. A total of five cycles of bevacizumab were administered (10 treatments). An elective cerebello-pontine angle metastasis resection was opted to relieve her debilitating neck stiffness.\nThe postoperative course was complicated by respiratory failure requiring tracheostomy, although there was no evidence of disease progression. The patient died form pulmonary infection, in turn complicated by severe sepsis.

[[40.0, 'year']]

F

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{'4596056-1': 1, '4596056-2': 1, '4596056-3': 1}

3977165-1

noncomm/PMC003xxxxxx/PMC3977165.xml

Small Cell Extraskeletal Osteosarcoma: A Rare Case Report

A-60-years-old woman presented with large, slowly enlarging and painful lesion in left thigh since last 18 months. She gave a history of trauma at the onset. On examination the lesion was firm, non mobile, fixed to skin and underlying structures on lateral aspect of thigh. MRI showed a variegated mixed intensity lesion in antero-medial aspect of left thigh arborizing left adductor, obturator, pectineus, vasti and fringe of sartorius and ilio-psoas musculature and enclosing neuro-vascular bundles with cystic degeneration, necrosis and associated solid density lesional matrix and discrete calcific foci (). Patient was referred for fine needle aspiration cytology (FNAC) of lesion and smears showed diffuse sheets of small round cells with mild pleomorphism, high nuclear cytoplasmic ratio (N:C ratio) and dark fine granular chromatin without classical rosseting pattern with few foamy histiocytes and scant osteoid (, ). A diagnosis of small round cell tumor with possibilities of ESOS and PNET was given. The lesion was then excised and sent for histopathological examination.\nGross examination of specimen showed an irregular, infiltrating firm, grey white lobulated growth measuring 17×13.5×8.7 cm invading skeletal muscle fibers. Focal gritty areas were observed ().\nMicroscopy showed nodules and islands of tumor with focal malignant lace like as well trabecular mineralized and non-mineralized osteoid formation without any cartilage or zoning pattern (). Trichrome stain highlighted neoplastic osteoid (). Extensive areas of necrosis were also observed. Tumor cells were small, round with inconspicuous cytoplasm, dense coarse chromatin with minimal pleomorphism with 1-2 mitosis/hpf and small round cells show PAS positivity (). Tumor was invading attached skeletal muscle fibers and fat however the resected skin, soft tissue margins and separately sent lymph nodes were free of tumor. S100 (), LCA, smooth muscle actin, chromogranin, desmin, pancytokeratin and EMA were negative. Patient was monitored for 6 months and was uneventful thereafter lost for further follow up.

[[60.0, 'year']]

F

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{'6489070-1': 1}

3977166-1

noncomm/PMC003xxxxxx/PMC3977166.xml

Renal Cell Carcinoma With Rhabdoid and Sarcomatoid Features Presented as a Metastatic Thigh Mass With an Unusual Immunohistochemical Profile

Male patient 70 years old presented with a thigh mass measured 35×24×9 cm with grayish white lobulated cut section. Histopathological examination revealed epithelioid sheets of cells exhibiting great pleomorphism and frequent mitoses (). Most of these malignant cells showed abundant eosinophilic cytoplasm with occasional eccentric nuclei (, ). Some areas showed clear cell changes (). Malignant multinucleated giant cells and areas of necrosis were also seen. The possibility for sarcoma was highly thought.\nImmunohistochemical panel of soft tissue sarcoma was performed including SMA, desmin, vimentin, S100 and pan cytokeratin. The neoplastic cells showed positivity for desmin () and vimentin and the mass was designated at that time as pleomorphic rhabdomyosarcoma. At this moment, the patient has not submitted to further investigations. The patient received 33 cycles of radiotherapy, during which, he suffered from bad wound healing of the thigh wound.\nUnfortunately, the patient suffered seven months later from abdominal pain. Abdominal CT revealed huge intra-abdominal mass that was located pararenal and extended to psoas muscle replacing and destroying it and both kidneys were free.\nThe patient underwent abdominal exploration where the intra-abdominal mass was resected. The mass measured 30×24×10 cm with whitish lobulated cut section (, ).\nMicroscopic evaluation of the abdominal mass revealed malignant epithelial cells characterized by clear cytoplasm with variable degrees of pleomorphism, where there were areas of moderate pleomorphiam to anaplastic areas (). The first impression of this mass is RCC versus adrenocortical carcinoma.\nStepping sections revealed areas simulating the morphology of thigh mass. Three iliac lymph nodes were dissected and revealed infiltration by the same neoplasm (). The tumor cells were diffusely positive for CD10 () and vimentin and focally positive for pan cytokeratin () and EMA ().\nThe tumor cells were completely negative for inhibin and other sarcoma markers such as SMA, desmin, myogenin and S100. Therefore, the morphological and immunohistochemical pictures indicated the diagnosis of RCC. But investigations failed to prove the presence of any renal masses. Paraffin blocks of thigh mass were retrieved and were submitted to immunostaining for CD10, EMA, vimentin, pancytokeratin, desmin, myogenin and carbonic anhydrase IX.\nFor our surprise, the tumor cells of thigh mass were diffusely positive for CD10 (), and vimentin and focally positive for pan cytokeratin (), EMA () and carbonic anhydrase () and still showed immunoreactivity for desmin. However, the tumor cells of thigh mass were negative for myogenin.\nTherefore, we are now dealing with the same tumor which is RCC metastasizing to the thigh. Patient died within two months after the resection of intra-abdominal mass and receiving one cycle of Doxorubicin.

[[70.0, 'year']]

M

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{'2858138-1': 1, '3271452-1': 1, '3229054-1': 1}

3977169-1

noncomm/PMC003xxxxxx/PMC3977169.xml

Primary Leiomyosarcoma of Peritoneal Cavity

A 65-year-old female presented with lower abdominal lump and pain for 3 months. On local examination the mass was suprapubic, freely mobile, nontender and measured 10×10 cm in size. contrast enhanced computed tomography revealed well defined heterogenous hypo dense solid cystic mass approx. 12×10×8 cm in peritoneum with area of calcification, necrosis and multiple septation (). Tumor marker (CEA: 1.9 ng/mL, CA125: 6.064 U/mL) were within normal limits.\nThe mass was surgically excised out in its entirety and peroperative finding revealed unremarkable adnexa and soft tissue mass arising from the mesentery. Grossly globular grey white soft tissue received which measured 15×10×7 in size. The cut section was solid, cystic with large area of haemorrhage and necrosis. Multiple histopathological sections examined revealed spindle cells arranged in alternating fascicles having pleomorphic nuclei, indistinct margin, eosinophilic cytoplasm with foci of haemorrhage and necrosis. Mitotic figures were 5-6/HPF (). The tumor cells were immunoreactive with smooth muscle actin (), desmin and negative for S-100, CD-34 and c-kit. There was no evidence of lung, liver or nodal metastases and peritoneal seeding. Final diagnosis of primary leiomyosarcoma of peritoneal cavity was made. The postoperative course was uneventful; however the patient expired after six month of surgery.

[[65.0, 'year']]

F

{'8708071': 1, '6979881': 1, '28287938': 1, '8686629': 1, '15123952': 1, '6729102': 1, '24711906': 2}

{}

3977170-1

noncomm/PMC003xxxxxx/PMC3977170.xml

Robotic-Assisted Surgery Approach in a Biliary Rhabdomyosarcoma Misdiagnosed as Choledochal Cyst

A 2 years-old girl was admitted for loss of appetite and slight fever. Laboratory studies showed: AST 537 mU/mL, ALT 589 mU/mL, GGT 738 mU/mL, alkaline phosphatase 718 mU/L, total bilirubin 1.8 mg/dL. Hepatic infection profile and tumor markers were negative. On physical examination there was no tenderness, hepato-spleenomegaly or abdominal mass. Abdominal ultrasound showed hypoechoic dilatation of the common hepatic duct (CHD) and common bile duct (CBD). Thickening of the CHD walls with dilatation of the intrahepatic bile ducts were suggestive of CC. Abdominal CT scan showed an ovoid, heterogeneously non enhancing mass localized at the liver hilum of 18×30 mm with hyperdense contents. Magnetic resonance imaging (MRI) confirmed the presence of marked dilatation with thickened wall of CHD and CBD consistent with congenital CC type IV (). Laparoscopic intraoperative cholangiography, prior to choledochal cyst excision, is usually valuable for detection of biliary variants. Liver biopsies are routinely done for grading of liver fibrosis in obstructive cholangiopathy (). Unfortunately cholangiography in our case was not conclusive and CHD and intrahepatic biliary ducts were not visualized. The biopsies showed fibrosis of the septum at the portal space associated with signs of chronic inflammation.\nThe child underwent mini-invasive robotic surgery for CC resection and Roux-en-Y choledochojejunostomy. Open umbilical insertion of the 8.5 mm stereoscope was used.\nTwo 5 mm working ports were placed at the left and right hypocondrium on either side of the umbilicus under direct vision, at 3 cm from the costal margins along the hemi-clavicular line bilaterally. A 3 mm servicing trocar was inserted in the right inferior iliac space. Transabdominal stitches were fixed on the gallbladder and on the falciform ligament for liver retraction. Pressure insufflations were around 4 mmHg. Circumferential dissection of the CC was achieved to the duodenum and ligated. Proximally dissection extended beyond the CHD to the left and right hepatic biliary ducts that were also involved in a grapelike tumor. The high degree of magnification allowed the resection to be carried out in the parenchyma to free the right posterior and anterior ducts and evidenced another supernumerary duct. On the left side, the lesion was freed from the grapelike cysts and healthy tissue was found at the two segmental tributaries. Although feasible by robotic approach, but still controversial in the literature, the anastomosis at the porta hepatis was carried out in open surgery. A retrocolic Roux-en-Y portoenterostomy was performed using 5/0 PDS. Histologic examination revealed a botryoidembryonal rhabdomyosarcoma of the bile ducts affecting both the CBD and CHD. The patient underwent chemotherapy after diagnosis. Twelve months later, the patient is relapse free, with normal bilirubin and liver profile.

[[2.0, 'year']]

F

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{'7519210-1': 1}

3977171-1

noncomm/PMC003xxxxxx/PMC3977171.xml

Angiosarcoma of the Seminal Vesicle: A Case Report of Long-Term Survival Following Multimodality Therapy

A previously healthy 45-year-old male developed sharp left lower quadrant and groin pain. He was evaluated by his primary physician and his symptoms were thought to be related to diverticulitis. He was treated conservatively with an antibiotic, though there was no resolution of his symptoms.\nA computed tomography (CT) scan of the pelvis revealed a 5.6×5.1 cm heterogeneously enhancing mass involving the left lobe of the seminal vesicle and minimally the right lobe across the midline. The mass was invading the left bladder base and ureterovesicular junction (UVJ), and a few cm of left distal ureter (). This was accompanied by left-sided hydronephrosis. The mass also invaded the left obturator internus muscle, and potentially the base of prostate gland as well as into the perirectal space abutting the rectum. There was no pelvic lymphadenopathy. A transrectal biopsy of the mass was performed which was reviewed at several different institutions, though it was considered indeterminate. A second transrectal biopsy of the periprostatic/seminal vesicle soft tissue mass was performed, which was reviewed at our institution and found to be a grade 4 (of 4) epithelioid angiosarcoma. Immunohistochemical stains showed the tumor cells reacted strongly and diffusely with antibodies to CD31 and vimentin, but did not react to antibodies to keratin (Cam 5.2, 7, 20 and wide spectrum), prostate specific antigen, actin, desmin, melanin A, S-100, CD117 (C-kit), synaptophysin, and chromogranin, supporting the diagnosis.\nThe patient was referred to our institution for further evaluation and management. Digital rectal examination revealed a normal anal sphincter tone and a large, firm, fixed mass in the left lateral rectal area without apparent rectal mucosal involvement. Magnetic resonance imaging (MRI) was performed, which showed an infiltrating soft tissue mass in the left lower pelvis involving the left seminal vesicle, the base of the prostate and the left bladder wall (). The mass extended laterally resulting in effacement of the left obturator internus muscle. A fatty soft tissue plane separated the mass from the adjacent left anterior rectal wall. A chest CT showed a few small indeterminate pulmonary nodules and a small calcified granuloma within the left lower lobe. A colonoscopy showed no evidence of rectal invasion. Given the presence of locally advanced tumor and the high risk for micrometastatic disease, the multidisciplinary team consisting of urology, medical oncology, and radiation oncology physicians recommended multimodality therapy consisting of neoadjuvant chemotherapy and radiotherapy followed by potential surgical resection.\nThe patient received two cycles of neoadjuvant IMAP chemotherapy, consisting of ifosfamide (2500 mg/m2 IV days 1-2), Adriamycin (40 mg/m2 IV day 2), mitomycin (4 mg/m2 IV day 2), cisplatin (60 mg/m2 IV day 2), and mesna (1500 mg/m2 IV and 2500 mg/m2 per days 1-2.) Repeat imaging following IMAP showed that the soft tissue mass in the left pelvis slightly decreased in size from 5.6×5.1 cm to 4.3×4.0 cm. The patient then received external beam radiation therapy () consisting of 50 Gray in 25 fractions delivered daily over 5 weeks with 2 cycles of concomitant MAP chemotherapy, consisting of mitomycin (8 mg/m2 IV), adriamycin (40 mg/m2 IV) and cisplatin (60 mg/m2 IV).\nFollowing a six-week recovery from preoperative chemoradiation, repeat imaging studies showed no significant change in the pelvic mass and no evidence of distant metastatic disease. He then proceeded to surgical resection with a radical prostatectomy, partial cystectomy, distal ureterectomy, bilateral pelvic lymph node dissection, and ureteroneocystostomy. Frozen section margins at the bladder and left pelvic sidewall were positive. Additional resection was performed and the margins were negative. An intraoperative electron radiation therapy boost (9 Gy) was given to the left pelvic sidewall as there was a concern for residual microscopic disease. Review of the surgical pathology demonstrated grade 4 (of 4) epithelioid angiosarcoma forming a 3.5×2.6×1.8 cm mass in soft tissue in the region of the left seminal vesicle (). The tumor involved the left seminal vesicle, infiltrated adjacent skeletal muscle, and extensively involved regional nerves and ganglia, but tumor did not extend into prostatic parenchyma. The final surgical margins were negative for tumor. Multiple left and right pelvic lymph nodes (external iliac, internal iliac, common iliac and obturator regions) were negative for tumor involvement.\nPost-operatively he had left thigh numbness that subsequently resolved. He developed a vesicourethral anastomotic leak which required prolonged (3 months) Foley catheter use; however, this completely resolved. He developed an abscess that was drained and resolved. The patient was then seen in regular follow up with serial imaging studies over the subsequent six years following surgery and he has not developed evidence of cancer recurrence.

[[45.0, 'year']]

M

{'18286475': 1, '3511294': 1, '16643634': 1, '32806524': 1, '16389189': 1, '19657238': 1, '27326413': 1, '4040580': 1, '21647357': 2, '22910841': 1, '7197190': 1, '19900102': 1, '12823047': 1, '2172316': 1, '21623272': 1, '22351253': 1, '17685450': 1, '2235094': 1, '2056582': 1, '18809609': 1, '18521298': 1, '24711908': 2}

{'3103974-1': 1}

3977172-1

noncomm/PMC003xxxxxx/PMC3977172.xml

A Case Series of Transformation of Teratoma to Primitive Neuroectodermal Tumor: Evolving Management of a Rare Malignancy

A 33 year-old man underwent right radical orchiectomy after presenting with severe back pain and right testicular swelling. A pre-operative computed tomography (CT) of the chest, abdomen, and pelvis revealed extensive retroperitoneal lymphadenopathy, including a confluence of tissue measuring 9.7×7.4 cm, as well as scattered mediastinal lymphadenopathy. His pathology demonstrated a mixed GCT composed of embryonal carcinoma (40%), teratoma (40%) and yolk sac tumor (20%). Surgery was followed by three cycles of bleomycin, etoposide and cisplatin (BEP). Follow-up imaging revealed a response to chemotherapy, however his disease persisted in the retroperitoneal lymph nodes. He then underwent retroperitoneal lymph node dissection (RPLND), which showed metastatic mature teratoma in multiple lymph nodes without any residual GCT.\nSix weeks following RPLND, he presented with acute kidney injury, fatigue, and an LDH >20,000 U/L. Imaging studies showed widespread recurrent disease, including supraclavicular lymphadenopathy, a new right inguinal soft tissue mass and an enlarging conglomerate of retroperitoneal lymphadenopathy in the para-aortic region (). The supraclavicular node was biopsied, which demonstrated a poorly differentiated high grade neoplasm though the definitive diagnosis remained in question. As a result, his original tumor and the RPLND specimens were reviewed at another institution in conjunction with the supraclavicular specimen. Upon further review, his original tumor was deemed primarily PNET (80%) with teratoma (10%), yolk sac tumor (8%) and embryonal carcinoma (2%). The RPLND, as well as the supraclavicular lymph node biopsy, confirmed PNET in both specimens ().\nThe patient was not initially a candidate for surgical resection. Therefore, neoadjuvant chemotherapy with VAC/IE was initiated. During his first cycle of chemotherapy, he developed ifosfamide-induced encephalopathy and renal tubular acidosis. As a result, the IE component of this regimen was held for his subsequent treatment and he received an additional four cycles of VAC thereafter.\nAt completion of his neoadjuvant chemotherapy, his imaging studies demonstrated complete response in his neck and mediastinal lymphadenopathy and partial response of his retroperitoneal lymphadenopathy () and right inguinal mass. Subsequently, the patient underwent repeat RPLND and excision of the right inguinal soft tissue mass. Pathology of both specimens showed extensive necrosis with rare atypical cells consistent with PNET. Adjuvant chemotherapy was not administered after surgery since the patient has already received maximum cumulative dosing of doxorubicin and due to his history of ifosfamide-induced encephalopathy. His last imaging studies two months after his surgery showed no recurrent disease.

[[33.0, 'year']]

M

{'2990657': 1, '9474169': 1, '28443239': 1, '2457658': 1, '14645417': 1, '34658596': 1, '20348883': 1, '30367327': 1, '23799289': 1, '11342908': 1, '19164198': 1, '8022439': 1, '6090001': 1, '3901266': 1, '9255252': 1, '24711909': 2}

{}

3977322-1

noncomm/PMC003xxxxxx/PMC3977322.xml

Axial Torsion of Gangrenous Meckel's Diverticulum Causing Small Bowel Obstruction

The present case is about a 26-year-old male patient who presented to our emergency department with 3 days history of abdominal pain, distention and bilious vomiting. He had no previous surgery and did not recollect similar episodes in the past. On examination, he was afebrile and hemodynamically stable. Blood counts and biochemical values were within the normal limits. On clinical examination, abdomen was distended with visible intestinal peristalsis, but without any guarding. There were no surgical scars and hernial orifices were free. Plain X-ray abdomen showed dilated small bowel loops with multiple air fluid levels []. Ultrasound abdomen suggested the possibility of an appendicular mucocele. He was taken up for urgent laparotomy with a clinical diagnosis of acute intestinal obstruction. Intra-operatively there was minimal hemorrhagic fluid localized in right iliac fossa and small bowel loops were dilated. A MD was seen attached to the mesentery of nonadjacent small bowel by a peritoneal band, which was arising from its tip. The diverticulum was axially torted and gangrenous. In addition there was compression of ileum by the peritoneal band resulting in intestinal obstruction, which was relieved on dividing the band []. Resection and anastomosis of the small bowel including the MD was performed. Recovery was quick and uneventful and patient was discharged within a week.

[[26.0, 'year']]

M

{'16680236': 1, '16047474': 1, '11774961': 1, '19534380': 1, '9707071': 1, '22577339': 1, '8720004': 1, '28944341': 1, '8623629': 1, '18959721': 1, '34457256': 1, '9124758': 1, '21860699': 1, '24741431': 2}

{}

3977323-1

noncomm/PMC003xxxxxx/PMC3977323.xml

Clinicoradiological Diagnosis of Cough-Induced Intercostal Hernia

A 66-year-old male presented to the clinic with an 11-month history of a painless enlarging mass on the left side of his chest wall. The patient noticed the mass after being discharged after a weeklong hospitalization for bilateral pneumonia. During that week the patient was continuously coughing and developed a pain in the left side of chest wall. Chest X-ray and computed tomography of the abdomen imaging showed no rib fracture or other type of injury to the chest wall, diaphragm, or abdominal wall. Discharge diagnosis included pneumonia and back pain. A few months later the patient found the mass on the left side of chest wall enlarging and decided to seek medical reevaluation by his primary care physician. He was later referred for another CT of his abdomen with intravenous contrast. This study report stated: “Patient developed a fracture with some displacement in the left posterior lateral eighth rib. The ribs more cephalad could be fractured as well. Associated with this finding there is some distortion of the ribs caudal to this left eighth rib fracture. Those ribs are displaced medially and there is bulging of the fat of the peritoneal cavity laterally without evidence of an actual hernia” []. The images were not conclusive for an intercostal hernia. A few more months past and the patient returned to the primary care physician with the same complaint of the chest wall mass. Additional CT of the abdomen was performed, and it showed the eighth rib fracture, the torn intercostal muscles, and no diaphragmatic defect [].\nPhysical examination revealed an obese patient who had a soft, nontender, reducible mass on the lateral aspect (midclavicular line to the midaxillary line) of the left-sided chest wall between eighth and 11th ribs. The mass measured 12 cm in diameter. Sensation over the mass was decreased slightly when compared to the right side.\nHis past medical history was significant for hyperlipidemia, hypertension, and benign prostatic hyperplasia. The patient had no history of any external trauma, no history of any rib fractures, and no lung disease other than the recent pneumonia. Patient denied any current tobacco use (quit 25 years earlier), patient occasionally used alcohol, and denied any illicit drug use.\nAfter reviewing the CT scans and examining the patient, a diagnosis of a chest wall hernia induced by severe coughing was established. The patient was referred to a cardiothoracic surgeon to repair the hernia.

[[66.0, 'year']]

M

{'17125506': 2, '2635946': 1, '17419863': 1, '23198242': 1, '33655114': 1, '27716425': 2, '21103115': 2, '16763340': 1, '24741432': 2}

{'5045639-1': 1, '2984347-1': 1, '1675993-1': 1}

3977329-1

noncomm/PMC003xxxxxx/PMC3977329.xml

Loss of Guide Wire: A Lesson Learnt Review of Literature

A 60-year-old woman presented to the emergency department with complaints of generalized abdominal pain, constipation, and fever. Patient was hospitalized with primary diagnosis of intestinal obstruction. Due to patient's history of heart disease, the central venous catheterization was done for fluid resuscitation via the right internal jugular (IJ) vein using the Seldinger technique. The catheter was inserted by a 1st-year surgical resident with no supervision by senior residents. No complications or difficulties in cannulation were reported; back flow was also normal. The catheter tray was checked for the guide wire after the procedure which was missing. After the patient was stabilized, she underwent chest X-ray, plain abdominal radiography, and ultrasonography and the patient was admitted in surgical intensive care unit. Resident noticed the guide wire in chest and abdominal radiographs. The radiographs showed that the catheter had entered in the IVC via the right IJ vein and then, had remained in the right iliac vein at the point of bifurcation into the internal and external iliac veins [Figures and ]. Based on the consultation with the vascular surgeons and radiologists, the patient underwent exploration of right iliac vein. The method was successful and the retained guide wire was removed from right external iliac vein. The procedure was successful and intestinal obstruction was managed conservatively. Her hospital stay was uneventful.

[[60.0, 'year']]

F

{'11881872': 1, '17955287': 1, '34353960': 1, '31335728': 2, '26417134': 2, '2112623': 1, '33447212': 1, '9678441': 1, '17522397': 1, '17062981': 1, '16085686': 1, '15040421': 1, '21966636': 2, '19234840': 1, '16189330': 1, '17470889': 1, '16297759': 1, '7214946': 1, '2221445': 1, '2707904': 1, '24741424': 2}

{'3177414-1': 1, '4563956-1': 1, '6709196-1': 1}

3977330-1

noncomm/PMC003xxxxxx/PMC3977330.xml

Isolated Pancreatic Metastasis from Malignant Melanoma: Is Pancreatectomy Worthwile?

In 1989, a 29-year-old woman was diagnosed with a dorsal malignant melanoma treated by a wide R0 resection. After 4 years of follow-up (1993), she developed a local recurrence treated by resection; the analysis of sentinel lymph nodes was negative. Sixteen years after initial diagnosis (2005), she presented an epigastric pain and a 5 kg weight loss. An echoendoscopy revealed a 50 mm tumor located in the head of the pancreas, without vascular invasion and the biopsy confirmed an IPMMM. Exhaustive radiologic staging did not reveal any other metastasis [Figure and ]. Primary chemotherapy was not delivered because of the long delay between resection of the primary tumor and recurrence and the only modest antitumor activity that could be expected with the conventional cytotoxic regimen (i.e., dacarbazine single-agent) used in metastatic melanoma. PD was performed and the histological analysis revealed a 60 mm tumor with clear resection margins. Immunohistochemistry detected the expression of protein S100, HMB45 but not of vimentin and melanA, features compatible with a metastasis of primary melanoma. Due to post-operative hemorrhage (day 7) arising from splenic vessels, the patient was re-operated and a totalization of pancreatectomy was performed. A new intervention was done at day 15 for gastro-jejunal anastomosis leak. Nineteen months after resection (2007), the patient presented a para-aortic lymph node recurrence that was treated by peri-aortic lymph node clearance []. After both initial PD and subsequent resection of the lymph node relapse, adjuvant treatment was not proposed because of (a) poor post-operative courses, (b) potential toxicities in a patient with complete pancreatic exocrine and endocrine insufficiency and (c) lack of available evidence demonstrating any impact of adjuvant systemic treatment in this setting. Since 2007, the patient has been under regular clinical and radiological surveillance without evidence of disease recurrence.

[[29.0, 'year']]

F

{'10623706': 1, '12374659': 1, '18784960': 1, '9565122': 1, '12167582': 1, '31134450': 2, '18086122': 1, '11569781': 1, '19744448': 1, '16372157': 1, '19261257': 1, '31228079': 1, '9576286': 1, '18196343': 1, '12734861': 1, '19434703': 1, '10796759': 1, '20525992': 1, '18332980': 1, '11064356': 1, '9337160': 1, '21639808': 1, '24741425': 2}

{'6885028-1': 1}

3977331-1

noncomm/PMC003xxxxxx/PMC3977331.xml

Dentigerous Cyst Associated with Ectopic Canine and a Supernumerary Tooth: A Rare Occurrence

A 10 year-old boy presented with a painless swelling in the left maxillary anterior region of 8-9 months duration. On general examination, the patient was apparently healthy with normal growth and development for his age and there was no history of systemic diseases or trauma. Clinical examination revealed an extraoral swelling on the left side of the face with elevation of the nostril and lateral border of the nose. The swelling was extending from the lateral wall of the nose to zygomatic region mediolaterally and from infraorbital region to right upper lip superoinferiorly. There was obliteration of the nasolabial fold. The swelling was soft, fluctuant, painless with positive crepitus.\nIntraorally the swelling was extending from maxillary left central incisor to the premolar region with obliteration of the vestibule []. The mucosa overlying the swelling appeared to be intact. Paranasal view of the radiograph [] showed a well defined unilocular radiolucency surrounding two teeth in the left anterior region of the maxilla. Displacement of the roots of the maxillary left lateral incisor was also seen. The lesion was extending from the lateral wall of the nose to zygomatico maxillary region mediolaterally and from maxillary alveolar ridge to infraorbital rim superoinferiorly.\nFine needle aspiration revealed the presence of straw colored fluid within the lesion. After clinical and radiographic examination, a provisional diagnosis of dentigerous cyst involving impacted teeth was made. Routine hematological investigations was normal. Surgical excision of the lesion was planned under general anesthesia. All aseptic precautions were taken. Crestal incision was given in the region of left maxillary central incisor and extended as crevicular incision around left maxillary first premolar. Vertical releasing incision was given distal to left upper premolar at an angle of 45°. Using a periosteal elevator carefully the full thickness mucoperiosteal flap was raised. On reflection of mucoperiostium, the exposed buccal cortical plate was found to be very thin and perforated in the region of retained deciduous canine. The cystic lining was located on removal of thin buccal cortical plate. Carefully the cystic lining was separated from the underlying bone along with the impacted teeth (permanent ectopic canine, supernumerary teeth), [Figures –] retained deciduous canine and lateral incisor, which was mobile and involved with the lesion. The supernumerary teeth were conical in shape resembling a peg shaped incisor.\nThe lesion was found to be measuring around 3 cm × 3 cm, involving the sinus wall. The perforated sinus wall was repaired using autogenous bone graft from anterior sinus wall. Due precaution was taken to avoid perforation or tearing of lateral nasal wall, which was closely attached to the cystic lining. After complete removal of the cystic lining, the mucoperiosteal flap was approximated and suturing done using 3-0 Mersilk. Dressing was given. The post-operative healing was uneventful. The suture removal was carried out after 7 days. Histological examination of the specimen confirmed the diagnosis of a DC []. Patient was under follow-up for 6 months and presented no complications, meanwhile, he was advised for orthodontic and prosthetic rehabilitation to correct the malocclusion and alleviate problems with patients lack of dentition.

[[10.0, 'year']]

M

{'17928734': 1, '31422412': 1, '31496577': 2, '9800020': 1, '22977579': 1, '9037974': 1, '15858310': 1, '24741426': 2}

{'6710952-1': 1, '6710952-2': 1}

3977332-1

noncomm/PMC003xxxxxx/PMC3977332.xml

Congenital Uterovaginal Prolapse Present at Birth

A 12-hour-old female neonate was presented to us with a fleshy mass protruding from the vulva since birth. The baby is a product of term gestation and was delivered breech. Labor was not prolonged, and there was no instrumental delivery. The baby passed meconium on the 1st day of birth and tolerated breast milk feeding.\nThe mother, a 31-year-old, para 3, seamstress had recurrent febrile conditions throughout the pregnancy and was treated at the primary health center where she booked. She neither ingested herbal medications nor any unprescribed drugs during pregnancy.\nOn examination, the child weighed 3.0 kg. There was a fleshy, reddish, and edematous mass protruding from the vulva []. The wall was thrown into folds. At the apex there was a blind-ended opening. The urethral opening was located separately above the mass. The anus was patent, and meconium stained finger noted on digital rectal examination. She has a sacral dimple with tufts of hair in it []. Lower limb motor activity, sensations, respiratory, and cardiovascular systems were all normal. No masses were felt on abdominal examination. The skin was neither wrinkled nor thrown into folds. Skin elasticity was normal.\nUnder sedation, size 6 Foley's urethral catheter was passed into the bladder. The mass was reduced by gripping it with the right hand and gently pushing it inwards. To prevent re-protrusion on straining, both lower limbs were strapped together using crepe bandage which was applied in a mermaid fashion extending from the buttocks to the lower legs sparing the anus for defecation. Both catheter and bandaging were removed after 72 h. Following successful reduction, the parents were unwilling to neither subject the child to further investigations nor comply with follow-up schedules. However, through contact tracing, the prolapse has not recurred 6 months after, and the child is growing appropriately.

[[12.0, 'hour']]

F

{'3895085': 1, '30050707': 2, '3715670': 1, '16481269': 1, '23543808': 1, '965192': 1, '26023398': 1, '21508572': 1, '8515312': 1, '19576821': 1, '8657402': 1, '22315847': 1, '1459691': 1, '16685658': 1, '24741427': 2}

{'6040269-1': 1}

3977333-1

noncomm/PMC003xxxxxx/PMC3977333.xml

Glomus Tumor of Thumb Occurring at Unusual Location

A 45-year-old female patient presented with a 10-year history of progressively intense pain, cold sensitivity, and severe tenderness to palpation of the lateral side of the volar aspect of her right thumb. She had diffuse swelling of right thumb present. No history of any previous trauma. We performed Love's pin test, Hildreth's test, and a cold sensitivity test. The point tenderness was localized on her right thumb, which was determined by pressing the head of a pin against the tender lesion. Tenderness disappeared after tourniquet at base of thumb for 20 min. The pain increased when her digit was exposed to cold.\nPlain X-ray of hand was normal []. Magnetic resonance imaging (MRI) was suggestive of swelling arising from insertion of flexure pollicis longus tendon, dark on T1 and bright MRI appearance on T2-weighted image [Figures and ]. They gave differential diagnosis of synovial swelling and glomus tumour.\nAt surgery, a red 3-mm diameter tumor was exposed through a lateral [L-shaped] volar incision of the pulp of the distal phalanx of the right thumb. It was entirely in the pulp space with no extension into subungual area []. It was removed completely [].\nHistopathological examination confirmed a glomus tumor with vascular areas with multiple glomus bodies. Surgical wound healed by primary intention []. Patient's symptoms were relieved immediately after the surgery. The patient was asymptomatic 1 year after the surgery.

[[45.0, 'year']]

F

{'12074607': 1, '34239958': 1, '30329513': 1, '12755514': 1, '197147': 1, '28203512': 1, '2831563': 1, '11878181': 1, '33110875': 2, '8732413': 1, '4341268': 1, '15509936': 1, '16877938': 1, '20038364': 1, '2990363': 1, '24741428': 2}

{'7586619-1': 1}

3977334-1

noncomm/PMC003xxxxxx/PMC3977334.xml

Total Reconstruction of Lower Eyelid in a Post-traumatic Patient Using Modified Fricke's Cheek Flap

An 22-year-old male patient presented with avulsion injury of the left lower eyelid and lateral periorbital area following a road traffic accident. On examination it was revealed that there was complete loss of the lower eyelid including the skin, subcutaneous tissue, tarsal plate, and palpebral conjunctiva. Few fibers of the orbicularis oculi survived. There was extensive skin loss in the lateral periorbital area. There was no injury to the cornea, sclera, bulbar conjunctiva, lower fornix, and lacrimal apparatus. The upper eyelid was absolutely normal []. The patient was at first treated conservatively with antibiotics and regular dressing of the wound until fresh granulation tissue was formed. Then he was posted for reconstructive surgery with the aim of creating a functional lower eyelid with maximum possible cosmetic result. A strip of cartilage was harvested from the ear concha and inserted in a pocket created within the fibers of orbicularis to serve as tarsal plate []. The remnant of the conjunctiva at the lower fornix was sutured with the orbicularis fibers to form the posterior lamella. The anterior lamella was reconstructed using a modification of the Fricke's flap where the vertical limb of the flap was designed over the cheek. The entire flap design was sketched out on the skin starting from the wound margin with the vertical limb extending over the cheek []. It was slightly longer and wider than the defect to compensate for its retraction and included the totality of the subcutaneous cellular tissue. The length-to-width ratio was roughly 4:1. The whole flap was elevated according to the outline sketched over the skin, and thorough hemostasis was performed []. The apex between the donor and the receptor area is sutured first near the medial canthus; [] followed by the margin with orbicularis oculi fibers, thus completing the anterior lamella. Rest of the defect over the cheek and the lateral temporal area was easily sutured primarily without any tension by adequate undermining of the margins resulting in satisfactory advancement displacement []. The repair was done in two layers. The subcutaneous layer was sutured with 5/0 vicryl and the skin margins opposed by horizontal mattress suture using 5/0 nylon except for the lid margin where simple suture was given avoiding excessive tension. The patient recovered smoothly without any significant postoperative complications. In the subsequent follow-up, the patient did not have major problems like irritation of the eyes, epiphora, synechia, or corneal ulcers [].

[[22.0, 'year']]

M

{'15655173': 1, '15375366': 1, '16141830': 1, '14871219': 1, '15861077': 1, '16217450': 1, '9207667': 1, '10654700': 1, '9915182': 1, '21778129': 1, '11886419': 1, '10323697': 1, '15996421': 1, '21713158': 1, '867633': 1, '24741429': 2}

{}

3977335-1

noncomm/PMC003xxxxxx/PMC3977335.xml

Successful Laparoscopic Removal of an Ingested Toothbrush

We describe a case report of an 18-year-old girl who had accidentally swallowed a toothbrush. Immediately following the ingestion she attended accident and emergency but was discharged home as no foreign body was visible on an abdominal plain film. Four years later she presented to our surgical out-patient clinic with vague epigastric pain, adamant that she had previously ingested a toothbrush. Ultrasound and abdominal plain films confirmed a foreign body within the stomach. Endoscopic removal was then attempted on two separate occasions but the toothbrush was found to be straddling the pylorus and partial embedded within the gastric mucosa. Therefore, despite using a polypectomy snare and biopsy forceps, the toothbrush could not be safely freed. Endoscopic mucosectomy was not considered in this particular case because the toothbrush was deeply embedded.\nThe decision was taken to perform laparoscopic removal of the toothbrush. The patient was positioned in the supine position with sacrum at the edge of the table and the legs abducted in stirrups. The patient was given 1.2 g of augmentin intravenously as antibiotic prophylaxis. The surgeon stood in between the patient's legs with the assistant on the right hand side of the patient. A Veress needle was used to establish pneumoperitoneum with a working pressure of 12 mmHg and an initial 10-mm trocar was placed supra-umbilically as the camera port. Two further 5-mm trocars were placed under direct vision in the right and left subcostal margins both in the mid-clavicular line. A Nathanson liver retractor was introduced through a 5-mm epigastric incision to allow retraction of the left lobe of the liver. With a 10-mm 30-degree laparoscope and a reverse Trendelenburg position, the outline of the toothbrush could be clearly seen projecting on to the anterior gastric wall and extending in to the duodenum [].\nUsing hook diathermy, a 4-cm gastrotomy was made in the distal anterior gastric wall overlying the toothbrush. With the aid of two graspers we were able to manipulate and gently free the partially embedded toothbrush and allow safe removal from the stomach in its entirety [].\nAn endoloop was placed around the handle of the toothbrush with the string left long. A 5-mm 0-degree laparoscope was inserted down the right lateral 5-mm port allowing the string to be delivered via the 10-mm supraumbilical port. Subsequent manipulation of the string then facilitated delivery of the handle of the toothbrush in to the port. We then removed the 10-mm port from the abdomen thus allowing the toothbrush to be retrieved through the existing incision. The 10-mm port was re-introduced and the gastrostomy was laparoscopically sutured using a continuous 2-layer intracorporeal technique with ethibond 1/0 [].\nWe did not feel that an abdominal drain or nasogastric tube were required at the end of the procedure. The total operating time was 90 minutes and the patient was given a light diet the following day. After 48 hours, the patient was discharged as she was tolerating a normal diet, was pain free, and fully mobile. The patient was followed up in the surgical out-patient clinic 6 weeks after the operation and had made a full recovery.

[[18.0, 'year']]

F

{'9153178': 1, '7698622': 1, '18666336': 1, '17131048': 1, '22567210': 1, '11967706': 1, '26082909': 2, '6696536': 1, '11293596': 1, '10549750': 1, '12023005': 1, '7698623': 1, '11077351': 1, '17865657': 1, '16996336': 1, '16805760': 1, '8215155': 1, '3277591': 1, '2227335': 1, '21416187': 1, '6852484': 1, '9711512': 1, '17616026': 1, '19019363': 1, '4073002': 1, '24741430': 2}

{'4461851-1': 1}

3977380-1

noncomm/PMC003xxxxxx/PMC3977380.xml

Recurrent primary lumbar vertebra chondrosarcoma: Marginal resection and Iodine-125 seed therapy

A 54 year old male presented with progressive back pain and lumbar swelling that had gradually increased in size over 3 years. He had undergone an operation for chondrosarcoma in the left transverse process of the third lumbar vertebra 4 years ago in another hospital. Two years prior to admission, he began to have pain in his left leg that radiated from the back and had left paraparesis. Physical examination revealed an 18-cm hard, immobile, round, nontender mass in the posterolateral left flank. Neurological examination showed atrophy of the left quadriceps and hypoesthesia in the left anterolateral thigh.\nPlain radiographs of the LS spine showed inconspicuous calcified points involving the left side of the L3 vertebrae. Computed tomography (CT) showed a mass at L1-5 level, 15 cm in diameter, originating from the left transverse process of L3 [Figure and ]. Lumbar spine magnetic resonance imaging (MRI) demonstrated a large mass lesion, compressing the left nerve root, close to the aorta at the L1-2 levels []. The lesion was completely resected anteroposteriorly, in a piece meal fashion until tumor free margins were obtained. The L3 left remnant transverse process and part of the normal articular process and lamina were removed. The nerve root was free of compression. According to the preoperative plan to which the patient and his family agreed, radioactive Iodine-125 particles with diameters of 0.8 mm, lengths of 4.5 mm and titanium alloy shells were put in gelatin sponges, then they were placed in the bed of the excised lesion. Neurological deficits gradually improved. The pathology specimen was compatible with conventional low-grade chondrosarcoma [].\nTwo years since the operation, the patient remained asymptomatic. Recently obtained X-ray, CT, and MRI show no sign of tumor recurrence [].

[[54.0, 'year']]

M

{'19829275': 1, '12243829': 1, '32362797': 1, '18299113': 1, '6462413': 1, '21246520': 1, '19829277': 1, '21437176': 1, '23496973': 1, '18764743': 1, '26064741': 2, '32089620': 2, '10413129': 1, '7751192': 1, '10751291': 1, '16498937': 1, '24741146': 2}

{'7008663-1': 1, '4433675-1': 1}

3977381-1

noncomm/PMC003xxxxxx/PMC3977381.xml

Disseminated Fusarium oxysporum neurospinal infection

A 60-year-old female patient was admitted with altered sensorium and fever for 2 weeks. The patient was drowsy with severe neck stiffness. She was a known case of type II diabetes mellitus and systemic hypertension.\nRoutine blood examination revealed polymorphonuclear leucocytosis (TC 12400, DC P97, L02, M01) and normal erythrocyte sedimentation rate (ESR). Lumbar puncture was performed, cerebrospinal fluid (CSF) study showed lymphocytic pleocytosis with elevated protein and normal glucose. Computed tomography (CT) brain showed small ring enhancing lesions in bilateral frontal lobes and features suggestive of meningoencephalitis. Magnetic resonance imaging (MRI) brain [] showed multiple well-defined enhancing lesions in both cerebral hemispheres and left cerebellum with pial enhancement. Treatment was started presuming bacterial/tuberculous meningitis with a broad spectrum antibiotic and anti tuberculous therapy. CSF culture was negative for any organisms. She was discharged after 3 weeks with the diagnosis of chronic meningitis with cerebral granuloma, type II diabetes mellitus and systemic hypertension.\nOne month later, she came with hypoglycemia, hypotension and fever. She was diagnosed with urinary tract infection with extended-spectrum beta-lactamase Klebsiella and was appropriately treated. Repeat MRI brain was done which showed no new lesions; anti TB treatment was continued.\nShe was readmitted after 5 months with vomiting, poor intake, fatigue and generalized body ache. She had developed right parieto-occipital infarct, so low- molecular- weight heparin and antiplatelets were started. MRI brain now showed persistence of lesions with only mild resolution of edema surrounding the lesions. She showed mild symptomatic improvement. Hence, she was further evaluated with tumor markers and CT thorax and abdomen. This showed a collapse at D8-D9 vertebral level. MRI spine with contrast showed spondylodiscitis at the D8-D9 level [Figure and ]. Patient underwent laminectomy, debridement of discovertebral infection and fusion. The lesion was approached through the posterior midline. Pedicle screws were applied at D6, D7 and D10, D11 levels. D8, D9 laminectomy was done as an approach to the infected site and D8/9 disc space was curetted []. Pus and granulation tissue were sent for histopathology and microbiological studies. The space was packed with grafts taken from the transverse process and stabilized with rods. Histopathology examination revealed chronic nonspecific granulomatous inflammation. Microbiology tests showed fungal hyphae on culture and the fungus was identified as F. oxysporum.\nShe was diagnosed as having meningospondylodiscitis due to F. oxysporum and was started on intravenous voriconazole 200 mg 12 hourly for 3 weeks, then changed to oral voriconazole 200 mg twice daily for a period of 7 weeks. In the meantime, tuberculosis (TB) polymerase chain reaction from the spinal tissue was found to be negative. Hence, ATT was stopped. At the time of discharge, 2 months later, she was asymptomatic and ambulant with the support of a brace. She was followed up regularly in the outpatient department with X rays and laboratory tests (ESR 13, TLC 9000), which showed reduction in infection and a progressive spine fusion [] X ray shows bony trabeculae crossing the fusion site and clinically there is no tenderness at the site. At her last followup, 36 months after the surgery, she was doing well, living an independent life [].

[[60.0, 'year']]

F

{'1590137': 1, '15897953': 1, '18837241': 1, '20876624': 1, '15979485': 1, '3875878': 1, '11315785': 1, '17921653': 1, '22567471': 2, '24741147': 2}

{'3336223-1': 1}

3977382-1

noncomm/PMC003xxxxxx/PMC3977382.xml

Double crush syndrome due to plating of humeral shaft fracture

A 62 year old woman sustained a closed fracture of right humeral shaft resulting from a car accident (OTA 12A3). We performed the open reduction and internal fixation through an anterolateral approach under general anesthesia and placed a 4.5 mm dynamic compression plate on the lateral aspect of the humerus. The placement of the implants was good except that the tip of the most proximal screw protruding approximately 1 cm through the medial cortex []. During in-hospital treatment, the patient recovered without complaining any discomfort of the right hand. 4 weeks postoperatively, however, she began to feel tingling over the thumb, index and middle fingers of the right hand, which was worse at night. The symptoms gradually progressed with thumb-index finger pinch weakness. When coming to our clinics 3 months postoperatively, she presented a sensory deficit of those fingers. Both Tinel's sign over carpal tunnel and Phalen's test were positive, as well as atrophy of the thenar muscles. She did not experience such symptoms prior to surgery to the humerus fracture. The neurophysiological study confirmed the clinical suspicion of CTS, with a prolonged distal latency and low amplitude of compound muscle action potential, so did the sensory nerve []. The neurophysiological finding of the proximal median nerve and ipsilateral ulnar nerve was normal. The criteria for electro-diagnosis of CTS included: Distal median motor latency >4.4 ms; difference between distal motor latency of median and ulnar nerve >1.1 ms; difference between distal sensory latency of median and ulnar nerve >0.2 ms. Although a transient improvement was observed with night splint treatment, the symptoms recurred after a few weeks. A carpal tunnel decompression was therefore recommended but the patient refused.\nAt 16 months postoperatively, the patient asked for removal of the implants. During the operation, we observed that the tip of the protruding screw twisted the median nerve with scar tissues. Extensive neurolysis around the median nerve was not performed, because we did not expect relief of symptoms of CTS after removal of the implants. At 2 weeks later, however, the patient experienced a significant relief of the tingling over fingers. At last review, 6 months after the implants removal, her sensations returned to near normal with full movement of the fingers. Although mild thenar atrophy was still present, the patient remained asymptomatic and denied additional carpal tunnel decompression surgery as she had no great difficulty in carrying out her daily activities.

[[62.0, 'year']]

F

{'701352': 1, '16326879': 1, '3275922': 1, '10679720': 1, '4124532': 1, '26201950': 1, '21259009': 1, '19685252': 1, '3611653': 1, '24741148': 2}

{}

3978101-1

noncomm/PMC003xxxxxx/PMC3978101.xml

Management of failed periodontal surgical intervention for a furcal lesion with a nonsurgical endodontic approach

A 42-year-old female, complaining of a painful swelling beside her right first mandibular molar, demanded a dental visit. She had normal hygiene and mentioned regular dental visits. On tooth #46, a class 1 composite filling with stained margins was evident. On the buccal gingival tissue just below the gingival margin, an inflamed swelling was present that revealed pain upon palpation. On probing assessment of the furcation, a non-through-and-through furcation lesion could be penetrated. Orthoradial periapical radiography () revealed that a root canal treatment had been performed on this tooth 5 years earlier following severe nocturnal pain. The radiographic quality of root canal therapy (RCT) was not good, and a large furcation lucency extending to the inter-radicular apical region was evident. It also seemed that a periapical lesion existed around the mesial root that had combined with the furcal lucency. The patient mentioned a visit to a periodontist a year before with the same chief complaint. He had diagnosed the problem to be periodontal in origin and performed an alloplastic operation on the furcation of the tooth. The graft was still visible in our radiography, and not only had the healing not occurred, but also, as mentioned before, the symptoms had started to recur.\nConsidering the furcation lucency that was not responsive to periodontal surgery, the poor quality of RCT, and the presence of the periapical lucency around the mesial root, a diagnosis of the primary endodontic, secondary periodontal lesion was made, and this lesion could be handled with endodontic intervention. The treatment plan was root canal retreatment, permanent restoration of the tooth, and patient follow-up. We also considered that further periodontal intervention might be required if the healing process was assumed to be insufficient during the follow-up.\nAfter local anesthesia with 2% lidocaine containing epinephrine 1 : 80,000 (Darou Pakhsh, Tehran, Iran), the composite filling of the crown was removed. The filling had severe marginal discoloration and upon removal with a high-speed bur, was assumed to be debonded in some areas. The chamber floor was covered with a layer of gutta-percha, which was removed. The orifices of the canals filled with gutta-percha were detected, and then, the tooth was isolated with a rubber dam. Then, the filling material in the coronal portion of the three canals (distal, mesiobuccal, and mesiolingual) was removed with No. 1 - 4 Gates-Glidden drills (Mani, Inc., Tochigi, Japan) and then, subsequent to using a drop of chloroform, the rest of the canal filling was removed with a D-RaCe retreatment file, DR2 (RaCe, FKG Dentaire SA, La Chaux de Fonds, Switzerland) at 900 rpm until the canal was totally cleaned. After the determination of the working length with radiography, the canals were completely shaped to #35/0.04 of the RaCe system, with simultaneous 5.25% NaOCl irrigation. Thereafter, canal obturation and restoration of the access cavity was completed (). After two weeks, the clinical signs/symptoms faded away.\nThe patient was put on a follow-up schedule with 3-month intervals. shows the 12-month follow-up periapical radiography. Bone healing in the furcation area around the previously inserted graft is evident, and the periapical lucency of the mesial root has healed.

[[42.0, 'year']]

F

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{'5911307-1': 1}

3978102-1

noncomm/PMC003xxxxxx/PMC3978102.xml

Biodentine-a novel dentinal substitute for single visit apexification

A 20-year old male patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of fractured and discoloured upper left front tooth. He gave a history of trauma 10 years back. The patient did not give any history of swelling or pus discharge. No other significant dental or medical history was found and no known drug allergies were noted. Intraoral examination revealed generalized dental fluorosis with Elli's Class IV fracture and discolouration in relation to tooth #21 (). Palpation and percussion test of the involved tooth did not reveal any tenderness. The tooth was not mobile and periodontal probing around the tooth was within physiological limits. Electric pulp testing (Parkell Electronics Division, Farmingdale, NY, USA) of the involved tooth gave no response, whereas response was obtained on adjacent teeth. The radiographic examination of the tooth revealed a wide canal with an open apex and a marked radiolucency periapically (). Clinical and radiographic examination indicated pulp necrosis with chronic apical periodontitis. The available treatment options were discussed with the patient and root canal therapy with calcium hydroxide dressing, followed by apexification with Biodentine using a matrix with synthetic collagen material was selected.\nFollowing rubber dam isolation, a conventional endodontic access cavity was established. A dental operating microscope (Roslane Meditech, Haryana, India) was used to facilitate all endodontic procedures for this tooth. As the apex locator (Raypex5, VDW, Munich, Germany) produced inconsistent canal length readings, the working length was established radiographically 1 mm short of the radiographic apex with a #110 H-file (MANI, INC., Utsunomiya Tochigi, Japan) and was recorded for reference (). The canal was gently instrumented to #140 H-files using a circumferential filing motion with copious irrigation with 3% sodium hypochlorite solution (Cmident, Cmident, New Delhi, India). The canal was dried with sterile paper points, and calcium hydroxide paste (Metapex, Meta Biomed Co. Ltd., Chungwon, Korea) was placed as an intracanal medicament and the access cavity was temporized with a cotton pellet and Cavit G (3M ESPE Dental Products, St. Paul, MN, USA) ().\nAfter 1 month, the tooth was again isolated under rubber dam and the calcium hydroxide was removed mechanically using hand H-files to the working length, while rinsing with alternating solutions of 3% sodium hypochlorite solution and 17% ethylenediaminetetraacetic acid (Prevest Denpro Ltd., Jammu, India). A final rinse with sterile saline was performed. After drying the canal with paper points, small piece of absorbable collagen membrane (CollaPlug, Zimmer Dental Inc., Carlsbad, CA, USA) was cut to fit the width of the canal. The membrane was introduced thorough the root canal and gently compacted using pre-fitted hand pluggers slightly beyond the apex into the bony space formed due to the periapical lesion in order to achieve a matrix.\nBiodentine was mixed according to the manufacturer's instructions. It was carried into the canal with the help of an amalgam carrier and was condensed against the collagen matrix using pre-fitted hand pluggers. Several increments were required to form an apical plug of 5 mm thickness, which was confirmed radiographically (). Following the placement of Biodentine over the barrier, butt-end of a paper point was used to clear out any excess material from the walls. After 12 minutes, the hardness of the Biodentine was examined using a plugger to confirm its set. The canal was back-filled with injection-moulded thermoplasticized gutta-percha (Calamus Dual, Dentsply Maillefer, Bellaiguise, Switzerland) and AH Plus resin sealer (Dentsply DeTrey, Konstanz, Germany). The access cavity was then restored with composite resin (Ceram-X Duo, Dentsply DeTrey) (). In the subsequent visit, the teeth were bleached with a combination of in-office and at-home whitening protocols. Following bleaching, tooth #21 was restored with all-ceramic crown ().\nOne year postoperative follow-up revealed restored aesthetics and function, absence of any clinical signs or symptoms of periradicular pathosis, resolution of periapical rarefaction, and a thin layer of calcific tissue formed apical to the Biodentine barrier ().

[[20.0, 'year']]

M

{'9055695': 1, '98608': 1, '32939456': 1, '17963961': 1, '28512495': 2, '10697473': 1, '22557824': 2, '20113774': 1, '20171353': 1, '11475951': 1, '18298574': 1, '29372451': 1, '27936042': 1, '15606825': 1, '24303363': 2, '3461104': 1, '12110105': 1, '23429542': 1, '20003930': 1, '1349289': 1, '6950346': 1, '4517751': 1, '9364090': 1, '18041512': 1, '23348482': 1, '27471534': 1, '21777256': 1, '23348450': 1, '31309344': 1, '6593412': 1, '7050284': 1, '16471532': 1, '15946263': 1, '27912821': 1, '10321187': 1, '24790925': 2}

{'3843039-1': 1, '5431724-1': 1, '3339020-1': 1}

3978103-1

noncomm/PMC003xxxxxx/PMC3978103.xml

Healing after horizontal root fractures: 3 cases with 2-year follow-up

A 33-year-old man presented to the Department of Conservative Dentistry at the Wonkwang University Dental Hospital (Iksan, Korea) with a complaint of discomfort of the maxillary right central incisor during mastication. Two days before, the tooth had impacted against a rigid object. The patient's medical history was noncontributory. Radiographic examination showed a horizontal fracture in the middle third of the root of the tooth and a slight displacement of the apex (). Intraoral examination revealed that all maxillary teeth had normal responses to pulp vitality tests, no mobility, and no discolored crown. Since the maxillary central incisor showed no signs of mobility or pathology, the patient was followed up without any splint appliances. His occlusion was checked and adjusted to eliminate loading on the traumatized tooth during function.\nFour weeks after the trauma, a radiolucent area appeared intra-canally on the apical portion of the coronal fragment and it continued to progress until 6 weeks of observation (). Root canal treatment was initiated on the coronal fragment with K-file and irrigated with 5% sodium hypochlorite. Working length was established with an apex locator (DentaPort ZX, Morita, Kyoto, Japan). Special care was taken to instrument within the coronal fragment. After 2 months of intracanal calcium hydroxide dressing, the canal was obturated with mineral trioxide aggregate (MTA, ProRoot, Dentsply, Tulsa, OK, USA) ().\nAt the 2-year follow-up evaluation, the patient did not report any clinical symptoms. Complete healing of the root fracture with the interposition of hard tissue between the fragments was observed on the periapical radiographs ().

[[33.0, 'year']]

M

{'15245518': 1, '20238280': 1, '23429855': 2, '30369978': 1, '18173686': 1, '15355385': 1, '3248578': 1, '10673660': 1, '15245519': 1, '18721336': 1, '5231441': 1, '18557757': 1, '24790926': 2}

{'3978103-2': 2, '3978103-3': 2, '3569405-1': 1}

3978103-2

noncomm/PMC003xxxxxx/PMC3978103.xml

Healing after horizontal root fractures: 3 cases with 2-year follow-up

A 60-year-old male patient was referred to the Department of Conservative Dentistry at the Wonkwang University Dental Hospital (Iksan, Korea) for the evaluation of the maxillary anterior teeth. He had a history of trauma that had occurred 7 days previously. The patient's medical history was noncontributory. The initial diagnosis by the emergency dentist was horizontal root fracture on the maxillary right central incisor and avulsion on the maxillary left central incisor. According to the emergency note, a crown fragment of tooth #11 had been extruded with a large amount of diastases. The emergency dentist performed pulp extirpation on the crown fragment and the teeth were repositioned and splinted with a semi-rigid splint (). Root canal treatment was performed on coronal fragment of tooth #11 with K-file and irrigated with 5% sodium hypochlorite. Working length was established with an apex locator (DentaPort ZX). After 6 weeks of intracanal calcium hydroxide dressing, the canal was obturated with MTA (ProRoot) ().\nAt the 2-year follow-up evaluation, the patient had no complaints of pain or discomfort. Radiographic examination showed the root-fractured tooth was completely healed with hard and soft tissue between the fragments ().

[[60.0, 'year']]

M

{'15245518': 1, '20238280': 1, '23429855': 2, '30369978': 1, '18173686': 1, '15355385': 1, '3248578': 1, '10673660': 1, '15245519': 1, '18721336': 1, '5231441': 1, '18557757': 1, '24790926': 2}

{'3978103-1': 2, '3978103-3': 2, '3569405-1': 1}

3978103-3

noncomm/PMC003xxxxxx/PMC3978103.xml

Healing after horizontal root fractures: 3 cases with 2-year follow-up

A 13-year-old female patient was referred to the Department of Conservative Dentistry at the Wonkwang University Dental Hospital (Iksan, Korea) for the evaluation of her maxillary anterior teeth. Seven days previously, the maxillary central incisors were traumatized when she slipped on the stairs and fell down. The coronal fragments of the incisors were luxated laterally, thereby showing the exposed labial surface of the root. The patient's medical history was noncontributory. The emergency dentist diagnosed the teeth as having horizontal root fractures with alveolar bone fractures. The teeth were repositioned with a rigid splint ().\nOne week after the trauma, both teeth had a normal response to pulp vitality tests. Three weeks later, localized swelling was observed on the labial gingiva of the maxillary left central incisor, and a radiolucent lesion was present near the fracture line. Both teeth had no responses to the thermal and electronic pulp tests. The narrow and deep pocket (approximately 8 mm) were explored by a dental probe through the gingival sulcus to the swollen portion (). Root canal treatment was initiated on both coronal fragments of the teeth with K-file and irrigated with 5% sodium hypochlorite. Working length was established with an apex locator (DentaPort ZX). Calcium hydroxide was applied into the canals between appointments. The deep pocket was debrided because of the possibility of the insertion of a foreign body at the time of the accident. At the 2-month follow-up evaluation, the swelling had disappeared and pocket depth was reduced to 3 mm. The canals were obturated with MTA (ProRoot) confined to the coronal fragment ().\nAt the 6-month and 1-year follow-up evaluation, she did not complain of any pain. However, she reported occasional swelling of the gingiva of the maxillary left central incisor. Clinically normal probing depth and normal response to percussion were observed on the teeth. Radiographic examination showed that the radiolucent area near the fracture line of the maxillary left central incisor had decreased, but the lesion remained (). At the 1½-year evaluation, a fragment of tooth-like material was observed in the gingival swelling area and the fragment was removed. At the 2-year follow-up evaluation, she reported no recurrence of gingival swelling since her last visit to the dental hospital. Slight mobility remained, but both teeth were retained well in the maxillary arch without any discomfort. Radiographic examination showed the teeth were healed with soft tissue between the fragments ().

[[13.0, 'year']]

F

{'15245518': 1, '20238280': 1, '23429855': 2, '30369978': 1, '18173686': 1, '15355385': 1, '3248578': 1, '10673660': 1, '15245519': 1, '18721336': 1, '5231441': 1, '18557757': 1, '24790926': 2}

{'3978103-1': 2, '3978103-2': 2, '3569405-1': 1}

3978104-1

noncomm/PMC003xxxxxx/PMC3978104.xml

Endodontic management of a mandibular second molar with radix entomolaris: a case report

A 27-year-old male patient was referred to the Department of Conservative Dentistry and Endodontics with the complaint of spontaneous pain in the lower left posterior tooth for 3 days. The patient reported a history of intermittent pain for the past one month. On clinical examination, there was a carious mandibular left second molar (tooth #37). The tooth was tender to percussion and palpation did not reveal any tenderness. There was no mobility, and periodontal probing was within the physiological limits. A heat test resulted in intense lingering pain. The involved tooth showed a premature response to electronic pulp stimulation. The preoperative radiograph showed disto-occlusal radiolucency with pulpal involvement and periodontal space widening relative to the mesial and distal roots with an additional distolingual root (). Based on these findings, the tooth was diagnosed with dental caries with symptomatic irreversible pulpitis and apical periodontitis. Endodontic management was planned for the involved tooth.\nAn inferior alveolar nerve block was performed with 1.8 mL of 2% lidocaine containing 1 : 200,000 epinephrine (LOX 2%, Neon Laboratories Ltd., Mumbai, India) followed by buccal infiltration (1.8 mL) of the same anesthetic solution. The endodontic access cavity was prepared under rubber dam isolation. The conventional triangular outline form of the access cavity was modified into a trapezoidal form to place the distolingually located RE under the surgical operating microscope. A clinical examination was carried out with a DG16 endodontic explorer (Hu-Friedy, Chicago, IL, USA), and the surgical microscope (Seiler 600 series) revealed two mesial and two distal canal orifices. Coronal enlargements of the canals were performed with the nickel-titanium Protaper series orifice shaper (Dentsply Maillefer, Ballaigues, Switzerland) (). The canal length was determined with an electronic apex locator (Root ZX, Morita, Tokyo, Japan) and later confirmed using a radiograph ().\nTo confirm RE, CBCT imaging of the tooth (Kodak 9500, tube voltage: 90 kV, current: 10 mA, Carestream health Inc., Rochester, NY, USA) was performed after obtaining informed consent from the patient. The transverse, axial, and sagittal CBCT sections of the involved tooth were taken. The CBCT scan slices confirmed the presence of RE (). During the next visit, the patient was asymptomatic, and cleaning and shaping was done with Protaper nickel-titanium rotary instruments (Dentsply Maillefer) in a crown-down manner until F2. Irrigation was performed with 2.5% sodium hypochlorite solution, 17% EDTA, and 2% chlorhexidine digluconate solution as the final irrigant. Obturation was done with Protaper gutta-percha cones (Dentsply DeTrey Gmbh, Konstanz, Germany) and AH Plus resin sealer (Dentsply DeTrey Gmbh, ). The access cavity was then restored with posterior composite resin, and the patient was advised to undergo full coverage restoration of the tooth.

[[27.0, 'year']]

M

{'29599601': 2, '5277376': 1, '22681628': 1, '2390962': 1, '17185133': 1, '20478452': 1, '18155501': 1, '20647088': 1, '17185117': 1, '24303362': 2, '20307739': 1, '23429761': 2, '21763895': 1, '2073191': 1, '19298577': 1, '3457033': 1, '5572604': 1, '2293344': 1, '15479262': 1, '5286234': 1, '2391179': 1, '20647084': 1, '26391768': 2, '19166773': 1, '9868938': 1, '6949672': 1, '24790927': 2}

{'4578332-1': 1, '3843038-1': 1, '3843038-2': 1, '3843038-3': 1, '5863398-1': 1, '3569404-1': 1}

3978939-1

noncomm/PMC003xxxxxx/PMC3978939.xml

Synchronous Metastasis of Prostate Adenocarcinoma to the Stomach and Colon: A Case Report

A 71-year-old African American man with a medical history significant for hypertension, prostate cancer treated with surgery and radiation therapy over 10 years ago, diabetes mellitus, and a bilateral knee arthroplasty for severe degenerative arthritis was admitted with complaints of weakness and dizziness. He stated that over the past few weeks, he experienced poor activity tolerance. He had to use tables and walls for support while walking. He denied any symptoms of nausea, vomiting, abdominal pain, melena, changes in bowel habit, bright red blood per rectum, or hematuria. Physical examination revealed a thinly built male in no acute distress with pale conjunctiva, otherwise essentially unremarkable. Vitals signs showed a temperature of 97.8, pulse 86, blood pressure 147/88 mm/Hg, and respiratory rate 16. Laboratory data revealed hemoglobin of 6.1gm/dl, hematocrit of 18.3%, platelet count of 196,000/μl, white blood cell (WBC) count of 4,000/μl, mean corpuscular volume of 80 μ3, red cell distribution width of 21.6%, reticulocyte count of 2.1%, blood urea nitrogen (BUN) of 12 mg/dl, creatinine of 0.75 mg/dl, prothrombin time of 15 sec, international normalized ratio of 1.2, activated partial thromboplastin time activated partial thromboplastin time (APTT) of 38.7 sec, and prostate-specific antigen (PSA) of >150 ng/ml. Iron studies revealed serum iron level of 68 μg/dl, ferritin of 1,500 ng/dl, iron binding capacity of 157 μg/dl, and an iron saturation of 43%. The patient's previous laboratory data revealed hemoglobin of 8.0 gm/dl and hematocrit of 24.6%. The patient was transfused three units of packed red blood cells; furthermore, gastroenterology was consulted to rule out gastrointestinal loss as the etiology of the patient's anemia. The patient underwent endoscopic evaluation with esophagogastroduodenoscopy (EGD) and colonoscopy. EGD [] revealed a 5-mm nodule in the fundus and a 5-mm clean-based ulcer in the body of the stomach; multiple erosions were found in the antrum. Biopsies were taken from the fundus nodule, gastric body ulcer, and antrum and sent for pathology. Colonoscopy [] revealed diminutive sessile polyps in the cecum, sigmoid colon, and rectum, in addition to large internal hemorrhoids. All polyps were removed by cold forceps polypectomy. Biopsy results from the antrum and body ulcer showed minimal inflammatory cell infiltration, and the stains for Helicobacter pylori were negative. The pathology results from the cecal polyp and rectal polyp revealed hyperplastic polyps. However, the pathology studies of the sigmoid polyp and fundus nodule [Figure and ] were consistent with adenocarcinoma, and special immunohistochemical staining [Figure and ] confirmed that it was consistent with prostatic origin. The patient was subsequently started on antiandrogen (bicalutamide 50 mg/day p.o.) and leuprolide acetate [luteinizing hormone-releasing hormone (LHRH) agonist]. The PSA level decreased to normal levels within 4 months. The patient has remained hemodynamically and clinically stable for 6 months since the diagnosis of synchronous metastasis of prostate cancer to the stomach and colon.

[[71.0, 'year']]

M

{'25667754': 1, '28784100': 2, '20577612': 2, '24132735': 1, '1564301': 1, '14629877': 1, '2311070': 1, '33263827': 2, '11437044': 1, '20305145': 1, '11319319': 1, '15072903': 1, '22373539': 1, '24741555': 2}

{'5547505-1': 1, '7710771-1': 1, '2890062-1': 1}

3979781-1

noncomm/PMC003xxxxxx/PMC3979781.xml

Terson syndrome and leukemia: a case report

A 45-year-old woman suffering from intraocular hemorrhage associated with chronic myeloid leukemia complicated by subdural hematoma was referred to our institution. Chronic myeloid leukemia had been diagnosed 10 years earlier and the patient’s comorbidities were treated arterial hypertension, hepatitis B virus positivity, and orally treated type 2 diabetes mellitus diagnosed 3 years earlier. At presentation, she was in blast crisis for the second time and the disease was rapidly progressing. She was hospitalized in the Hematology-Oncology Department, University of Turin, with a very low platelet count (8,000/mm3) and red cell count (2,000 mm3), asthenia, fever, and occipital headache radiating to the anterior parts. A severe subdural hematoma was discovered, with ventricular dilatation and signs of high intracranial pressure. She was treated with repeated platelet transfusions and conservative medical therapy. The patient’s condition improved slowly, with progressive reabsorption of the hematoma and normalization of ventricular morphology on brain computed tomography scan.\nWe followed up this patient for a year by assessment of visual acuity, fundus examination, color retinography, and A-scan and B-scan ultrasonography. The patient complained of visual impairment in the left eye since the onset of her neurological symptoms, and was referred to our clinic. At presentation, her best corrected visual acuity on the right was 20/63 and on the left was 20/320. Retinal examination of the right eye revealed blurring of the optic margins surrounded by retinal and preretinal hemorrhages, preretinal fibrosis starting from the optic disc and extending along the vascular arcades, and perivascular retinal infiltrates (). Massive fibrosis with hard exudates and severe preretinal hemorrhage were observed in the left eye at the posterior pole (). The optic disc was surrounded by retinal and preretinal hemorrhages. Roth spots and many circular and preretinal hemorrhages were noted at the retinal periphery (). The other ocular structures were within normal limits. Ocular tension was good (right, 20 mmHg; left, 17 mmHg).\nA-scan and B-scan ultrasonography showed similar clinical features in both eyes, ie, an anechogenic vitreous cavity, a small increase in the thickness of the chorioretinal complex, and some minute retinal lines with higher reflectivity, likely representing hemorrhages. The patient was monitored for 12 months, with no changes in her clinical and functional characteristics.

[[45.0, 'year']]

F

{'11535467': 1, '15076959': 1, '21117599': 1, '15002029': 1, '18537934': 1, '13197505': 1, '10950415': 1, '15453050': 1, '31179143': 2, '24729684': 2}

{'6507114-1': 1}

3979787-1

noncomm/PMC003xxxxxx/PMC3979787.xml

Effectiveness of methylphenidate as augmentation therapy after failure of adjunctive neuromodulation for patients with treatment-refractory bipolar depression: a case report

Mr U, a 56-year-old man with bipolar I disorder according to DSM-Fifth Edition criteria, experienced his first melancholic depression in 1976, which was followed by five melancholic episodes and four manic episodes. He did not show any comorbid psychiatric condition and had no history of drug or alcohol abuse.\nHis sixth melancholic depressive episode began in March 2008, just after a prison guard workmate had committed suicide. Mr U was admitted to our bipolar department on April 1, 2008. He showed a depressed and anxious mood, negative and obsessive thinking, loss of interest in activities, impairment in activities of daily living, psychomotor retardation, self-blaming behavior, guilty and suicidal thoughts, insomnia, reduced appetite, and a 5 kg loss of body weight. His laboratory examinations included a full blood count, blood biochemistry and urinalysis, electrocardiography, electroencephalography, and structural cerebral magnetic resonance imaging. His physical and laboratory examinations were normal. From April 1, 2008, blood pressure, pulse and temperature were monitored once daily by a nurse. His initial 21-item Hamilton Depression Rating Scale score was 37 and his Clinical Global Impression-Severity score was 6. From April 1, 2008 until June 10, 2010, he received various antidepressant (venlafaxine extended- release, clomipramine or duloxetine, combined with either paroxetine or mirtazapine) and mood stabilizer (olanzapine, aripiprazole, or sodium valproate) combinations with no significant clinical improvement. Each medication was prescribed at an optimum and stable dosage for the minimum recommended duration, with no significant clinical improvement. On February 6, 2009, we assessed the patient’s whole-brain voxel-based regional cerebral blood flow with 99mTc-ethyl cysteinate dimer single photon emission computed tomography, and hypoperfusion was shown in the bilateral anterior cingulate cortices, the right inferior parietal cortex, and the left dorsolateral and bilateral orbital prefrontal cortices. rTMS was initiated on February 15, 2009. Twenty treatment sessions were administered over a 4-week period (five sessions per week). In mid March, after these sessions were completed, Mr U showed no significant clinical improvement. rTMS was initiated again, with 20 treatment sessions being administered over a 4-week period until April 15, 2009. After the last rTMS session, Mr U showed no significant clinical improvement. His physicians initiated electroconvulsive therapy three times a week on April 18, 2009 for 2 months until June 19, 2009. Mr U showed no significant clinical improvement after 24 sessions of electroconvulsive therapy. At that time, he was treated with a combination of fluoxetine 80 mg/day, duloxetine 360 mg/day, mirtazapine 60 mg/day, and sodium valproate 1,000 mg/day. On June 29, 2009, we added methylphenidate at a dose of 10 mg/day for one week. Two days after introduction of methylphenidate, Mr U reported some mood improvement after a single early morning dose. The second week after its initiation, the dose of methylphenidate was increased to 20 mg/day for one week using an extended-release tablet formulation, with significant improvement. Two weeks later, Mr U achieved significant and lasting clinical improvement, with Hamilton Depression Rating Scale and Clinical Global Impression-Severity scores of 8 and 3, respectively. He was in a stable condition one month after starting adjunctive treatment with methylphenidate. He tolerated his medications well and did not report any side effects. His antidepressants and methylphenidate were gradually tapered and finally discontinued after one year. He remains well on sodium valproate monotherapy and is regularly followed up at our bipolar department.

[[56.0, 'year']]

M

{'8591972': 1, '14399272': 1, '18425966': 1, '17338594': 1, '1960383': 1, '28144880': 1, '17110825': 1, '16520686': 1, '19624385': 1, '9635549': 1, '24729710': 2}

{}

3979789-1

noncomm/PMC003xxxxxx/PMC3979789.xml

Overflow proteinuria as a manifestation of unrecognized polymyositis

A 41-year-old man visited our clinic with swelling and weakness of both lower extremities of 1-month duration. Recently, he had begun to have pain in both thighs and difficulty in lifting his legs. He had no history of recent trauma, administration of drugs, infections, physical exercise, endocrinopathies, or other factors that could cause rhabdomyolysis. On physical examination, there was pitting edema of the lower extremities without cutaneous eruption. shows the laboratory data. He recently noticed that his urine was tea-colored. The urine dipstick showed a positive test for blood in the absence of red cells in the sediment. The spot urine protein-to-creatinine ratio was 1,714 mg/g. His serum myoglobin was 0.405 mg/dL and urine myoglobin was undetectable. Aggressive volume replacement was started for the treatment of rhabdomyolysis.\nA 24-hour urine collection showed protein excretion of 3,140 mg/day and albumin excretion of 122.5 mg/day. Albuminuria was 3.9% of total proteinuria. The electrophoretic analysis of the serum and urine proteins is shown in . The serum electrophoresis pattern showed decreased albumin and increased α1-fraction, β-fraction, and γ-globulins, suggesting polyclonal gammopathy (). The urine electrophoresis showed increased β-fraction, which accounted for 53.3% of the urinary proteins (). Immunofixation of serum and urine was performed to identify monoclonal immunoglobulins and/or free light chains, and gave negative results. Despite fluid replacement, the patient’s creatine phosphokinase (CPK) level increased to 21,450 IU/L and his leg weakness did not improve. Nerve conduction studies were normal but the electromyography showed short-duration, low-amplitude, and polyphasic patterns in all of the left upper and lower extremity muscles, suggesting inflammatory myopathy. The test for anti-Jo-1 antibody was positive, with a titer more than 8.0 EU. Biopsy of the left vastus lateralis muscle demonstrated endomysial chronic inflammation and muscle fiber necrosis (), and immunohistochemical stain showed infiltration by CD8+ T cells (). Polymyositis was diagnosed by the criteria of Bohan and Peter, as he had symmetric proximal muscle weakness, histologic evidence of myositis, elevated serum muscle enzymes, and characteristic myopathic changes on electromyography, without skin changes. The patient was started on prednisone, 1 mg/kg daily, which resulted in gradual improvement of his leg pain, weakness, and swelling. After 1 month, his CPK level decreased to 461 IU/L and the spot urine protein-to-creatinine ratio decreased to 24.1 mg/g.

[[41.0, 'year']]

M

{'20146695': 1, '3293746': 1, '15618327': 1, '301732': 1, '21782130': 1, '15854195': 1, '17143706': 1, '18793567': 1, '15985512': 1, '16541204': 1, '10906171': 1, '1090839': 1, '24378741': 1, '8730148': 1, '8821813': 1, '17909702': 1, '2758641': 1, '24729735': 2}

{}

3979790-1

noncomm/PMC003xxxxxx/PMC3979790.xml

Intrarenal artery pseudoaneurysm after blunt abdominal trauma: a case report of successful superselective angioembolization

A 54-year-old man was admitted to the Emergency Department of the Hospital de São João, Porto, Portugal, a trauma center, for right flank pain and gross hematuria. He was referred from a secondary level health care hospital, where he stayed for 4 days due to a right grade III renal traumatic injury (as per the Organ Injury Scaling Committee of the American Association for Surgery of Trauma), after falling from a height of 2 meters and sustaining blunt abdominal and right flank trauma. During this period, the patient was hemodynamically stable, without gross hematuria. He underwent conservative management, with bed rest, hydration, antibiotics, analgesics, and serial laboratory and imaging evaluations.\nOn arrival at our institution, the patient was hemodynamically stable (blood pressure: 102/71 mmHg, heart rate: 88 bpm), eupneic, and afebrile, complaining of right flank and abdominal pain. On physical examination, he had right costovertebral angle tenderness, regional ecchymosis, and grossly bloody urine. Blood analysis showed decreased hemoglobin (11.8 g/dL) and hematocrit (33.2%). He had normal electrolytes and coagulation tests, with a creatinine level of 1.17 mg/dL, corresponding to an estimated glomerular filtration rate (eGFR) of 84.9 mL/min/1.73 m2, as calculated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation.\nA computed tomography (CT) scan showed a 3 cm posteroinferior laceration of the right kidney, apparently entirely enclosing the thickness of renal parenchyma, clearly without involvement of the renal sinus or excretory system. Moreover, there was a significant delay in elimination of the intravenous contrast, and the right renal pelvic content was spontaneously hyperdense, suggesting hematic nature. During the arterial phase, the inferior third of the right renal parenchyma showed a hyperdense rounded lesion, of 16 mm at its greatest diameter, suggesting a posttraumatic RAP (). Finally, there was also a posteroinferior right perirenal hematoma, measuring 55×55×37 mm (). Selective angiography of ventral and dorsal branches of the right renal artery revealed a contusion focus in the upper two-thirds of the right kidney, with partial cortex devascularization. It also showed a RAP, of 16 mm diameter, from two interlobar branches of the posterior division of the right renal artery (). Superselective embolization of these branches was performed, using a 5F catheter, with 2×5 mm microcoils and gelfoam particles. Postembolization images confirmed the complete pseudoaneurysm devascularization, exclusion of other arterial afferents, and preservation of the remaining renal vasculature (). The patient’s postoperative course was uneventful (blood pressure: 132/84 mmHg, heart rate: 81 bpm). He was discharged 5 days after the procedure, with a normalizing hematocrit (hematocrit 38%, hemoglobin 12.8 g/dL) and a creatinine level of 1.02 mg/dL, corresponding to an eGFR of 84.9 mL/min/1.73m2.

[[54.0, 'year']]

M

{'16323986': 1, '18609285': 1, '16291147': 1, '11242281': 1, '14608177': 1, '12559307': 1, '15205894': 1, '11880095': 1, '31827593': 1, '8601869': 1, '9510292': 1, '34430639': 1, '8970568': 1, '20338463': 1, '18180131': 1, '24809039': 2}

{}

3979793-1

noncomm/PMC003xxxxxx/PMC3979793.xml

Two cases of malignant glaucoma unresolved by pars plana vitrectomy

Case one was an 88-year-old woman with a history of pseudoexfoliation glaucoma in the right eye (OD) with maximum IOP >30 mmHg. Both eyes were pseudophakic and showed normal anterior chamber depth. Because her IOP OD could not be controlled with additional glaucoma eyedrops and oral acetazolamide, she underwent trabeculotomy. Three days after the trabeculotomy, she developed a flattening of the anterior chamber and an elevated IOP OD. She was diagnosed with malignant glaucoma. The condition could not be resolved with systemic hyperosmotic agents and oral carbonic anhydrase inhibitors, so she underwent an emergent PPV (total vitrectomy) using a 25 gauge vitreous cutter with vitreous base shaving and removal of the anterior hyaloid. Her anterior chamber deepened, and her IOP decreased to 10 mmHg the following day. Her IOP was maintained in the mid-teens OD by using three types of glaucoma eyedrops. Four months after PPV, her IOP increased to 70 mmHg again with a flat anterior chamber (, ). We hypothesize that the cilio-pupillary block mechanism was related to her clinical condition, and we performed an emergent iridectomy and local zonulectomy using a 25 gauge vitreous cutter. The posterior synechia of the iris was partially, but not completely, observed intraoperatively. Her anterior chamber had deepened (, ); for 10 months, her IOP has been maintained in the low-teens OD with the use of two types of glaucoma eyedrops.

[[88.0, 'year']]

F

{'29299722': 1, '23577950': 2, '8790091': 1, '15617869': 1, '10406625': 1, '3740172': 1, '20609709': 1, '21575128': 1, '33437606': 2, '23375590': 1, '28257136': 1, '24729683': 2}

{'3979793-2': 2, '3639836-1': 1, '7787094-1': 1}

3979793-2

noncomm/PMC003xxxxxx/PMC3979793.xml

Two cases of malignant glaucoma unresolved by pars plana vitrectomy

Case two was an 85-year-old man with a history of primary angle closure in both eyes (OU) and pseudoexfoliation glaucoma OD. He underwent phacoemulsification and aspiration (PEA), and intraocular lens (IOL) implantation OU. Following cataract surgery, he frequently exhibited a flattening of the anterior chamber and elevated IOP of >40 mmHg on maximal glaucoma medications. As his clinical condition OD was considered to be related to the malignant glaucoma mechanism, he underwent a YAG capsulohyaloidotomy and goniosynechialysis (GSL) for severe peripheral anterior synechia (PAS). Ten months after cataract surgery, his IOP OD was 32 mmHg, and his anterior chamber was still very shallow. He then underwent PPV (total vitrectomy) using a 25 gauge vitreous cutter with vitreous base shaving and removal of the anterior hyaloid, and GSL OD, at which point his anterior chamber deepened significantly and his IOP decreased to the low-teens. One month after PPV, he once again exhibited a flattening of the anterior chamber and severe PAS, and was referred to Kyoto University Hospital (, ). He presented with spontaneous IOL dislocation within the capsular bag. His IOP OD increased to 32 mmHg, and his visual acuity worsened to counting finger vision. He underwent an iridectomy without zonulectomy using a 25 gauge vitreous cutter near the area where Zinn’s zonule had been partially ruptured. We further performed GSL and trabectome surgery (NeoMedix Corporation, Tustin, CA, USA) (a surgical procedure that ablates an arc of trabecular mesh-work). His anterior chamber had deepened (, ); for 6 months, his IOP has been maintained in the high-teens OD by using additional glaucoma eyedrops.

[[85.0, 'year']]

M

{'29299722': 1, '23577950': 2, '8790091': 1, '15617869': 1, '10406625': 1, '3740172': 1, '20609709': 1, '21575128': 1, '33437606': 2, '23375590': 1, '28257136': 1, '24729683': 2}

{'3979793-1': 2, '3639836-1': 1, '7787094-1': 1}

3979796-1

noncomm/PMC003xxxxxx/PMC3979796.xml

Anterior capsulotomy improves persistent developmental stuttering with a psychiatric disorder: a case report and literature review

A 28-year-old male first presented with stuttering at the age of 7 years. No management was carried out at that time because his symptoms were mild. By the age of 20 years, he was being ridiculed and humiliated by his college classmates. He became more introverted and did not want to communicate with others. Since then, his stuttering had worsened. He experienced multiple blocks in expressing words, including sound and syllable repetitions, circumlocutions, and monosyllabic repetitions, that made it difficult to conduct the interview.\nIn addition to deterioration of his PDS, he developed depression and anxiety and was afraid to communicate with others. He also had physical concomitants of involuntary jerking of his head and upper extremities and muscle spasm of his neck and lower jaw while stuttering. He was diagnosed with depression and anxiety disorder by the psychiatrists at the age of 24 years. He was managed medically with multiple antipsychotics in conjunction with cognitive behavioral therapy. Significant improvement in his psychiatric disorder but not his PDS was achieved at that time.\nOne year earlier, because of his local culture, he had refused to take any medicine, which led to a relapse of his psychiatric symptoms. Subsequent antipsychotics and cognitive behavioral therapy were of limited help in alleviating his psychiatric symptoms. We carefully addressed his treatment options, which included further medical treatment, deep brain stimulation, or capsulotomy. Both the patient and his family opted for capsulotomy for financial reasons and in the hope of being able to avoid using antipsychotics. The surgery was approved by the ethics committee at our hospital.\nPreoperative magnetic resonance imaging was done to rule out an intracranial tumor, hemorrhage, infarction, and infection. No family history of a speech disorder was reported. The preoperative neuropsychological evaluations were carried out using the 24-item Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Mini-Mental State Examination, the similarities and block design subtests of the Wechsler Adult Intelligence scale, the logical memory and visual reproduction subtests of the Wechsler Memory Scale, and the Wisconsin Card Sorting Test-Simplified (WCST-S). Both the logical memory and visual reproduction tests were carried out immediately and after a 30-minute delay. The WCST-S included 48 cards, and his performance was assessed by the number of correct answers, number of errors, number of perseverative errors, number of nonperseverative errors, and number of categories completed. Neuropsychological and PDS evaluations were done before surgery and at 6-month follow-up by the same psychiatrist and speech therapist, who were both aware that the patient had undergone neurosurgery.\nTo better identify the magnetic resonance images without fixation of the head frame were obtained the day before surgery. A 3 T Trio Unite magnetic resonance imaging system (Siemens AG, Muenchen, Germany) was used with T1-weighted and T2-weighted spin-echo sequences in the axial and coronal planes. The slice thickness was 2 mm with an interval gap of 0.02 mm. The preplanning procedure was completed using the Surgi-plan workstation (version 2.1; Elekta Instruments AB, Stockholm, Sweden). On the day of surgery, a Leksell model G head frame (Elekta Instruments AB) was positioned on the skull parallel to the anterior commissure–posterior commissure line under local anesthesia. A repeat magnetic resonance scan with the same parameters as the preplanning scanning was performed using a 1.5 T Sonata Unite magnetic resonance imaging system (Siemens AG). With the help of the Surgi-plan workstation, the prescanned images were then coregistered with the images using location markers. The coordinates of the target and the angles of electrode penetration were calculated. The lesion targets were located 14 mm anterior and 18 mm lateral to the anterior commissure and 5 mm below the anterior commissure–posterior commissure plane. Under the guidance of the Leksell multifunctional stereotactic operation system (Elekta Instruments AB), the lesion electrode was then inserted into the lesion target according to the calculated coordinates. A test stimulation generated by the Elekta neurostimulator at both high frequency (130 Hz) and low frequency (5 Hz) was then carried out to verify the target of the electrode. Next, multiple lesions were produced using the Elekta neurostimulator at 75°C for 70 seconds each. The length of the lesions on both sides was 14 mm ( and ).

[[28.0, 'year']]

M

{'9106763': 1, '22114265': 1, '21926485': 1, '17707915': 1, '5057250': 1, '22138231': 1, '23963548': 1, '18664696': 1, '20726757': 1, '18678796': 1, '15159193': 1, '13638508': 1, '16476140': 1, '15590909': 1, '14399272': 1, '22721950': 1, '19500713': 1, '21642484': 1, '25897232': 1, '22961476': 1, '28072743': 1, '1512391': 1, '18626285': 1, '6700202': 1, '20075648': 1, '21192161': 1, '19223226': 1, '17531310': 1, '10917410': 1, '21753016': 1, '22851483': 1, '22875083': 1, '17272973': 1, '24729709': 2}

{}

3979823-1

noncomm/PMC003xxxxxx/PMC3979823.xml

Targeting the unfolded protein response, XBP1, and the NLRP3 inflammasome in fibrosis and cancer

A spayed, 9-y-old, female boxer had been cytologically diagnosed with stage IVb multicentric, high grade non-Hodgkin lymphoma, and grade II mast cell tumor. She had been diagnosed with lymphoma 5 mo prior to enrollment in the study and had failed various standard canine protocols (CHOP-based treatment, single agent Lomustine, prednisone, and MOPP). At the start of treatment, she had been on 0.5 mg/kg prednisone daily, and her tumor was rapidly progressive. She had generalized peripheral lymphadenopathy and suspected progression of lymphoma to the lung parenchyma based on clinical signs and thoracic radiographs. Her last treatment prior to Naclynamide had been her fourth dose of subcutaneous l-asparaginase, to which she had had a partial response that lasted 1.5 wk.\nAll peripheral lymph nodes measured approximately 2 cm in diameter except for the right prescapular lymph node, which measured 6.5 × 5 × 5 cm. We chose the prescapular lymph node to monitor the efficacy of Naclynamide treatment. During treatment all other peripheral lymph nodes either decreased in size or remained at 2 cm. On the third treatment visit (1.5 wk after the start of the treatment), the prescapular lymph node was reported to be painful, and was evaluated by cytology. Marked neutrophilic inflammation was noted without the obvious presence of bacteria (). A lymph node aspirate was evaluated cytologically by a board-certified clinical pathologist and it was reported to have no evidence of lymphoma and the cytological diagnosis was suppurative inflammation.

[[9.0, 'year']]

F

{'33207628': 1, '19362023': 1, '21792841': 1, '18650916': 1, '34209019': 1, '21809331': 1, '21858728': 1, '17875675': 1, '25330206': 1, '21350580': 1, '19652710': 1, '25337575': 1, '21138464': 1, '32444946': 1, '15342372': 1, '19218193': 1, '18577586': 1, '16407890': 1, '19234215': 1, '23400395': 1, '18403674': 1, '20385749': 1, '18604214': 1, '22215619': 1, '25138219': 1, '21124315': 1, '27474884': 1, '29472925': 1, '19675207': 1, '18793350': 1, '22290938': 1, '16990137': 1, '16435160': 1, '12475201': 1, '27904144': 1, '22430787': 1, '16622904': 1, '31687078': 1, '19835390': 1, '19258328': 1, '16861911': 1, '22538852': 1, '30147026': 1, '24496016': 2}

{'3979823-2': 2, '3979823-3': 2}

3979823-2

noncomm/PMC003xxxxxx/PMC3979823.xml

Targeting the unfolded protein response, XBP1, and the NLRP3 inflammasome in fibrosis and cancer

A castrated, 11.5-y-old, male greyhound had been diagnosed with a metastatic colorectal carcinoma five years prior. He had been extensively treated with multiple surgeries and courses of chemotherapy (carboplatin, adriamycin, 5-FU, cytoxan, palladia, masitinib, piroxicam, deramax, and leukeran) and had also undergone 3 treatments for rectal stricture with an internal medicine specialist. The mass had been biopsied 4 times during the course of the previous treatments, and all biopsies confirmed the continued presence of rectal carcinoma. By early 2013, the patient’s tumor began to grow and protrude externally around the anus to an extent that compromised the anal region.\nA board-certified surgeon evaluated the patient and determined that no further surgery should be performed. Given the lack of other treatment options, the patient was enrolled and received the first four doses of Naclynamide without incident. The tumor progressively decreased in size and began to suppurate. At this point the patient also began to lick at the tumor obscuring objective measurements of the tumor’s exterior appearance because of the consequent inflammation. Cytology was evaluated, and while there were still rafts of carcinoma cells present, the majority of the sample showed suppurative inflammation. Bacterial organisms were present, as would be expected based on tumor location. Internally, the patient’s rectal stricture improved markedly in diameter to approximately double that at the beginning of Naclynamide treatment. Initially on digital palpation, the rectal canal measured <5 mm in diameter but increased to approximately 1 cm during the course of treatment. The tumor itself shrank from 8 cm in its largest measurement to 4 cm.

[[11.5, 'year']]

M

{'33207628': 1, '19362023': 1, '21792841': 1, '18650916': 1, '34209019': 1, '21809331': 1, '21858728': 1, '17875675': 1, '25330206': 1, '21350580': 1, '19652710': 1, '25337575': 1, '21138464': 1, '32444946': 1, '15342372': 1, '19218193': 1, '18577586': 1, '16407890': 1, '19234215': 1, '23400395': 1, '18403674': 1, '20385749': 1, '18604214': 1, '22215619': 1, '25138219': 1, '21124315': 1, '27474884': 1, '29472925': 1, '19675207': 1, '18793350': 1, '22290938': 1, '16990137': 1, '16435160': 1, '12475201': 1, '27904144': 1, '22430787': 1, '16622904': 1, '31687078': 1, '19835390': 1, '19258328': 1, '16861911': 1, '22538852': 1, '30147026': 1, '24496016': 2}

{'3979823-1': 2, '3979823-3': 2}

3979823-3

noncomm/PMC003xxxxxx/PMC3979823.xml

Targeting the unfolded protein response, XBP1, and the NLRP3 inflammasome in fibrosis and cancer

A castrated 6.5-y-old, male Yorkshire terrier presented 3-legged lame with a 6 cm, firm mass in the area of the right proximal tibia and stifle joint. Seventeen months prior, the same lesion was surgically biopsied and diagnosed as a sarcoma, most consistent with osteosarcoma. During that time, the lesion had grown and the patient had become progressively more lame, but 3-view thoracic radiographs showed no evidence of progressive disease. The owner declined other treatment, and was then offered Naclynamide. The patient was treated with intravenous Naclynamide for 6.5 wk with little to no change noted in the tumor size based on caliper measurement and repeat radiographs. Softening of the central tumor was noted, however, as evidenced by a progressively increasing range of motion starting in the second week of Naclynamide treatment. Eventually, the patient’s tumor and limb were amputated and the patient received a 2-wk course of Naclynamide to treat potential metastases. The mass was biopsied and again confirmed to be osteosarcoma.

[[6.5, 'year']]

M

{'33207628': 1, '19362023': 1, '21792841': 1, '18650916': 1, '34209019': 1, '21809331': 1, '21858728': 1, '17875675': 1, '25330206': 1, '21350580': 1, '19652710': 1, '25337575': 1, '21138464': 1, '32444946': 1, '15342372': 1, '19218193': 1, '18577586': 1, '16407890': 1, '19234215': 1, '23400395': 1, '18403674': 1, '20385749': 1, '18604214': 1, '22215619': 1, '25138219': 1, '21124315': 1, '27474884': 1, '29472925': 1, '19675207': 1, '18793350': 1, '22290938': 1, '16990137': 1, '16435160': 1, '12475201': 1, '27904144': 1, '22430787': 1, '16622904': 1, '31687078': 1, '19835390': 1, '19258328': 1, '16861911': 1, '22538852': 1, '30147026': 1, '24496016': 2}

{'3979823-1': 2, '3979823-2': 2}

3980147-1

noncomm/PMC003xxxxxx/PMC3980147.xml

Methomyl Poisoning Presenting with Decorticate Posture and Cortical Blindness

A 61-year-old Taiwanese man was admitted to our emergency room because of altered mental status. His wife informed the medical personnel that her husband had quarreled with their son a few days previously, and had remained in a bad mood since the incident. That morning, when she awoke at approximately 6:30 am, she found her husband lying on the bathroom floor. An empty can of liquid methomyl was beside him. She estimated that her husband had swallowed approximately 300 cm3 of methomyl. Further examination revealed depressed consciousness (Glasgow Coma Scale, E1M1V1). The patient’s eyes had pinpoint pupils and his blood pressure and pulse were absent. He was also unable to breathe spontaneously. Cardiac arrest was confirmed and the patient underwent cardiac massage for 11 minutes. He was also intubated to maintain his breathing. After cardiopulmonary resuscitation (CPR), his vital signs of blood pressure, temperature, pulse rate, and respiratory rate, returned to within reference rages: 110/70 mmHg, 36.7°C, 68 beats/min, and 29 breaths/min, respectively. An emergency doctor provided a gastric lavage. The patient was sent to an intensive care unit for close observation. On the second day of admission, he regained consciousness and could open his eyes spontaneously and under instruction. However, his posture was irregular (upper extremities flexed upwardly and lower extremities extended). We instructed him to extend his upper extremities but he was unable to follow this order. On the sixth day of admission, the patient was extubated after showing general improvement in condition. However, he started to complain of unclear vision. Although he could sense an object in front of him and could recognize the object when placed in his hands, he was unable to identify the object correctly. Suspecting an eye problem, we consulted an ophthalmologist to determine whether any ocular abnormality existed. A fundoscopy and other eye testing revealed no obvious abnormalities. A neurological examination was also conducted, confirming decorticate posture and cortical blindness. Other neurological findings, including those regarding the patient’s motor and sensory systems, coordination, deep tendon reflexes, and cranial nerves, were all unremarkable. Therefore, we arranged a brain MRI to eliminate possible central visual pathway lesions. The brain MRI revealed lesions in the bilateral tips of the occipital lobe areas (). We hydrated the patient with normal saline and administered 75 mg of aspirin once daily and 150 mg of piracetam twice daily. He remained in the hospital for 3 weeks, after which he was discharged for neurology outpatient clinical follow-up. He attended outpatient clinical follow-ups for 2 months after discharge and his vision improved, whereas his decorticate posture remained refractory. A second brain MRI was performed, revealing the disappearance of the bilateral occipital lobe lesions and symmetrical putaminal high signal abnormalities (). This patient continues to attend regular follow-ups at the clinic.

[[61.0, 'year']]

M

{'16490098': 1, '11443300': 1, '8612055': 1, '21516165': 2, '32046287': 1, '2390322': 1, '509881': 1, '20923394': 1, '13593938': 1, '11064628': 1, '24744847': 2}

{'3074331-1': 1}

3980151-1

noncomm/PMC003xxxxxx/PMC3980151.xml

Traumatic Infra-renal Aortic Dissection After a High-energy Trauma: A Case Report of a Primary Missed Diagnosis

We report a 54-year old Caucasian female patient who was involved in a car accident. She was the driver of the car, and was hit by another car on the driver’s side. The fellow passenger of the car was seriously injured and was treated in hospital for traumatic brain injury. Both of the passengers were wearing their seatbelts correctly, and the female patient did not lose consciousness.\nAt the first hospital, where the female patient underwent pelvic X-ray, an acetabular fracture on the left side was detected. The patient was then transported to the second hospital, where a CT scan of the pelvis was performed. This revealed a multiple-fragment fracture of the left acetabulum. The patient was later given a tetanus vaccination and a trans-urethral catheter was put in place. At this time, urine did not show any signs of macroscopic hematuria.\nLater, following communication via telephone, the patient was brought to our institution, a level 1 trauma-center, by helicopter. Because of the nature of the accident, with a high-energy trauma, complete polytrauma management was performed. During the body check, under pain in the left part of the pelvis, a moderate tension of the lower parts of the abdomen was observed. The ultrasound did not reveal any free abdominal fluid. Blood count showed normal values. In addition to the multiple-fragment fracture of the left acetabulum, the CT scan revealed an aneurysm of the infra-renal aorta with a dissection from the height of the second lumbar vertebral body to the iliac artery ( and ).\nBecause of the aneurysm, the patient required operative vascular surgical intervention on the day of admission. During this operation, a vascular substitute of the aorta with a 14/7 mm Dacron-Y-prosthesis was used to reconnect the superior mesenteric artery.\nNine days postoperatively, the open reduction and internal fixation of the acetabular fracture was performed without any incidence.\nNineteen days post trauma, the patient was discharged from the hospital in good general condition. She did not show any signs of vascular deficits of the lower limbs or in the abdominal organs.

[[54.0, 'year']]

F

{'7717246': 1, '12876003': 1, '5852141': 1, '9715145': 1, '33116964': 2, '2241388': 1, '22842964': 1, '4834728': 1, '5409757': 1, '31724636': 1, '5921622': 1, '13573559': 1, '1147706': 1, '24744835': 2}

{'7569054-1': 1}

3980158-1

noncomm/PMC003xxxxxx/PMC3980158.xml

Posterior Sternoclavicular Dislocations: A Brief Review and Technique for Closed Management of a Rare But Serious Injury

The patient is an 18 year-old male college student with no past medical history who presented with severe pain, difficulty swallowing, and decreased range of motion of his right shoulder after he was driven to the ground playing rugby. He was seen at the emergency department and presented for a second opinion for sternoclavicular joint injury. Radiographs and CT scan were performed and demonstrated a posterior superior sternoclavicular dislocation (). On exam, there was significant tenderness localizing over the right SCJ as well as an obvious deformity with less prominence of the joint on the right as compared to the left. He was neurovascularly intact. Radiographs of the right shoulder demonstrated SCJ asymmetry on the right as compared to the left, and MRI demonstrated a superior and posterior SCJ dislocation.\nThe patient was scheduled for urgent closed reduction within 24 hours, and underwent closed reduction of the right posterior SCJ dislocation by the technique described 3 days post injury confirmed by radiographs (). At twelve weeks, the patient had no complaints, and the joint was stable on exam. Radiographs demonstrated no change in position of the SCJ, with slight superior and anterior displacement (). He returned to sports 6 months post injury without difficulty ().

[[18.0, 'year']]

M

{'9070528': 1, '7552675': 1, '15711799': 1, '7616482': 1, '2204634': 1, '32801951': 1, '20303290': 1, '14711951': 1, '2915008': 1, '18539660': 1, '21276369': 1, '16679231': 1, '20044687': 1, '19292236': 1, '8194250': 1, '18803982': 1, '14608175': 1, '8437185': 1, '4742528': 1, '15175849': 1, '26257278': 1, '18248716': 1, '22035392': 1, '30675574': 1, '33559637': 2, '14832323': 1, '18979876': 1, '22036535': 1, '6699054': 1, '9294804': 1, '18450627': 1, '22608929': 1, '17437121': 1, '6047697': 1, '24744842': 2}

{'7944707-1': 1}

3980559-1

noncomm/PMC003xxxxxx/PMC3980559.xml

Aggressive osteoblastoma involving the craniovertebral junction: A case report and review of literature

The present case report is about a 34-year-old gentleman who presented with a painful swelling behind the angle of left mandible of 5 months duration. He also complained of change in character of voice, dysphagia and weakness of left upper limb for 3 months prior to admission.\nOn neurologic examination, he had IX, X and XI cranial nerve palsy on the left side. There was a 3.5 cm × 3.0 cm bony hard swelling underneath the angle of left mandible leading to obliteration of post auricular groove. It was extremely tender. On examination of the oral cavity, the swelling was bulging into the tonsillar fossa and compressing the palatal arches.\nSince, the mass was palpable externally, fine-needle aspiration was attempted pre-operatively (twice) and on both occasions, but it was found to be inconclusive.\nThe axial and reformatted sagittal computed tomography showed a large expansile and destructive bony lesion involving the foramen magnum on the left side from lower clivus up to the axis. There were calcifications seen within the tumor. Thin sclerotic rim was visible around most of the periphery of the lesion [Figure –]. The lesion had involved the lateral masses and part of anterior and posterior elements of upper 2 cervical vertebrae.\nMagnetic resonance imaging showed a heterogenous mass (size approximately 5.3 cm × 6.2 cm × 5.5 cm) with strong post contrast enhancement. The lesion was displacing left internal carotid artery peripherally causing mild compression and had involved the left vertebral artery, the oblique part of V3 segment [Figure –].\nWith pre-operative impression of a high grade bony lesion, the patient was planned for surgical decompression of the mass through left sided far lateral approach. At surgery, near total excision of the tumor was achieved, deliberately leaving a thin rim of tumor tissue attached to posterior pharyngeal wall to prevent opening the oral cavity [Figure and ]. The tumor was very vascular and bled profusely. Occipito-cervical fusion was also done. The patient recovered uneventfully after surgery. Histopathological evaluation of the resected tissue showed epithelioid osteoblasts lining the bony trabeculae separated from the thin walled vessels by the osteoclastic giant cells. Mitotic figures were also seen. Hence, a pathological diagnosis of AO was made [Figure and ]. The patient was referred to radiotherapy for residual lesion. At 5 months follow-up, the patient was doing well.

[[34.0, 'year']]

M

{'20923301': 1, '13364889': 1, '28210742': 1, '6859240': 1, '13413389': 1, '18337062': 1, '175701': 1, '20436846': 1, '4764948': 1, '8119712': 1, '932083': 1, '19292265': 1, '3704675': 1, '3753174': 1, '1913494': 1, '16129654': 1, '9698743': 1, '11518051': 1, '9078333': 1, '3810461': 1, '6600112': 1, '26879919': 1, '24744565': 2}

{}

3980560-1

noncomm/PMC003xxxxxx/PMC3980560.xml

Unilateral lateral mass hypertrophy: An extremely rare congenital anomaly of atlas

The present case report is about a 28-year-old female patient who presented with posterior cervical pain of 2 years duration along with ascending spastic quadriparesis for 1 year. On examination, she had subtle quadriparesis (power 4/5 on the right upper and lower limbs with 4+/5 power on the left side). Deep tendon reflexes were uniformly exaggerated and plantars were bilaterally up going. There was graded sensory impairment below C4 dermatome (30-50%) and posterior column impairment was noted in upper and lower limbs. She had left sided torticollis and neck movements, particularly rotation, were restricted toward the right side. There were no lower cranial nerve dysfunction and no stigmata pertaining to the CVJ anomalies were found on general examination.\nShe was investigated with computed tomography (CT) scan and magnetic resonance imaging (MRI) of the CVJ. On CT scan, there was hypertrophy involving the right lateral mass of atlas causing impingement into the bony cervical canal and consequent narrowing of the transverse canal diameter. The bony overgrowth was similar in density as the rest of the C1 ring. Posterior arch of C1 was hypoplastic and left hemi-arch was absent. There was no evidence of atlanto axial dislocation or basilar invagination [Figure –]. MRI of this area showed compression of the spinal cord from right lateral aspect with distortion of the cord. Cerebellar tonsils were seen impacted at the foramen magnum with obliteration of the cistern magna. The tonsilar descent was seen up to the level of C1. There was T2 hyperintensity inside the substance of the cord at the level of C2 body [Figure and ].\nAs the patient had both lateral and posterior compression on the spinal cord, we performed transoral decompression of the hypertrophied lateral mass followed by removal of posterior lip of foramen magnum, excision of hypoplastic posterior arch of atlas and occipito-cervical (C2) fusion with titanium cable. The histopathological examination of the hypertrophied lateral mass revealed the presence of fibro-osseous tissue and no evidence of malignancy was found.\nPost-operatively, the patient had relief of the neck pain and reduction in severity of spasticity. Post-operative reconstructed CT of CVJ revealed adequate bony decompression and the posterior construct in situ [Figure –]. The patient had an uneventful post-operative period and was discharged in stable condition. At the time of writing this report, she had completed 12 months follow-up and she had complete recovery of power in her limbs.

[[28.0, 'year']]

F

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{'3530704-1': 1, '2857503-1': 1, '2857503-2': 1, '2857503-3': 1}

3980561-1

noncomm/PMC003xxxxxx/PMC3980561.xml

Isolated spinal neurosarcoidosis: An enigmatic intramedullary spinal cord pathology-case report and review of the literature

A 44-year-old African American man presented at an outside hospital with history of neck pain and left arm pain in a nondermatomal distribution associated with left hand numbness/tingling and left-sided weakness for a couple of months. Examination revealed presence of subtle left sided hemiparesis (4+/5 on Medical Research Council (MRC) grade) and considering a diagnosis of cervical spondylosis, a plain MRI of cervical spine was ordered which revealed presence of moderate cervical stenosis associated with T2 signal changes with no significant focal compression and he was treated conservatively. He however had progression of symptoms over the next few weeks due to which he was referred to our institution. Examination revealed presence of worsening weakness involving the left side (3/5) with brisk reflexes in bilateral upper and lower extremities. Sensory exam showed no gross dermatomal sensory deficits with presence of Hoffman's reflex. These neurologic findings prompted us to repeat an MRI with contrast enhancement due to presence of signal changes on the MRI without significant compression and disconcordance between clinical examination and imaging findings. MRI revealed presence of an approximately 1.5 cm patchy enhancement involving the left half of the cervical spinal cord at C4 level with presence of T2 signal changes spanning three to four segments in the cervical spine along with presence of moderate to severe spinal canal stenosis [Figures and ]. In light of the clinical symptoms and neuroimaging abnormalities, the diagnosis of spondylotic compressive myelopathy was questioned and a differential diagnosis of a neoplasm (astrocytoma/ependymoma), inflammatory, ischemic, and demyelinating lesions was entertained. Initial laboratory workup including lumbar puncture revealed that the patient had a mildly elevated protein level (43.5 mg/dl), a normal immunoglobulin (Ig)G/albumin CSF ratio (0.2), negative oligoclonal bands, and no malignant cells on CSF cytology studies. His CSF also demonstrated 110 red blood cells and 15 white blood cells per ml with 90% lymphocytes. Quantiferon gold tuberculosis (TB) test, aerobic, anaerobic, fungal, and TB cultures were all negative making infection an unlikely diagnosis. Erythrocyte sedimentation rate and C-reactive protein were slightly elevated with values being 19 (N: 0-17 mm/h) and 17 (N: 0.0-8 mg/dl). He was started on pulse dose of steroids with a likely diagnosis of myelitis and his clinical examination improved with improvement in motor strength to 4+/5 and he could ambulate better. However, while the steroids were being tapered, he had recurrence of symptoms with worsening weakness (3/5). The steroids were restarted, but because it was not possible to make a definitive diagnosis based on laboratory studies, in the face of neurological worsening on tapering steroids, despite the risks of an intramedullary biopsy, this was thought to be the best option for diagnosis. A C3 through C6 laminoplasty and excisional biopsy of the C4 intramedullary lesion was performed to address the cervical stenosis and biopsy the intramedullary lesion []. Intraoperatively, the cord appeared normal except that it was quite swollen laterally on the left-hand side at C4 level and a dorsal root entry zone myelotomy was performed and abnormal tissue was immediately encountered which was quite distinct from the normal spinal cord tissue. This was sent for frozen section, which revealed gliosis versus neoplasm. Given the fact that this could be neoplastic tissue, further dissection was then carried out and a dissectible plane was found separate from normal spinal cord and a gross total resection could be achieved. The patient initially had worsening of his strength on left side and became essentially hemiplegic, but started improving gradually. Final pathology demonstrated non-necrotizing granulomatous disease consistent with sarcoidosis []. After the diagnosis was confirmed, an MRI of the brain [] and CT of the chest abdomen and pelvis were done to rule out any other site of involvement which demonstrated slightly, but nonsignificant mediastinal and retroperitoneal lymph nodes. Serum and CSF angiotensin converting enzyme (ACE) levels performed were within normal limits. He was subsequently treated with pulse dose of intravenous (IV) methylprednisolone, methotrexate, and induction infliximab (chimeric monoclonal antibody against tumor necrosis factor (TNF)-α) therapy and was discharged home with significant improvement in his motor strength. He remained in clinical follow-up with rheumatologist and neurologist and was treated on an outpatient basis with prednisolone 60 mg/day for 6 months along with methotrexate and infliximab. At his last follow-up at 9 months, he was on tapering dose of prednisone with continued weekly oral methotrexate and eight weekly maintenance infliximab therapy. He maintained neurological improvement in his motor strength except residual left ankle dorsiflexion weakness required an ankle foot orthosis and could ambulate independently with occasional use of walker for stability.

[[44.0, 'year']]

M

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{'3012843-1': 1}

3980562-1

noncomm/PMC003xxxxxx/PMC3980562.xml

A rare case of spontaneous Aspergillus spondylodiscitis with epidural abscess in a 45-year-old immunocompetent female

The present case report is about a 45-year-old female patient who presented with low backache for the past 1 month and bilateral lower limb weakness. There was no history of fever, cough or weight loss. She was a known diabetic on treatment since 18 months. Clinical examination revealed tenderness over S1 region with dorsiflexors weakness on both sides. Routine laboratory investigations were within the normal limits. Human immunodeficiency virus antibodies and hepatitis B surface antigen was negative. Magnetic resonance imaging of spine performed showed L5-S1 endplate and intervertebral disc destruction, altered signal intensity changes and anterior epidural granulation tissue/abscess measuring 7.4 mm in thickness, causing spinal encroachment at the same level. Para-discal marrow edema, end plate erosions, with small prevertebral, paravertebral and ventral epidural abscess lesions causing compression of cauda equina. Diagnosis of paradiscal infective spondylodiscitis at L5-S1 disco-vertebral unit was made []. Surgical posterior decompression laminectomy of L5-S1 was done and part of L5-S1 disc and epidural granulation/abscess removed after laminectomy was sent for histopathological examination and for culture.\nGross examination revealed fragmented pieces of gray white soft-tissue of about 2 cc volume. Sections studied from received material showed hyalinized fibro-collagenous tissue, fragments of skeletal muscle, mature adipose tissue, foci of degenerated bony trabeculae and inflammatory cells. The admixed foci showed large areas of hemorrhage, granulation tissue infiltrated by mixed inflammatory infiltrate, necrosis with multiple fragmented viable and degenerated fungal hyphae invading the tissue. Hyphae were uniform, narrow with regular septation and acute angle branching []. Periodic acid Schiff stain confirmed the fungal hyphae. The culture confirmed growth of Aspergillus fumigatus []. The patient was started on oral itraconazole 200 mg twice daily for 3 months. Patient is clinically improving since 9 months after surgery.

[[45.0, 'year']]

F

{'15165794': 1, '29531797': 1, '7803635': 1, '20191397': 1, '10219401': 1, '20512571': 1, '6866873': 1, '879933': 1, '22448068': 2, '33211946': 2, '21330747': 1, '2105711': 1, '10377933': 1, '24744568': 2}

{'8021829-1': 1, '3308671-1': 1, '3308671-2': 1}

3980563-1

noncomm/PMC003xxxxxx/PMC3980563.xml

Anterior transarticular screw fixation for atlantoaxial arthrodesis: A report of two cases

This is a first case of a 34-year-old male patient presented to the orthopedic out-patient clinic with a diagnosis of chronic AAI secondary to an os odontoideum. On presentation, he complained of neck stiffness and denied numbness or weakness. On examination, the patient was neurologically intact and had full range of motion of the cervical spine in flexion, extension, lateral bending and axial rotation. CT and plain radiographs demonstrated significant displacement in flexion and extension, os odontoideum and instability at C1-2 []. MRI of the brain showed cerebellar infarct, with confirmation on CT angiogram of bilateral vertebral artery occlusions between C2 and C3, collateral reconstitution from the right occipital artery and bridging anastomoses on the left. Significant instability at C1-2 warranted surgical fusion and an anterior approach was selected due to anomalous vascular anatomy, which precluded a safe posterior exposure and fixation by C1 LMS-C2PS.\nThe patient was treated with anterior transarticular C1-2 instrumentation and fusion as described by Sen et al.[] Post-operative CT scans confirmed acceptable screw placement in the axial [Figure and ], sagittal [] and coronal [Figure and ] planes. At 16 months follow-up, the patient maintained painless range of motion of the cervical spine with stable fixation and fusion without sensorimotor deficit.

[[34.0, 'year']]

M

{'11707712': 1, '348703': 1, '34194158': 1, '1132209': 1, '20693942': 1, '7998495': 1, '8755749': 1, '16509484': 1, '10851104': 1, '18171958': 1, '8882690': 1, '8559297': 1, '12445339': 1, '17538356': 1, '15105686': 1, '10851106': 1, '11440461': 1, '20838946': 1, '7899957': 1, '16908576': 1, '17051397': 1, '9331044': 1, '16849023': 1, '10815673': 1, '11935247': 1, '9779526': 1, '17857077': 1, '15692824': 1, '12973157': 1, '15668776': 1, '16888557': 1, '15799804': 1, '20140465': 1, '24737928': 2}

{'3980563-2': 2}

3980563-2

noncomm/PMC003xxxxxx/PMC3980563.xml

Anterior transarticular screw fixation for atlantoaxial arthrodesis: A report of two cases

The second case report is about a 68-year-old female patient who presented to the orthopedic out-patient clinic with a 3 years history of persistent right-sided axial neck and occipital pain. On presentation, she complained of severe pernicious neck pain that radiated to her occiput. On physical examination, she was hypesthetic in a C2 distribution. Objective motor strength was 4/5 in the right deltoid and 3/5 in the right shoulder internal/external rotators, consistent with her previous total shoulder replacement. CT [] and plain radiographs of the cervical spine demonstrated coronal deformity, severe right sided facet arthropathy at C1-2 and congenital fusions at C2-3, C3-4 and C4-5. Attempted conservative management included C1-2 facet injections and occipital nerve block, which provided only transient relief. The association of Klippel-Feil syndrome with anomalous vertebral artery anatomy that frequently follows a less predictable course,[] made an anterior approach for C1-2 fusion an appealing surgical option.\nThe patient was treated with anterior transarticular C1-2 fusion []. At 6 months follow-up, the patient reported 90% improvement in her pre-operative symptoms of neck pain and paresthesia [].

[[68.0, 'year']]

F

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{'3980563-1': 2}

3980564-1

noncomm/PMC003xxxxxx/PMC3980564.xml

Unique paradoxical atlantoaxial dislocation with C1-C2 facet diastases and isolated ligamentous injury to the craniovertebral junction without neurological deficits: A case report

This 32-year-old gentleman was involved in a high speed car accident without a fastened seatbelt. He survived a whiplash injury, lost consciousness, and sustained severe facial injuries with soft tissue swelling. On examination he had stridor, airway compromise, and hypoxia for which he underwent an emergency tracheostomy. He had no neurological deficits. He had a fractured mandible and his neck was tilted to the right with chin to the left.\nHis X-ray cervical spine showed a displaced odontoid, anterior to the anterior arch of atlas. Computed tomography (CT) scan of the CVJ showed a dislocated odontoid, anterior to C1 arch in front of right lateral mass of atlas []. The C1-C2 facets were seen diastased bilaterally []. Magnetic resonance imaging (MRI) of CVJ [] showed disrupted posterior longitudinal ligament with severe kinking of the spinal cord. TAL was seen intact on T2 axial MRI. MR angiography showed a flow cutoff in the left vertebral artery at the level of C2-C3 and a thin streak of flow was noted in the right vertebral artery at the level of CVJ [].\nHe underwent an awake reduction of the dislocation in the OR. Using Gardner-Wells skull traction, slow distraction with gradual rotation to the left was applied. A continuous fluoroscopy revealed progressive realignment of the odontoid []. This also corrected the neck tilt. He was awake when positioned prone and after confirming the position of odontoid and intact neurological status, he underwent C1 lateral mass and C2 pedicle screw fixation with fusion across the C1-C2 joint. The joint capsule was torn with a large gap between C1 and C2 facets. It was filled with bone graft after debridement to facilitate fusion. The vertebral arteries were looking perfectly normal and were seen positioned normal in relation to the CVJ.\nHe had quadriparesis in the immediate postoperative period. It was predominantly proximal in involvement and was symmetrical. CT scan of the CVJ revealed normal alignment of atlas and axis and implants in situ []. MRI of the CVJ revealed normal spinal cord with normal alignment. MRA of the vertebral artery showed occlusion of the right vertebral artery beginning at the origin and extending up to the origin of the basilar artery intracranially, suggesting complete thrombosis secondary to a possible traumatic dissection. The possibility of worsening secondary to surgical manipulation could not be ruled out. However, the left vertebral flow pattern was the same as preoperative MRA with segmental loss of flow at the distal V1 segment []. The patient was treated with anticoagulants and he made gradual recovery without any deficits at 2 weeks after surgery. He was able to go back to work after 3 months and neurologically intact at 1 year after surgery. Repeat CT scan showed good alignment of implants.

[[32.0, 'year']]

M

{'20173531': 1, '5781589': 1, '15933263': 1, '2053005': 1, '7835016': 1, '21207046': 1, '18259747': 1, '19714372': 1, '24744569': 2}

{}

3981223-1

noncomm/PMC003xxxxxx/PMC3981223.xml

Multiple Pancreatic Pseudocysts Treated with Endoscopic Transpapillary Drainage

Our patient is a 44-year old African American lady who presented to the emergency room with acutely worsened abdominal pain on a background of several week history of chronic abdominal pain associated with nausea and vomiting. Patient had a history of alcohol abuse. She had a laparoscopic cholecystectomy done 10 years prior for acute calculous cholecystitis. A computed tomography (CT) scan was performed which showed multiple pseudocysts in relation to the body and tail of pancreas (). Pancreatic enzymes, amylase and lipase, were borderline abnormal. She was diagnosed with alcohol induced pancreatitis complicated with pseudocysts. In view of symptomatic mature pseudocysts, a drainage procedure was mandated. Endoscopic retrograde pancreatogram was performed which showed a markedly dilated pancreatic duct and filling of a saccular structure inferior to the pancreatic tail, consistent with a visible communication with the cyst(s) (). We attempted transpapillary drainage of the cystic spaces through placement of a 5 French×7 cm (Cook Medical, Limerick, Ireland) pancreatic duct stent. Patient did well post-procedure and was discharged home after 72 h with good pain control.\nTwo weeks later the patient was readmitted with high fevers and worsening abdominal pain. A repeat endoscopic pancreatogram showed a dilated pancreatic duct in the body of pancreas with tapering in the region of head, suggesting occlusion of the stent. This was treated by balloon dilatation and replacement with a single pigtail stent, 5 French×10 cm (Cook Medical) in the pancreatic duct. Postprocedure, the patient recovered well with 7 day antibiotic treatment. A follow up CT scan after 3 and 6 months showed significant resolution in the pseudocysts ( and ) with remarkable improvement in symptoms of abdominal pain. Patient was referred to the deaddiction clinic to prevent further attacks of alcoholic pancreatitis.

[[44.0, 'year']]

F

{'7498684': 1, '10363891': 1, '7517648': 1, '7498683': 1, '16564865': 1, '14986795': 1, '19890418': 1, '16780558': 1, '8885346': 1, '29541568': 2, '24765490': 2}

{'5844594-1': 1}

3981224-1

noncomm/PMC003xxxxxx/PMC3981224.xml

Citrullinemia Type I and Hypertrophic Pyloric Stenosis in a 1-Month Old Male Infant

A 1-month old male infant with CTLN1 presented to the biochemical genetics clinic with 1-week of vomiting and weight loss. The diagnosis of CTLN1 had been made at 4 days of age after he presented with hyperammonemic coma.\nHe was born at term by vaginal delivery to a primigravid Japanese mother and a Caucasian father. Prenatal and family histories were unremarkable. APGAR scores were 8 and 9 and the patient was discharged after 24 h with mild feeding difficulty, which continued at home. At 4 days old, the infant presented with lethargy, hypothermia, seizure, hemodynamic instability and hyperammonemia to greater than 1000 μmol/L. He required prolonged intensive care admission with dialysis and mechanical ventilation. Given high suspicion for urea cycle disorder, the patient was treated with IV sodium phenylacetate, sodium benzoate and L-arginine. During admission, plasma amino acids were consistent with a diagnosis of CTLN1 and newborn screening returned positive with elevated citrulline. Two known mutations for CTLN1 were identified on ASS1 gene sequencing: a heterozygous exon 7 mutation c.421-2A>G and a heterozygous exon 8 mutation c.539G>A (p.Ser180Asn). The infant was discharged home at 17 days of age with proteinrestricted nasogastric tube feeds, L-arginine and sodium phenylbutyrate.\nAt approximately 3 weeks of age, the patient was twice evaluated at an outside hospital for lethargy and emesis. Ammonia level was normal at both visits and labs revealed mild transaminitis and elevated total bilirubin to 3.4 mg/dL. Both times, the infant improved with IV hydration and was discharged home with reflux precautions. However, he was seen 4 days later at the genetics clinic and parents reported non-projectile vomiting for 1 week. Further history revealed that the nasogastric tube had been accidentally removed prior to onset of emesis, and thereafter replaced by parents with reported home nurse confirmation of positioning. In the clinic, the infant was vigorous but diffusely mottled with a weight loss of 0.12 kg in the last 2 weeks. Nasogastric tube placement was again confirmed and the infant was admitted to the inpatient genetics service for further management.\nUpon admission, labs were notable for the following (reference ranges within parentheses): potassium 5.1 mmol/L (3.6-5.5 mmol/L), chloride 100 mmol/L (100-113 mmol/L), bicarbonate 29 mmol/L, (22-26 mmol/L) ALT 44 IU/L (7-35 IU/L), alkaline phosphatase 440 IU/L (50-350 IU/L), total bilirubin 4.3 mg/dL, direct bilirubin 3.4 mg/dL (0.0-0.3 mg/dL). Ammonia level was 59 μmol/L (11-60 μmol/L) and venous blood gas revealed pH 7.45, pCO of 42 mmHg and lactic acid level of 4.1 mmol/L (0.5-2.0 mmol/L). The infant was started on IV dextrose-containing fluids, sodium phenylacetate, sodium benzoate and L-arginine. Sepsis workup with cerebrospinal fluid, blood and urine cultures did not yield a source of infection. Oral challenge without nasogastric tube resulted in continued emesis; therefore, an abdominal ultrasound was obtained. Results revealed hypertrophic pyloric stenosis (HPS) (). Pediatric surgery was consulted and uncomplicated laparoscopic pyloromyotomy was performed on hospital day 2. On post-operative day 4, the infant was discharged home on continuous nasogastric tube feeds and ranitidine for peri-procedural gastritis. The patient has now undergone liver transplant, remains on low-dose L-arginine and is doing well at 11 months of age with age-appropriate neurocognitive parameters.

[[1.0, 'month']]

M

{'21895878': 1, '18925679': 1, '16257926': 1, '12403252': 1, '4210621': 1, '21736982': 1, '21098534': 1, '12234269': 1, '16758311': 1, '24765495': 2}

{}

3981226-1

noncomm/PMC003xxxxxx/PMC3981226.xml

Agenesis of dorsal pancreas with eventration of diaphragm and intrapancreatic pseudocyst: a rare entity

A 43-year-old chronic alcoholic male patient presented in emergency with complaints of severe diffuse pain abdomen associated with vomiting of 2 h duration with a history of mild upper abdominal pain for last 15 days. He was not a known diabetic or hypertensive. On clinical examination, the patient had diffuse tenderness and distension of abdomen and no guarding or rebound tenderness. Laboratory investigations revealed leucocytosis with counts of 16,500, raised serum amylase and lipase with normal liver enzymes and alkaline phosphatase and random blood sugar was raised. X-ray chest and abdomen showed raised left hemidiaphragm and no air fluid levels or free gas under diaphragm. Ultrasonography of the abdomen did not reveal any significant abnormality. Diagnosis of acute pancreatitis was made and patient was managed conservatively and responded well to treatment but his blood sugar level remained high for which he was given insulin. Contrast enhanced computed tomography (CECT) of abdomen was performed after 6 days of admission, which showed intrapancreatic pseudocyst in the head of pancreas with dorsal agenesis of pancreas and eventration of left hemidiaphragm ( and ). Patient was discharged in stable condition after 9 days of admission on oral antibiotics and insulin.

[[43.0, 'year']]

M

{'18618254': 1, '22011826': 1, '17079954': 1, '9831413': 1, '19390403': 1, '12851784': 1, '3805410': 1, '16567893': 1, '24765500': 2}

{}

3981227-1

noncomm/PMC003xxxxxx/PMC3981227.xml

Retroperitoneal Approach for Recurrent Benign Multicystic Peritoneal Mesothelioma

A 32-year-old female presented with recurrent lump in right lumbar region. There were no associated urinary or bowel complaints. She was operated twice for similar lumps in a rural hospital 10 and 3 years back. Her discharge card of previous surgery showed the diagnosis of lymphangioma. Her case papers of first surgery done 10 years back were not available. On physical examination a lump in right lumbar region just lateral to previous paramedian incision was palpated. Rest of the abdomen was unremarkable.\nUltrasonography showed multicystic complex mass in right lumbar region measuring 25×8×7 cm. Computed tomography scan abdomen and pelvis () showed a 25×10×6.5 cm sized well defined non enhancing lobulated multiloculated cystic lesion in right paracolic gutter on lateral aspect of ascending colon. Inferiorly it was abutting the lateral wall of urinary bladder. Similar morphology lesions were seen in pouch of Douglas and mesentery. All these finding were suggestive of recurrent lymphangioma.\nPatient was subjected to surgery with a retroperitoneal approach as majority of the mass was retrocolic in position. Incision was taken below and parallel to 12th rib extending from posterior axillary line and going anteriorly towards umbilicus by keeping the patient in left lateral position. Initially retroperitoneal component of lesion was dissected out from kidney and ureter and lastly from retro peritoneal surface of colon. During this peritoneum was opened and the intra peritoneal component including pelvic component was completely removed. Intra operative finding showed a cystic multiloculted mass loosely attached to serosal surfaces of the ascending colon extending into pelvis with intra peritoneal extension into pouch of Douglas. The rest of the appendix, caecum, large and small bowel appeared grossly normal. Both ovaries and the uterus were visualized and found to be normal. The lesion was friable, hence care was taken to avoid rupture contamination of the pelvis with the cyst fluid. Complete resection of the lesion was performed. The diagnosis was not clear at this point, but our differential included a mucinous cystadenoma or pseudomyxoma peritonei or lymphangioma. As the diagnosis of BMPM was not established hence intraoperative hyperthermic peritoneal infusion with cisplatin was not considered. The specimen was a multicystic mass that was 22 cm wide in its greatest dimension (). The individual cysts, which ranged between 3 and 9 cm in diameter, contained serous fluid.\nPost operative recovery was uneventful. Histopathology showed cystic spaces lined by flattened cuboidal to hobnail epithelium separated by thin fibrous septa () .The lining epithelium showed strong immunopositivity for calretinin () and immunonegativity for CD31. Hence diagnosis of multilocular peritoneal inclusion cyst was confirmed. Follow up of 1 year has shown patient to be disease and symptom free.

[[32.0, 'year']]

F

{'27899951': 2, '2766227': 1, '7928060': 1, '3294158': 1, '22811829': 1, '1336927': 1, '7116294': 1, '9989843': 1, '16343188': 1, '11328842': 1, '12729358': 1, '476578': 1, '7121070': 1, '2671878': 1, '3789251': 1, '3421410': 1, '16092670': 1, '24765496': 2}

{'5102685-1': 1}

3981228-1

noncomm/PMC003xxxxxx/PMC3981228.xml

Retropancreatic Teratoma with Intra-thoracic Extension

A 23-year old unmarried female presented with complaints of abdominal pain and backache. The pain was dull aching and mostly localized to her left upper quadrant. There were no bowel or urinary complaints. There was no history of abdominal operation or trauma to the abdomen. Menstrual history was unremarkable.\nClinical examination revealed moderately built lady with unremarkable general examination. Abdomen was soft with no organomegaly. Routine blood tests and urinalysis were all within normal limits. Ultrasonography of abdomen showed large mass near upper pole of left kidney, encasing left suprarenal gland. Computerized tomography (CT) scan revealed 7.6×3.1×3.8 cm well defined lesion of fat attenuation with calcific focus within, posterior to pancreatic body and tail. It was in close proximity to celiac axis (Figures 1 and 2) and had intra thoracic extension into the posterior mediastinum. A provisional diagnosis of teratoma was made.\nThe patient underwent an exploratory laparotomy which revealed a well circumscribed mass in the retroperitoneal region behind the pancreas. The tumor was situated along the course of the celiac axis over the aorta with blood supply from the splenic and the left gastric arteries. It was not firmly fixed to any overlying structures. It was completely resected along with the extension entering the mediastinum through the esophageal hiatus () as its blood supply was only from the abdominal vessels. Mass was excised completely () and sent for histopathological examination. Cut section of tumor was composed of tan brown soft tissue with gelatinous secretion with bony components at the centre of mass. Histologic sections reported mucous glands with a cyst lined by flattened cuboidal epithelium and focus of maturing neuroepithelium. The diagnosis was consistent with Immature retroperitoneal teratoma. Follow up of 1-year shown her to be disease and symptom free.

[[23.0, 'year']]

F

{'9179701': 1, '9509650': 1, '5686638': 1, '7355206': 1, '3627612': 1, '24765493': 2}

{}

3981229-1

noncomm/PMC003xxxxxx/PMC3981229.xml

Colectomy for Porto-Systemic Encephalopathy: Is it Still Topical?

A 59-year-old man, was diagnosed as having cirrhosis of unknown etiology since 1993. Viral serology and auto-antibodies were negative. There was neither iron overload, nor alcohol consumption, nor signs of metabolic syndrome. Copper tests were normal. He had 3 episodes of esophageal bleeding between 1993 and 2003 treated successfully with sclerotherapy. The Child-Pugh score was A.\nIn 2003, he had an uncontrolled variceal bleeding refractory to medical and endoscopic therapy. As TIPS was not available, salvage therapy with DSRS was performed in emergency. There was no post-operative complications. Until 2010, he had no recurrent variceal bleeding, no HE and no ascitis.\nIn 2010, he developed a slight tremor of the upper extremities, predominating on the right, but he did not consult.\nOne year later, he presented recurrent episodes of agitation, disorientation, amnesia, stupor and slurred speech. Physical examination disclosed asymmetrical tremor predominating on the right and temporo-spatial disorientation. There was neither focal deficit, nor extra-pyramidal rigidity, nor muscular incoordination. Biochemical analysis revealed normal glycemia and renal function, absence of severe liver dysfunction, no thyroidal disorders, no hypoxia. Ammonemia was not available in our unit. Cerebral computed tomography (CT) scan showed no abnormalities whereas magnetic resonance (MR) disclosed hyperintensity of the globus pallidus on T1 (). Electroencephalogram demonstrated slowing of alpha rhythm. abdominal doppler ultrasound and CT scan showed patency of the spleno-renal shunt, partial portal thrombosis, no signs of hepato-cellular carcinoma.\nThis picture led to the diagnosis of HE associated with porto-systemic shunt. Treatment with lactulose and rifaximin allowed transient resolution of disorientation but tremor persisted. Anticoagulation for portal thrombosis was not effective and dangerous because of mistakes in doses.\nA few weeks later, he presented recurrent episodes of gross disorientation, ideo-motor apraxia and loss of consciousness requiring repeated admissions in intensive care unit. He never became free from symptoms. Lactulose, rifaximin and flumazenil allowed only temporary improvement.\nWe were in front of a persistent and severe HE refractory to medical therapy. The risk of rebleeding after reduction of the shunt was obvious, hepatic transplantation was not available, so we performed a subtotal colectomy with ileo-rectal anastomosis in order to reduce ammonia production. The patient was operated by laparotomy, without intra-operative bleeding. Post-operative course was uneventful, in particular, no postoperative ascites and no need for transfusion. Neurological examination disclosed normal consciousness, intellectual function and behavior while a slight tremor persisted in the right hand. Ten days after the operation, the patient was able to be discharged home.\nIn the follow-up, 17 months later, he was still improved, keeping only the slight tremor of the right hand, and liver function did not worsen. He did not have a recurrence of disorientation, intellectual function and behavior remained normal.

[[59.0, 'year']]

M

{'16498256': 1, '15768459': 1, '2181710': 1, '18003996': 1, '1994594': 1, '16168979': 1, '16772792': 1, '10199316': 1, '14094682': 1, '3202707': 1, '5831216': 1, '11442253': 1, '1568772': 1, '21145874': 1, '20002027': 1, '8311803': 1, '1483303': 1, '24765497': 2}

{}

3981230-1

noncomm/PMC003xxxxxx/PMC3981230.xml

Air Embolism during Arthrography for Developmental Dysplasia of the Hip

The patient was an 8-month-old female infant with left DDH. She had been diagnosed with dislocation of the left hip at another hospital at the age of 3 months, and she was treated with a Pavlik harness for 4 weeks. However, her left hip was not reduced, and she was admitted to our institution at the age of 8 months. The anteroposterior radiograph showed that the left femoral head was completely dislocated and had shifted to the lateral and proximal side (). She did not have the abnormality at the time of birth; in addition, no past illness, allergy, or family history of DDH were noted. At our institution, she underwent closed reduction under general anesthesia. Her hip joint was reduced; however, it was unstable, and the femoral head was easily dislocated when we decreased the hip abduction angle down to 60°.\nSubsequently, arthrography was performed to verify the reduction and to analyze the obstructive factors and afferent nature of the femoral head. First, the legs were maintained in the frog-leg position, and then, a 23-gauge Cathelin needle was inserted in the central part of the femoral proximal epiphyseal line using the anterior approach. After confirming that blood was not aspirated, 1 mL of air was injected to confirm that the Cathelin needle was accurately sited in the joint; subsequently, we injected 1 mL of the contrast medium.\nTwo minutes after air injection, the endtidal carbon dioxide (ETCO2) concentration decreased suddenly from 37 mmHg to 19 mmHg, and the blood oxygen concentration decreased from 99% to 97% (). The anesthesiologist noticed the change, and he increased oxygenation from 33% oxygen to 100% under observation. The blood oxygen concentration and ETCO2 concentration gradually improved and returned to normal values after 2 min and 12 min, respectively. Other vital signs such as blood pressure and pulse rate remained unchanged. An arthrogram showed good reduction of the femoral head. Plaster cast fixation was performed at an abduction angle of approximately 70°. After the operation, she was placed in a plaster cast, abduction brace, and Pavlik harness, for 4 weeks each. At the latest examination performed at the age of 4 years, the patient had not experienced any recurrence of dislocation.

[[8.0, 'month']]

F

{'10488865': 1, '9459237': 1, '32489214': 1, '7466411': 1, '2764299': 1, '20286347': 1, '11982846': 1, '17322443': 1, '14612652': 1, '15264743': 1, '1747313': 1, '7089263': 1, '11961453': 1, '24765492': 2}

{}

3981231-1

noncomm/PMC003xxxxxx/PMC3981231.xml

Syringomyelia Regression after Shunting of a Trapped Fourth Ventricle

A 28-year-old female was admitted in our department because of a large right-sided intracerebral hemorrhage as a result of a ruptured arteriovenous malformation. She underwent neurosurgical and endovascular treatment. Due to a post hemorrhagic hydrocephalus external ventricular drain was performed. During the intensive care treatment she unfortunately developed meningitis. After antibiotic treatment, the meningitis was cured and a ventriculo peritoneal shunt was performed. However, the follow up imaging, revealed an isolated enlarged fourth ventricle despite shunting of the lateral ventricles. Therefore a shunting of the fourth ventricle has been done as well. Nearly 22 months later the patient presented again with secondary walking and coordination impairment.\nNeurological examination showed increasing ataxia and eye movement disorder beside the known left-sided hemiparesis. Cranial computed tomography (CT) demonstrated remarkable dilation of fourth ventricle indicating a shunt dysfunction. Furthermore syringomyelia without tonsil herniation has occurred, which was identified through cervical magnetic resonance imaging (MRI) extending from C2 to C7. The complete replacement of the dysfunctional shunt system was immediately performed. Postoperatively, the syringomyelia resolved within 6 months and the associated neurological deficits improved as well. An entire resolution of the trapped fourth ventricle was confirmed on CT scan ().

[[28.0, 'year']]

F

{'8271018': 1, '6979109': 1, '8869706': 1, '15271243': 1, '17587782': 1, '14345682': 1, '21937936': 1, '3973704': 1, '21795864': 1, '2479867': 1, '15915302': 1, '31209641': 1, '1933919': 1, '29285106': 1, '24765489': 2}

{}

3981232-1

noncomm/PMC003xxxxxx/PMC3981232.xml

Multiple Pulmonary Nodules: A Complex Case of Wegener’s Granulomatosis

A 78-year old male with past medical history significant for chronic shortness of breath (for the last two years), chronic systolic heart failure secondary to non-ischemic dilated cardiomyopathy, pulmonary hypertension, essential hypertension, coal miner’s pneumoconiosis, and chronic obstructive lung disease was found to have bilateral pulmonary nodules on pre-operative chest X-ray. The work-up for the pulmonary nodules was initially planned on an outpatient basis. However, two weeks later the patient was admitted to the hospital with progressive shortness of breath. Upon admission, vital signs included temperature 35.8°C, pulse 56 beats/min, respiratory rate 22 breaths/min, and blood pressure 110/54 mmHg. Oxygen saturation on room air was 96%. On review of systems he reported decreased appetite for the past three months and a 20 pound weight loss. He denied hematuria, rhinorrhea, rashes, sinus pain, muscle aches, ear ache, hearing loss or hemoptysis. Physical exam was significant for bilateral rhonchi on auscultation of the lungs. Fecal occult blood was negative. Electrolytes were within normal limits. Blood urea nitrogen was 18 mg/dL, creatinine 1.2 mg/dL, glomerular filtration rate 59 mL/min. The patient’s urine microscopy was initially negative. Chest X-ray revealed bilateral hilar and right upper lobe areas of infiltrate increased from the prior imaging examination. Computed tomography (CT) scan revealed multiple cavitary lesions, the largest on the right, with a large air fluid level suspicious for infection. The day after admission the patient underwent CT guided fine needle aspiration of the right lung. A catheter was placed and a 10 cc of frankly purulent material was aspirated. Pathological examination showed acute inflammation. Tissue cultures showed no growth. No acid fast bacteria were seen on smear. Potassium hydroxyde preparation was negative and no fungus was isolated. All blood cultures were the negative and so were cultures of the pleural fluid and the surgical specimen. One of the expectorant sputum samples grew Rhodococcus equi. The patient was then started empirically on ciprofloxacin and rifampin for Rhodococcus equi. However, the antibiotics were soon discontinued secondary to low suspicion for the presence of active infection. At that point the diagnosis of vasculitis was entertained and a vasculitis panel was significant for elevated sedimentation rate at 84 mm/h. Anti-glomerular basement membrane antibody level was negative, but proteinase 3-anti-neutrophil cytoplasmic antibody (PR3-ANCA) level was elevated at 3.8 units. Liver function tests were normal.\nLung biopsy revealed chronic and acute inflammation and granuloma formation. Two weeks after hospital admission the patient complained of diarrhea. Laboratory results indicated that he was in renal failure. Stool studies were positive for Clostridium difficile for which the patient was started on flagyl. Repeat urinalysis showed brown colored urine with pH 6, specific gravity 1.023, moderate occult blood, bile negative, small leukocyte esterase, nitrate negative, 9-10 red blood cells (RBC)/high power field (HPF), 9-10 white blood cells/HPF, rare squamous epithelial cells, rare hyaline casts, 30A protein. Urine microscopy was positive for RBC casts. At that time the patient also developed purpuric rash over his extremities. The patient was empirically started on oral cyclophosphamide and IV methylprednisolone. Kidney biopsy was inadequate for diagnosis. During the course of his treatment he also completed 5 cycles of plasmapheresis. The patient remained dialysis dependent at 2 months follow-up.

[[78.0, 'year']]

M

{'16728414': 1, '12905485': 1, '12632437': 1, '20454762': 1, '33869612': 2, '29670798': 1, '20083584': 1, '9366584': 1, '2202308': 1, '15334441': 1, '18209443': 1, '21103126': 1, '24765494': 2}

{'8026843-1': 1}

3981234-1

noncomm/PMC003xxxxxx/PMC3981234.xml

Spontaneous Transmesenteric Hernia: A Rare Cause of Small Bowel Obstruction in an Adult

A 28-year-old female presented to emergency department with complaints of generalized abdominal pain, non-passage of feces and flatus, and multiple episodes of vomiting of 4 days duration. There was no history of surgery and no comorbidities. On examination, there was tachycardia, hypotension, and signs of dehydration. Abdomen examination revealed generalized distension, diffuse tenderness, guarding and absent bowel sounds. Hematological and biochemical investigations revealed leukocytosis with neutrophilia, raised blood urea and serum creatinine. X-ray chest and abdomen showed no free gas under diaphragm, there were multiple air fluid levels, and dilated small bowel loops. Ultrasonography of abdomen showed dilated small bowel loops with moderate amount of interbowel fluid. As there were signs of septic shock, and strangulation, and renal function tests were deranged, contrast enhanced computed tomography (CECT) was not performed. With the diagnosis of small bowel obstruction and a possibility of strangulation, after nasogastric decompression, aggressive preoperative fluid replacement, and correction of electrolyte disturbances, emergency exploratory laparotomy was done. On exploration, small bowel loops were dilated, and a long segment of small bowel were infarcted. The mid, distal jejunum and proximal ileal loops were found to pass through a defect in the proximal jejunal mesentery () with compression of vascularization of herniated bowel loops (). Rest of the small bowel, colon and stomach were normal. After reduction of herniated bowel loops, resection of the gangrenous loops with end to end anastomosis between proximal jejunum and mid ileum was performed and mesenteric defect was closed properly. Postoperative period was uneventful and patient was discharged on postoperative day 8.

[[28.0, 'year']]

F

{'6729672': 1, '19422936': 1, '11152781': 1, '9773941': 1, '8346096': 1, '3752377': 1, '6988996': 1, '34522423': 1, '24765499': 2}

{}

3981235-1

noncomm/PMC003xxxxxx/PMC3981235.xml

First Trimester Diagnosis of VACTERL Association

A 20-year-old primigravid, Caucasian woman was referred to our Fetal Medicine Unit at 11 weeks’ gestation for first trimester aneuploidy screening. Maternal blood sampling for β-HCG and PAPP-A measurement was performed on the first appointment at 11 weeks.\nThere was no relevant personal or family medical history or exposure to any known teratogen. She was under no medication, except folate supplementation. The couple was nonconsanguineous.\nAbdominal ultrasound performed at 13 weeks of amenorrhoea revealed an intrauterine gestational sac containing a live fetus with a crown-rump length of 53 mm. A detailed sonographic examination detected caudal dysplasia with hypoplastic lower limbs () as well as an intra-abdominal cystic formation (), which was thought to correspond to the gastric bubble. The differential diagnosis of caudal regression and VACTERL association was considered.\nThe risk for aneuploidies, based on ultrasound and biochemical markers, was low (Trisomy 21 – 1:21163, Trisomy 13/18 – 1:37147).\nRegardless the uncertainty of the definitive diagnosis, the poor prognosis was discussed and the couple opted for medical termination of pregnancy, which was performed using a combined regimen of oral Mifepristone and vaginal Misoprostol. The procedure had no reported complications. A vaginal ultrasound was performed after fetal expulsion and confirmed uterine vacuity.\nThe fetal patho-histological study confirmed the sonographic findings and revealed additional multiple malformations: low-set ears, hypoplastic unilobated lungs, absent spleen, hypertrophic pyloric stenosis with marked stomach distension (), horseshoe dysplastic and cystic kidney with a single ureter, rudimentary bladder, bilateral intraabdominal testes, urethral and anal atresia, distended bowel, recto-perineal fistula and ambiguous genitalia. Craniosynostosis, hydrocephalus and coloboma were not observed in fetal autopsy.\nAsymmetric lower limbs were also noticed, with absent foot and rudimentary leg on the left and syndactyly (lobster claw malformation) of the right foot ( and ).\nPlacental study revealed nonspecific changes with increased fibrin deposits and lateral insertion of the umbilical cord, which had three vessels. Placental weight and maturity were considered appropriate for the gestational age (). No other alterations were found in the umbilical cord or placenta.\nFetal karyotype was normal (46 XY).\nFetal x-ray revealed absent sacral and lower lumbar vertebrae, absent lower limb bones on the left and hypoplastic right femur and tibia as well as absent right fibula. Absent pelvic bones on the left and hypoplastic on the right were also reported ().

[[20.0, 'year']]

F

{'4372554': 1, '20964119': 1, '12001200': 1, '17923191': 1, '9215761': 1, '21235632': 1, '33143152': 1, '18386801': 1, '20683998': 1, '4681850': 1, '6835768': 1, '11982991': 1, '21465648': 1, '18186125': 1, '3351894': 1, '21846383': 1, '24765498': 2}

{}

3981258-1

noncomm/PMC003xxxxxx/PMC3981258.xml

A Rare Case of Multiple Jejunal Diverticulosis Presenting as Intestinal Obstruction

A 54-year old male patient presented himself at the Emergency Department with extensive abdominal pain and multiple episodes of bilious vomiting for the previous two days. The patient had a history of multiple episodes of pain and occasional fullness in the upper abdomen for the previous three years. The patient had earlier taken a complete course of anti-tubercular treatment empirically based on features of recurrent intestinal obstruction at other medical centers on the pretext of the prevalence of tuberculosis in this region. On presentation, the patient was found to be hemodynamically stable. Abdominal examination showed distension in the epigastric and umbilical regions with localized tenderness and hyperactive bowel sounds.\nLaboratory work-up revealed raised blood urea and serum creatinine. Contrast enhanced computed tomography was, therefore, not performed but erect and supine abdominal radiograpghs revealed multiple air fluid levels () and dilated jejunal loops (), respectively.\nA diagnosis of acute intestinal obstruction was made after which an emergency exploratory laparotomy was performed. This revealed multiple inflamed diverticulae () in the jejunum with a band 15 cm from ligament of Treitz. The largest diverticulum was 5x4x4 cm at the mesentric border () with multiple adhesions () in jejunum and proximal ileum forming a blind loop. Pin-point pus exudation was seen from one of the diverticulum (). A segmental resection of two and half feet of jejunum with end-to-end jejuno-jejunostomy was performed after removing all the bands and adhesions. The patient’s post-operative course was uneventful and the patient was discharged on Day 10 after surgery. The histopathological examination of the specimen showed focal mucosal ulceration with sub-mucosal edema and chronic inflammatory infiltrate, whereas multiple sections taken from diverticulae exhibited features of diverticulitis along with an area of stricture.

[[54.0, 'year']]

M

{'31940112': 1, '10478885': 1, '27853337': 2, '16149162': 1, '25984521': 1, '18506936': 1, '7963370': 1, '9860418': 1, '20697923': 1, '22666695': 2, '31574453': 1, '8845613': 1, '3132909': 1, '24765509': 2}

{'5106572-1': 1, '3364665-1': 1}

3981260-1

noncomm/PMC003xxxxxx/PMC3981260.xml

Osseous Hamartoma Arising from the Eustachian Tube

A 56-year-old male patient presented with right aural fullness and nasal obstruction that had been evident for three years. He had no juvenile history of nasal disease or otitis media. At the first admission, the secretory otitis media (SOM) in the right ear was investigated, and a solid, smooth and poorly mobile tumor was detected in the posterior part of the nasal cavity and nasopharynx (). Initial diagnosis of a transnasal biopsy sample suggested fibroma. Computed tomography (CT) examination showed that the tumor occupied the nasopharynx, and a high-intensity shadow was evident within it (, and ). Although CT was unable to reveal the origin of the tumor, the high-intensity shadow extended in the direction of the ET () and thus the tumor was thought to have arisen from the ET. Magnetic resonance imaging (MRI) showed that the tumor consisted of heterogeneous components with T1 enhancement (), and that the inside of the tumor appeared more contrasted with T2 enhancement (). The T2 enhanced image showed a smooth line of the nasopharyngeal mucosa, suggesting no tumor invasion in the nasopharynx. Enhancement with intravenous contrast medium revealed no remarkable features by both CT and MRI.\nUnder a preoperative diagnosis of nasopharyngeal tumor possibly involving the Eustachian tube, partial resection of the nasopharyngeal tumor was performed by transnasal endoscopic surgery to obtain a definitive diagnosis and to relieve the nasal obstruction. A hard mass with a smooth surface was seen to arise from the pharyngeal ostium of the ET (). The mass was reduced piecemeal using scissors and sharp forceps, taking care to preserve the normal mucosa of the nasopharynx. The tumor was not attached to the nasal and pharyngeal mucosa and protruded into the ET. However, its point of origin could not be detected precisely because the surgical devices were unable to reach the inside of the ET. Part of the tumor in the ET therefore remained, and a tympanostomy tube was inserted into the right ear to resolve the SOM. Pathological examination showed that the tumor consisted of bony tissue, fat cells and proliferated fibroblasts, and was diagnosed as osseous hamartoma arising from the ET (). Ten months after the reduction surgery, the tumor was not markedly enlarged (). The nasal obstruction, right aural fullness and conductive hearing loss that were evident on initial presentation were diminished after the surgery.

[[56.0, 'year']]

M

{'13852335': 1, '12707668': 1, '22939326': 1, '15121226': 1, '23118582': 2, '12648377': 1, '22160144': 1, '7190630': 1, '3566627': 1, '19132715': 1, '14631680': 1, '8708057': 1, '20818917': 1, '7822182': 1, '18661215': 1, '18084819': 1, '24765513': 2}

{'3484304-1': 1}

3981262-1

noncomm/PMC003xxxxxx/PMC3981262.xml

Disseminated Herpes Zoster Ophthalmicus in an Immunocompetent 8-Year Old Boy

A previously healthy 8-year old boy presented with a five-day history of right sided headache and a four day history of a vesicular rash on the ipsilateral forehead, eye lid and nose. There was associated pain and swelling of the areas involved. The rash later progressed to involve the ipsilateral side of the scalp while the facial swelling spread to the contralateral side of the face (). Three days after the onset of the facial rash, a vesicular rash was noticed on the chest, back, upper and lower limbs. There was associated fever and generalized headache. Review of systems was negative. There was a past history of a febrile exanthematous illness suggestive of chicken pox at 3 years of age and his parents and siblings had similar illness at about the same time. There was no history of recurrent illnesses, intake of neither steroids nor cytotoxic drugs. A history of contact with individuals with varicella infection was uncertain but the child had been attending school before his illness. He presented during an ongoing chicken pox outbreak as evidenced by an increased number of cases observed within and outside the hospital setting.\nAt presentation, he was acutely ill looking, febrile with an axillary temperature of 39.6°C. He had coalesced pustulo-bullous crusting lesions on the right peri-orbital and frontal areas, extending upwards into the temperoparietal region of the scalp on the ipsilateral side and downwards to the right nostril, in keeping with involvement of the ophthalmic branch of the trigeminal nerve. There was associated gross facial edema involving both periorbital areas and extending to the chin and submandibular region. The swelling on the right side of the face was crepitant, suggestive of subcutaneous emphysema. Both eyes were tightly shut with copious discharge. He had right-sided pre-auricular, posterior auricular, submandibular and cervical lymphadenopathy. His weight was 33.5 kg (90th percentile) and his height was 128 cm (50th percentile). He had disseminated lesions on the trunk and extremities except spared the soles and palms. There were umbilicated vesicles on erythematous base with some crusting of some of the lesions ().\nOther systems were essentially normal. A diagnosis of herpes zoster ophthalmicus with suspected secondary bacterial infection was made.\nHis hematocrit was 38%, the white cell count was normal at presentation. HIV antibody test was non-reactive. His random plasma glucose was 123 mg/dL. Serology for varicella antibodies could not be carried out until 6weeks after and was reported as positive for varicella immunoglobulin (Ig) G and negative for IgM. Viral cultures and polymerase chain reaction (PCR) were not available.\nHe was admitted and nursed in isolation and was managed by both the pediatric infectious diseases unit in conjunction with the ophthalmologists. He was tolerating oral fluids and feeds fairly well and commenced on oral acyclovir at 20 mg/kg five times a day (the intravenous form was not available), acyclovir eye ointment and drops, regular ocular toileting with 0.9% saline and dexamethasone eye drops on account of chemosis observed on eye examination. A full eye examination was not possible at this point as it was difficult to prise the lids open. He received in addition, intravenous flucloxacillin, ceftriaxone and metronidazole on account of the bilateral periorbital cellulitis. Topical acyclovir was applied to the lesions on the frontal region.\nWithin 24 h of oral acyclovir treatment, new skin lesions ceased to appear. He improved remarkably over the next week (). The pustules became ulcerated and gradually healed. Fever and facial edema gradually resolved. He was able to open both eyes and had no problems with vision. He was discharged home with acyclovir ointment application after having completed a week of systemic acyclovir use and antibiotics. Follow-up at six weeks showed residual ptosis of the left eye () without evidence of Bell’s palsy or other neurological findings that may be in keeping with a complication including Ramsay-Hunt or Trigeminal herpes zoster. A slit-lamp examination of the eye did not reveal any significant corneal scarring and ophthalmoscopy did not show any intraocular lesion (). Visual acuity was normal.

[[8.0, 'year']]

M

{'7876622': 1, '16320806': 1, '12634596': 1, '22121271': 1, '17585291': 1, '34321894': 2, '29895579': 1, '12037117': 1, '25692062': 2, '16516488': 1, '22659447': 1, '21273297': 1, '14120593': 1, '16651676': 1, '18418805': 1, '1195231': 1, '9354356': 1, '10881585': 1, '16351732': 2, '20170376': 1, '21269735': 1, '21731332': 1, '22690988': 1, '22766968': 1, '24765504': 2}

{'4323070-1': 1, '1327670-1': 1, '8313509-1': 1}

3981263-1

noncomm/PMC003xxxxxx/PMC3981263.xml

Leiomyoma of the Seminal Vesicle: A Rare Case

A 78-year old male presented with gradually increasing symptoms of straining at micturition, increased frequency, hesitancy and terminal dribbling .No history of hematuria, or significant loss of weight, or low back ache. General examination was within normal limits. Abdominal examination was unremarkable. On per rectal examination, a soft swelling was palpable anteriorly with slight mobility below prostate.\nBlood examinations were within normal limits and serum prostate specific antigen was not raised. Ultrasonography suggested a lump in the pelvis with close adherence to the base of the bladder. Computed tomography (CT) of abdomen and pelvis suggested a soft tissue swelling in the pelvis measuring 4.7x4.3x3 cm with connection to the left seminal vesicle (). Ultrasound guided trans-rectal needle biopsy of the tumor was done. Histological evaluation showed spindle cell tumor. Surgical excision was done through a suprapubic approach. Intra-operatively the tumor was found arising from the lateral margin of left seminal vesicle with no adhesions to surrounding organs rectum, urinary bladder and prostate (). The tumor was excised leaving the seminal vesicle intact (). Post operative period was uneventful with near complete relief of symptoms. Histopathology report confirmed the tumor to be a leiomyoma (). Follow up of six months has shown him to be disease and symptom free.

[[78.0, 'year']]

M

{'8961499': 1, '15905997': 1, '12754634': 1, '9215185': 1, '14587232': 1, '2180171': 1, '29991843': 1, '19675768': 2, '10081878': 1, '15576008': 1, '7815605': 1, '8126778': 1, '24765520': 2}

{'2721502-1': 1}

3981265-1

noncomm/PMC003xxxxxx/PMC3981265.xml

Predominantly Cystic Central Mucoepidermoid Carcinoma Developing from a Previously Diagnosed Dentigerous Cyst: Case Report and Review of the Literature

An 80-year old female patient came with a chief complaint of pain and swelling over the left lower half of the face since 3 months. Patient was unaware of the swelling previously. Patient gave a history of impacted mandibular 3rd molar, which was extracted 2 years ago. On extraoral examination, an ill-defined swelling was noted on the lower left side of the face, irregular in shape, measuring about 2×3 cm in size (). Intraorally, on palpation left ramus of mandible was obliterated and on orthopantamograph, a multilocular radiolucent lesion in relation to left angle ramus of mandible was noted. A straw colored fluid was aspirated from the cystic space. A provisional diagnosis of odontogenic keratocyst/ameloblastoma/ dentigerous cyst was considered.\nIncisional biopsy was performed. On histopathological examination, a non-keratinizing cystic lining epithelium with mucous cell metaplasia and a connective tissue wall was noted. () Correlating patient’s history with the clinical, radiographical and histopathological findings, a diagnosis of long standing case of dentigerous cyst with mucous metaplasia was given.\nA surgical excision of the entire lesion was performed and histopathological examination of the excisional specimen revealed numerous microcysts and macrocysts, islands of epidermoid cells and mucous cells, minimal to absence of pleomorphism () and cholesterol clefts with multinucleated foreign body type giant cells. Foci of the section showed a single layer of non-keratinizing cystic lining epithelium with mucous cell metaplasia, which stained positive with mucicarmine staining (). A final diagnosis of low-grade central mucoepidermoid carcinoma was rendered.

[[80.0, 'year']]

F

{'27721620': 2, '20625861': 1, '12773198': 1, '7473267': 1, '1059064': 1, '1311758': 1, '21187636': 1, '19300374': 1, '14505620': 1, '25386530': 1, '10936840': 1, '16050487': 1, '1089038': 1, '10833151': 1, '4525092': 1, '29238382': 2, '30572495': 2, '27957281': 1, '26155575': 1, '4125136': 1, '2662106': 1, '24765507': 2}

{'6320197-1': 1, '5051303-1': 1, '5713067-1': 1}

3981266-1

noncomm/PMC003xxxxxx/PMC3981266.xml

Toxic Megacolon Complicating a First Course of Crohn’s Disease: About Two Cases

A 35-year-old man with history of diabetes, presented with bloody diarrhea. Colonoscopy has demonstrated typical findings of Crohn’s colitis with severe inflammation. He underwent glucocorticoid therapy, and on the 20th day of treatment, he exhibited sudden severe abdominal pain and distension. On physical examination, the patient had tachycardia of 125 beats per min, fever to 38.3°C, hypotension, and his abdomen was diffusely tender. A plain abdominal radiography revealed TM, showing prominent dilatation of the transverse colon (). Computed tomographic (CT) examination excluded perforation. Intravenous corticosteroids and broad-spectrum antibiotics during 72 h not relieved symptoms. The patient underwent subtotal colectomy with ileostomy. The resected specimen confirmed diagnosis of CD. The postoperative course was uneventful. Recovery of digestive continuity was performed. Endoscopic evaluation six months later did not shown recurrence (Rutgeerts score i-0). There was no indication to postoperative medical therapy to maintain remission. The evolution was uneventful at 2 years follow-up.

[[35.0, 'year']]

M

{'22040786': 1, '15776138': 1, '14784154': 1, '9482465': 1, '5305933': 1, '2394349': 1, '24765512': 2}

{'3981266-2': 2}

3981266-2

noncomm/PMC003xxxxxx/PMC3981266.xml

Toxic Megacolon Complicating a First Course of Crohn’s Disease: About Two Cases

A 57-year-old man, with no past medical history, presented with bloody diarrhea and fever to 39°C. Colonoscopy showed findings of severe acute colitis. Biopsy specimen revealed severe Crohn’s colitis. The patient underwent intravenous corticosteroid therapy and antibiotics. Seven days later, he presented abdominal pain and distension. On physical examination, the patient had pulse rate of 123 beats per min, hypotension, abdominal distension and tenderness with signs of general peritonitis. Laboratory findings revealed hyperleucocytosis (18,200/mm3), C-reactive protein 296 mg/L. A plain abdominal radiography showed dilatation of the transverse colon and linear pneumatosis. CT examination revealed TM with free perforation, showing prominent dilation of the transverse colon and linear pneumatosis pararelling the bowel wall (). The patient underwent emergent subtotal colectomy and ileostomy. The final histological patterns were consisting with the diagnosis of CD associated with the presence of cytomegalovirus (CMV) inclusions. The patient underwent antiviral therapy (ganciclovir 10 mg/kg/day) during 15 days. Because of the high risk of postoperative recurrence, the patient underwent immunosuppressive therapy (azathioprine 2.5 mg/kg/day). Recovery of digestive continuity was performed with no recurrence at 8 months follow-up.

[[57.0, 'year']]

M

{'22040786': 1, '15776138': 1, '14784154': 1, '9482465': 1, '5305933': 1, '2394349': 1, '24765512': 2}

{'3981266-1': 2}

3981267-1

noncomm/PMC003xxxxxx/PMC3981267.xml

Acute Traumatic Tear of Latissimus Dorsi Muscle in an Elite Track Athlete

The patient was a 27-year old female elite track and field athlete (100 m hurdler) who has been competing for the last 10 years in many games, including the Olympic games. She felt contraction around the right axillary region during a weight-training workout (snatch) and a week later, she felt sudden tearing pain after a vigorous start from the crouched position in the blocks. Pain, ecchymosis and swelling at the axilla were the most apparent complaints when she visited a physician 4 days later. Nonsterodial anti-inflammatory drugs and muscle relaxants were prescribed. However her symptoms continued and she was referred to Sports Medicine Department of a tertiary medical center with the presumptive diagnosis of axillary lymphadenopathy 6 weeks after the injury. A soft tissue swelling (3×5 cm) with a gap in the mid portion and ecchymosis along the right posterolateral axillary region was noted on physical examination (). There was no neurologic or vascular anomaly. Shoulder adduction and internal rotation were slightly limited and painful. Manual muscle tests of isometric strength (internal rotation and adduction) were 4/5. US revealed a complete (17 mm long) tear of LD muscle close to the myotendinous junction on the right axillary region. Muscle fibers at both ends were slightly retracted and freely moving. Accompanying hematoma was quite minimal, likely due to late admittance ().\nLD muscle is a large fan-shaped muscle that covers the whole posterolateral aspect of the trunk. The fan-shaped edge originates from multiple sites such as the thoracic, lumbar and sacral spinous processes and the iliac crest then tapers superiorly to insert as a single long tendon to the intertubercular groove of the humerus. Therefore, injuries often occur close to the insertion site (). In our case, a mild grade I muscle sprain to LD, which occurred during snatch exercises, most likely predisposed the muscle to consequent tearing injury. The actual tear (grade II) occurred later when the patient was trying to generate power to run from the crouched position in the block by pushing her trunk forcibly forward while arms were extended, adducted and fixed on the ground. Similar mechanisms were described for slam-dunking in basketball and vaulting in gymnastics.\nOn the basis of patient preference, a conservative approach was preferred rather than surgery; because competitions were close and requiring immediate treatment plan. Presence of an intramuscular tear in an auxiliary muscle, not actively and dominantly involved in running, increased the likelihood of a successful conservative treatment. This was a late admittance case in which 6 weeks had already passed from the time of initial injury; therefore classic physical treatment modalities [protection, rest, ice, compression and elevation (PRICE)] were not closely followed. Antiinflammatory and analgesic medication, kinesiotaping were prescribed. Three-plane shoulder range of motion (ROM) exercises were initiated (10-15 times × 2 sets per day). Within a week, complaints subsided, ROM was full and movements were pain free. Palpation was slightly painful and tender but no swelling was noted. The patient resumed full athletic activity after two weeks of treatment, which made 8 weeks in total after the initial injury. The patient did not have any complaint in the follow-up exam 6 weeks later.

[[27.0, 'year']]

F

{'27047816': 1, '12469095': 1, '21880950': 1, '32548012': 1, '32399153': 1, '12792217': 1, '16247124': 1, '23204569': 1, '17620788': 1, '16636353': 1, '10955471': 1, '646009': 1, '28028567': 1, '26502450': 1, '16506877': 1, '19541846': 1, '9850790': 1, '10921654': 1, '22197182': 1, '24765503': 2}

{}

3981268-1

noncomm/PMC003xxxxxx/PMC3981268.xml

Acute steatohepatitis, due to extreme metabolic dysregulation, as the first presentation of non-alcoholic fatty liver disease

A 50-year old man was admitted to our hospital because of a 1-week history of jaundice, fatigue and malaise. On physical examination, the patient was obese, with a body mass index of 37 kg/m, and a waist circumference of 136 cm. His temperature was 36.6°C, blood pressure 160/90 mmHg, and heart rate 107 bpm. Hepatomegaly was detected. The liver was soft, and nontender, with a smooth edge palpable 5 cm below the right costal margin. No xanthomas were found.\nThe patient’s medical history included type II diabetes mellitus, diagnosed 7 years ago, dyslipidemia (elevated triglycerides, mildly increased cholesterol, and reduced high density lipoprotein - cholesterol), two-vessel coronary artery disease, treated with percutaneous transluminal coronary angioplasty plus stenting 7 months before this admission, and an episode of acute pancreatitis 4 years ago. His family history was notable for gastric cancer in his father.\nThe patient was an unmarried chandler, who lived with his parents and brother in a working-class suburb of Athens. He had been a heavy smoker (approximately 115 pack-years), but consumed only small quantities of alcohol during social events (<100 g per week). He reported no use of illicit drugs or anabolic steroids, no ingestion of mushrooms, herbal preparations or nutritional supplements, and no exposure to environmental toxins. He was following an extremely unhealthy dietary pattern, characterized by exorbitant calorie intake (estimated amount of 8000 kcal per day), and excessive consumption of saturated animal fats and simple carbohydrates, combined with a sedentary lifestyle and lack of physical activity. His daily medication regimen included aspirin, nebivolol, enalapril, metformin, vildagliptin, and omega-3 fatty acids [eicosapentaenoic (EPA), and docosahexaenoic acid (DHA)].\nThe most prominent laboratory abnormalities were conjugated hyperbilirubinemia (total bilirubin 10 mg/dL, direct bilirubin 6.6 mg/dL), elevation of liver enzymes, with a disproportionate rise of aminotransferases in comparison to alkaline phosphatase (aspartate transaminase 474 U/L, alanine transaminase 647 U/L, gamma-glutamyltransferase >1453 U/L, alkaline phosphatase 409 U/L), and striking hypertriglyceridemia (triglycerides >1420 mg/dL). The glycosylated hemoglobin value of 11.1% indicated poor diabetic control. Additional abnormal test results were as follows: hematocrit 39%, hemoglobin 13g/dL, mean corpuscular volume 84 fl, lactate dehydrogenase 512 U/L, serum sodium 112 meq/L, glucose 431 mg/dL, total cholesterol >705 mg/dL, high density lipoprotein - cholesterol (HDL-C) 26 mg/dL, erythrocyte sedimentation rate 103 mm/h, C-reactive protein 43 mg/L. The patient’s plasma had a turbid appearance. Urinalysis showed marked glycosuria and bilirubinuria.\nHepatitis A immunoglobulin M (IgM) antibody, hepatitis B surface antigen and core IgM antibody, a polymerase chain reaction assay for hepatitis C viral RNA, and serologic tests for Epstein-Barr virus, human immunodeficiency virus, and cytomegalovirus were negative. Tests for anti-nuclear, anti-smooth-muscle, anti-liver-kidney microsomal type 1, antimitochondrial, and anti-neutrophil cytoplasmic antibodies were also negative. Levels of α1-antitrypsine and ceruloplasmin were normal, and transferrin saturation was less than 40%.\nAbdominal ultrasound examination revealed hepatic enlargement and a diffuse increase in echogenicity of the liver as compared with that of the kidneys (bright liver). No other organ abnormality was observed. An abdominal computed tomography scan (), obtained after oral and intravenous administration of contrast material, demonstrated a low-density hepatic parenchyma, which appeared darker than the spleen. Both imaging studies were consistent with fatty infiltration of the liver.\nGiven the patient’s history, physical examination, laboratory results and imaging findings, we concluded the following clinical diagnoses: first, type IV hyperlipoproteinemia, according to Fredrickson’s classification (familial hypertriglyceridemia), exacerbated by excessive intake of simple carbohydrates, obesity, and insulin resistance, all of which increase very-low-density lipoprotein synthesis; second, acute form of NASH. Moreover, the patient met Adult Treatment Panel III criteria for metabolic syndrome.\nThe patient was then started on a low calorie diet, with complete exclusion of carbohydrates and fats, and pure intake of high quality protein (chicken breast). He was also treated with isophane insulin (40-30 IU), and omega-3 fatty acids (EPA/DHA 920/760 mg bid). During the next 10 days, the patient showed dramatic improvement of his clinical and laboratory status (), and was discharged from the hospital. He was advised to keep on the medication received during his hospitalization, reduce calorie intake, eat plenty of vegetables and fruits, rich in fiber and complex carbohydrates with a low glycemic index, avoid saturated fats and simple carbohydrates, walk 30 min every day, quit smoking, and abstain completely from alcohol.\nEight weeks later, the patient was invited for a follow-up appointment. Having strictly implemented medical recommendations, he had lost 20 kg of body weight. His signs and symptoms were entirely resolved. Further, impressive amelioration of laboratory values was noted (). Continuation of lifestyle modification was emphasized, and isophane insulin dose was reduced by 20% (32-24 IU). Aspirin 100 mg qd, metformin 850 mg bid, pioglitazone 30 mg qd, atorvastatin 20 mg qd, and EPA/DHA 920/760 mg bid were prescribed.

[[50.0, 'year']]

M

{'17511754': 1, '18081738': 1, '22278337': 1, '19585618': 1, '22488764': 1, '21198708': 1, '22481692': 1, '11961152': 1, '21947639': 1, '18821619': 1, '16157765': 1, '20955971': 1, '10566758': 1, '20460905': 1, '12003403': 1, '14262568': 1, '32354182': 1, '18510618': 1, '15967341': 1, '20492324': 1, '12190177': 1, '24765505': 2}

{}

3981269-1

noncomm/PMC003xxxxxx/PMC3981269.xml

Rhabdomyolysis as a Presenting Manifestation of Very Long-Chain Acyl-Coenzyme A Dehydrogenase Deficiency

A 13-year old female was admitted for severe, generalized muscle pain and dark urine lasting less than one day. The day before, she underwent prolonged physical effort as a result of four soccer games. No history of recent infection or trauma neither intake of herbs, alcohol or other drugs. No history of previously similar episodes or other relevant medical history, such hypoglycemia, recurrent vomiting, liver disease or coma.\nShe was the second of three children born to healthy first-degree cousins. Her 19-year old brother had a history of repeated similar episodes of muscle pain and dark urine after physical exertion of moderate intensity since the age of 17 and a hospitalization, one year ago, for rhabdomyolysis, but without further etiologic diagnosis.\nOn admission her temperature was normal. Except for tenderness in her muscles with mobilization difficulties, the physical and neurologic examinations were normal.\nBlood sample analysis showed CPK 215,800 U/L (normal<167), lactate dehydrogenase 6000 U/L (normal 240-480), myoglobin 30,950 ng/mL (normal 25-58); and aspartate aminotransferase 4773 U/L (normal 10-50). Glucose, urea, creatinine, sodium, potassium, calcium and phosphorous levels were normal. Venous blood gas measurement revealed no abnormalities. Urinalysis was positive for blood by reagent testing and had 5-10 red blood cells per high-power field by microscopy. Influenza A and B, Epstein-Barr, herpes simplex, parainfluenza, coxsackie, echovirus, adenovirus, human immunodeficiency virus or cytomegalovirus were excluded based on serological studies.\nBased on clinical presentation, family history and laboratory results, the diagnosis of metabolic myopathy with rhabdomyolysis precipitated by exercise was suspected. For further clarification additional investigations revealed serum lactate 1.20 mmol/L (normal 0.63-2.44), pyruvate 77 μmol/L (normal 54.1-119.9), ammonia 77 μg/dL (normal 45-80) and free carnitine 15 μmol/L (normal 30-50). The urine organic acids profile showed 3-hydroxybutyric acid and acetoacetic acid. Acylcarnitine analysis by tandem mass spectrometry of the patient’s dried blood spot disclosed elevated tetradecanoyl carnitine (C14) (0.26 μM, normal< 0.24), tetradecenoyl carnitine (C14:1) (0.26 μM, normal<0.18) and tetradecadienoyl carnitine (C14:2) (0.13 μM, normal<0.08), suggesting VLCAD deficiency. This was confirmed on acyl-CoA dehydrogenase very longchain (ACADVL) gene analysis, using standard polymerase chain reaction procedures, with in-house designed primers, to amplify from genomic DNA all exons and exon-intron boundaries of this gene. Sequence analysis was performed in an ABI Prism 3100xl genetic analyzer using the Big Dye terminator v3.1 Cycle Sequencing kit (Applied Biosystems, Inc., Foster City, CA, USA) and allowed the identification of a homozygous mutation, p.L500del (c.1500_1502delCCT), already described. Echocardiography was performed and showed no signs of hypertrophy or cardiomyopathy.\nAnalgesic treatment with acetaminophen was started as well as aggressive intravenous hydration in order to avoid acute renal injury. Favorable clinical and biochemical evolution was noted, always with preserved renal function and no electrolytic abnormalities, and she was discharged after five days.\nDespite having received advice on lifestyle and diet, a second episode of rhabdomyolysis occurred two months later, following a prolonged physical effort, a two hour long soccer game without hydration or food intake during the exercise. Between the two episodes she was asymptomatic with no laboratory abnormalities. Since the second episode, patient compliance has improved, and she remains asymptomatic when following a dietary regimen avoiding fasting for more than eight hours overnight, prolonged exercise and a high-carbohydrate, low-fat diet. She also started supplementation with medium-chain triglyceride oil before physical exercise.\nRecently, her brothers were also studied for VLCAD deficiency. The older brother revealed the same homozygous mutation on ACADVL gene analysis. Her younger brother, though asymptomatic, was studied through acylcarnitine analysis by tandem mass spectrometry of a dried blood spot specimen collected during a period of fasting that showed no alterations. ACADVL gene analysis was also performed and no mutation was identified.

[[13.0, 'year']]

F

{'11524729': 1, '21932095': 1, '33110664': 2, '11870710': 1, '20373143': 1, '16214072': 1, '16488171': 1, '9973285': 1, '10906171': 1, '9709714': 1, '10700700': 1, '19157942': 1, '19327992': 1, '34194748': 1, '1730632': 1, '8845838': 1, '10738914': 1, '8739957': 1, '9498103': 1, '32654032': 1, '10077518': 1, '24765510': 2}

{'7578713-1': 1}

3981271-1

noncomm/PMC003xxxxxx/PMC3981271.xml

Congenital Oligomeganephronia: Computed Tomography Appearance

A 16-year old male presented with non-bilious emesis. His emesis began 5 days earlier, upon discharge from the hospital after posterior spinal fusion for scoliosis. Born in Korea, he was adopted and brought to the United States as a baby. His birth history and biological family medical history are unknown. He underwent left congenital diaphragmatic hernia repair soon after birth, orchiopexy for undescended testis at age 5 years, Ladd procedure for small bowel malrotation and obstruction at age 6 years, and additional laparotomy for small bowel volvulus with lysis of peritoneal adhesions and appendectomy at age 14 years. His medical history also included left lung hypoplasia, ostium secundum atrial septal defect (ASD), left pulmonary vein stenosis, and chronic asthma, for which he took fluticasone proprionate/salmeterol and trimethoprim/sulfamethoxazole. He had no known history of renal disease, vesicoureteral reflux, urinary tract infection (UTI), or embolic disease. He was a junior in high school, taking advanced placement courses.\nThe patient’s height and weight were 170 cm (between 25th and 50th percentiles for age) and 35.9 kg (below 5th percentile for age). He had an oral temperature of 36.1°C, blood pressure of 127/76 mmHg, and heart rate of 81 beats per minute. His precordium was hyperdynamic, and a II/VI systolic murmur was heard. He had a midline abdominal wall scar, normal bowel sounds and no rebound tenderness or guarding. Scoliosis and a healing incision from recent spine fusion were apparent. Micrognathia was also present, but no other orofacial, ocular, aural, or limb deformities were noted. Laboratory results obtained in evaluation of emesis included normal serum electrolytes, amylase and lipase.\nChest and abdomen radiographs showed mixed bubbly lucencies and curvilinear opacities in the left lower hemithorax, and the possibility of a recurrent diaphragmatic hernia with bowel migration into the chest was raised. Due to complexity of the patient’s anatomy and his past surgical history, abdominopelvic CT with oral and intravenous contrast was pursued in lieu of ultrasound for further evaluation of the diaphragm and bowel. CT revealed evidence of prior left diaphragmatic hernia repair and Ladd procedure with bowel malrotation. No recurrent diaphragmatic hernia was seen; pleuroparenchymal scarring and atelectasis at the left lung base, alternating with areas of relatively well-aerated lung, explained the plain radiographic abnormalities. There were no CT findings of bowel obstruction, mass, or inflammation. However, renal craniocaudal dimensions of 7.5 cm on the right and 8.7 cm on the left were below the 5th percentile for age. In addition, both kidneys were abnormal in appearance (), providing impetus for further investigation into the patient’s renal status.\nSerum creatinine was 1.2 mg/dL (reference range: 0.6-1.1 mg/dL), and blood urea nitrogen was 13 mg/dL (reference range: 6-20 mg/dL). Estimated creatinine clearance was 99.2 mL/min/1.73 m2 [calculated by the original Schwartz equation, before isotope dilution mass spectrometry (IDMS)-traceable standardization of creatinine calibration]. Hemoglobin (12.7 g/dL) and hematocrit (36%) were normal. Although urine dip testing showed no protein seven days prior to the CT scan, protein was present in urine (30 mg/dL) on repeat dip testing done the day after CT scanning.\nOpen surgical biopsy of the right kidney was performed. The surgeon did not report any visible scarring on the exposed surface of the kidney. Histopathological examination of the biopsy specimen revealed findings consistent with oligomeganephronia, namely normal parenchymal organization but hypertrophy of glomeruli and tubules (). There were very few globally sclerotic glomeruli, but many tufts contained segmental zones of perihilar sclerosis. These changes were accompanied by streaks of fibrosis, tubular atrophy, and chronic inflammation. There was no evidence of renal dysplasia, medullary nephronophthisismedullary cystic disease complex or polycystic kidney disease. Electron microscopy demonstrated minimal foot process effacement and was negative for glomerular basement membrane changes of hereditary nephritis. Liver biopsy, performed in conjunction with renal biopsy, was normal.\nThe patient’s emesis was attributed to postoperative ileus and narcotic effect. Symptoms resolved as narcotics were weaned. With improvement in nutrition, along with sodium, potassium, and phosphorus restriction, the patient gained ten pounds in five months. Lowdose lisinopril was initiated for mild hypertension and proteinuria. In addition, vitamin D3 therapy was begun. With time, serum creatinine increased (), and the patient became progressively fatigued. Prior to renal transplantation for renal failure at age 20 years, serum creatinine was 5.4 mg/dL and creatinine clearance was 13.6 mL/min/1.73 m2 (calculated for an adult using the IDMS-traceable modification of diet in renal disease study equation). Urine protein:creatinine ratio peaked at 1.9 (reference range: <0.2).\nUltrasound of the native kidneys () was first performed after renal transplantation and showed small, echogenic kidneys with poor corticomedullary differentiation, in keeping with presence of chronic renal parenchymal disease. The sonographic appearance had no specific features to indicate etiology of the renal disease. No renal cysts or calcifications were seen.

[[16.0, 'year']]

M

{'8922124': 1, '4024943': 1, '1233441': 1, '3588043': 1, '14494740': 1, '3895872': 1, '6289457': 1, '1892691': 1, '8108293': 1, '860352': 1, '2658558': 1, '7501851': 1, '3787876': 1, '554364': 1, '16908915': 1, '32520748': 1, '24765519': 2}

{}

3981272-1

noncomm/PMC003xxxxxx/PMC3981272.xml

Adenocarcinoma of an Ileostomy in a Case of Hirschprung’s Disease with Retroviral Disease

A 55-year old male patient of Indian origin presented to the Emergency Department with complaints of decreased stoma output, abdominal pain, distension and vomiting for two days. He had a history of Hirschprung’s disease for which he underwent a pull-through procedure at Day 10 of life along with a temporary transverse colostomy. Efforts to close the transverse colostomy at ten years of age failed as the patient developed bowel obstruction and a second temporary loop colostomy was performed. At 25 years of age, the patient underwent right hemicolectomy with an end ileostomy as second surgery since closure of loop colostomy was not possible because of the patient’s case hisotry. No medical records of previous surgical interventions were available.\nThe patient was positive for retroviral infection and had been on retroviral therapy for the past seven years. His CD4 count was 490. Abdominal x-ray was suggestive of small bowel obstruction with multiple air fluid levels which was managed conservatively. Digital rectal examination showed a stricture in the rectum. On abdominal examination, there was a proliferative growth involving the mucocutaneous junction of the ileostomy site (). However, no regional lymphadenopathy was seen on clinical examination. The sprout of the ileostomy site was thickened. Biopsy from the lesion was suggestive of adenocarcinoma. Computed tomography of the abdomen did not reveal metastasis to pelvic lymph nodes (). Levels of the tumor markers carcinoembryonic antigen (CEA) and alpha feto protein were normal. The patient underwent en bloc wide local excision of the ileostomy along with the adjacent anterior abdominal wall with a 3 cm margin () and re-siting of the ileostomy. On pathological examination, grossly the tumor measured 3x2.5x2 cm and on microscopic examination moderately differentiated adenocarcinoma was seen (). Margins were tumor free. The patient did not receive any adjuvant therapy and is asymptomatic after one year of follow up.

[[55.0, 'year']]

M

{'6210427': 1, '8537059': 1, '12794579': 1, '9136826': 1, '23059133': 1, '18306002': 1, '12682552': 1, '10813131': 1, '23792479': 1, '5763672': 1, '8712299': 1, '12151696': 1, '15075655': 1, '5654566': 1, '3371615': 1, '10204509': 1, '9593235': 1, '11224623': 1, '4863723': 1, '24765515': 2}

{}

3981274-1

noncomm/PMC003xxxxxx/PMC3981274.xml

Acinar Cell Carcinoma: A Rare Pancreatic Malignancy

A 35-year old male patient presented in out patient department, with complaints of diarrhea for last 2 years and pain upper abdomen for last 15 days. There were no other associated symptoms, co-morbidities and he was nonalcoholic and non-smoker. General physical examination revealed no abnormality, and on abdomen examination there was a firm, nontender, 8×8 cm retroperitoneal lump, with well-defined margins, in epigastrc region and also occupying part of left hypochondrial and umbilical region, with no organomegaly and no free fluid. Hematological, biochemical investigations and routine stool examination and Xray chest were normal. Ultrasonography of the abdomen showed a large 7.7×6.4×8.4 cm size heterogeneously hypoechoic mass, involving the body of pancreas, while the head of the pancreas, liver, spleen and other organs were normal. Contrast enhanced computed tomography showed a large, heterogeneously enhancing, well defined intrapancreatic lesion, of size 12×7.5 cm in body and tail region, with few small non-enhancing areas, indentation on posterior wall stomach, and loss of intervening fat plane (). There were no evidence of ascites, liver and peritoneal metastasis, and peripancreatic and retroperitoneal lymphadenopathy. Oesopha - gogastroduodenoscopy showed the presence of extrinsic impression on the posterior wall of gastric body. Colonoscopy and tumor marker CA 19-9 were normal. In view of a large mass involving the body of the pancreas and no evidence of metastasis, after adequate preoperative preparation, patient was taken up for surgery. Intra-operatively, there was a large mass of size 12×8 cm arising from the body and part of tail of pancreas, abutting splenic vessels and transverse mesocolon while pancreatic head was normal. The mass was free from stomach, transverse colon, duodenum and spleen (), and there were no palpable lymph nodes, liver and peritoneal metastasis and ascites. Distal pancreatectomy with splenectomy was done while the head of the pancreas was preserved. On histopathological examination, grossly, well circumscribed grey brown soft tissue mass measuring 12×8×8 cm, with multinodular external surface, and cut section was variegated with layers of hemorrhage and necrosis, and on microscopy, there was partly encapsulated tumor composed of cells arranged mainly in diffuse sheets, trabecular and focally in acinar pattern, at places tumor sheets are separated by thick fibrous septa and cells shows mild pleomorphism, round in shape, with indistinct cell membranes, moderate amount of granular eosinophilic cytoplasm, round to oval hyperchromatic nuclei (). Periodic acid-Schiff (PAS) staining with diastase showed granular cytoplasmic positivity (), and immunohistochemistry demonstrated acinar enzymes, trypsin and chymotrypsin. This histopathological picture was suggestive of acinar cell carcinoma of the pancreas. Post-operative period was uneventful and the patient received 6 cycles of chemotherapy (FOLFOX regimen) and got discharged on post-operative day 18.

[[35.0, 'year']]

M

{'34425650': 1, '28588779': 1, '1384374': 1, '16033080': 1, '12488412': 1, '11891193': 1, '8362971': 1, '31737144': 1, '26628966': 1, '24765506': 2}

{}

3981275-1

noncomm/PMC003xxxxxx/PMC3981275.xml

Alveolar Soft Part Sarcoma: Unusual Etiology of Mediastinal Mass in an Adolescent

A previously healthy 13-year-old girl presented with a five-day history of headache that was unresponsive to non-steroidal anti-inflammatory drugs. Other than a new mediastinal bruit, her physical examination was unremarkable. Chest radiograph revealed a large left mediastinal mass.\nOn contrast computed tomography (CT) (), the 9.6x8.6x8.6 cm anterior mediastinal mass appeared hypervascular, with large vessels, dense peripheral enhancement, and central non-enhancement, consistent with necrosis. No fat or calcifications were seen in the mass, and no vascular invasion, osseous destruction, or adenopathy was evident. Numerous well-defined pulmonary nodules suggested metastatic disease.\nContrast-enhanced head CT also revealed an avidly and homogeneously enhancing left parietal mass, measuring 3.3x3.0x 3.7 cm, with large feeding arteries from the left middle cerebral artery. Circumferential vasogenic edema and mass effect on the left lateral ventricle were present. Brain magnetic resonance imaging (MRI) showed the well-circumscribed left parietal mass to be minimally T1 hyperintense, T2 hyperintense, and homogeneously enhancing, without necrosis, hemorrhage, or diffusion restriction. Large vessels were present both in the mass and radiating from its lateral margin. On MRI perfusion imaging, the mass was hypervascular with increased peripheral blood volume and blood flow. Single voxel MR spectroscopy revealed a highly elevated choline-to-creatine ratio, no lactate peak, and an undetectable N-acetyl aspartate peak, consistent with a non-neuronal, nonnecrotic neoplasm with high cell turnover.\nThe patient underwent wedge biopsies of middle and lower lobe pulmonary nodules. Histopathology was diagnostic of ASPS (), with a pseudoalveolar architectural pattern, Periodic acid-Schiff (PAS) positivity, and uniformly positive anti-transcription factor E3 (TFE3) immunohistochemical staining. Due to presence of metastases and the projected difficulty of complete resection, the mediastinal mass was not excised. However, palliative left parietal metastasectomy was performed, again showing histopathology consistent with ASPS.\nThe patient was referred to the National Cancer Institute for a phase 2 trial of Cediranib. During pre-study evaluation, right thigh MRI revealed an additional 6.7x4.5x2.8 cm soft tissue mass with T1 and T2 hyperintensity, internal flow voids, large peri-tumoral vessels, and avid enhancement (). It was centered in the vastus intermedius muscle, abutting right femur. Normal signal intensity was maintained in the right femur, and no right femoral abnormality was seen on technetium-99m bone scan. Bone scan did reveal abnormal radionuclide uptake in right ischium and proximal right tibial metaphysis, potentially representing bone metastases.\nTen months after presentation, the patient has progressive disease. Due to increasing pain, she has undergone palliative resection of her mediastinal and right lower extremity masses. In addition, a new right frontal lobe brain metastasis has been excised, and two smaller brain metastases have been treated with stereotactic radiosurgery.

[[13.0, 'year']]

F

{'26358060': 1, '29113207': 1, '11271548': 1, '9416489': 1, '32000418': 2, '22173238': 1, '21105138': 1, '9306602': 1, '11943706': 1, '10342010': 1, '3790364': 1, '24765514': 2}

{'7004695-1': 1}

3981990-1

noncomm/PMC003xxxxxx/PMC3981990.xml

Novel treatment of coronary artery fistulae concealing severe coronary artery lesion: using thrombus aspiration catheter as a delivery guide

A 83 years old man with diagnosis of unstable angina pectoris who underwent coronary angiography in a different hospital was refered to us for occlusion of CFA originating from left anterior descending (LAD) and empting to the pulmonary artery. He had huge CAF () and subtotal stenosis of mid right coronary artery (RCA) lesion ().\nDecision of closure of fistulae with amplatzer vascular plug 4 and stenting of right coronary artery mid lesion was taken. At first, we aimed to treat mid RCA lesion. During the engagement of RCA ostium, another fistulae was detected (). It was originating from right sinus valsavla and most likely communicating to pulmonary artery. Then, we engaged left coronary artery ostium with 7F Judkings guiding catheter. Sequential and simultaneous contrast injection demonstrated that both of fistulae were openning to the pulmonary artery at the same place (). We decided to occlude left sided CAF at first. Vigorous attempts were done to proceed multi-purpose and right Judkings catheter through fistulae. But we could not succeed. Then, we decided to use thrombus aspiration catheter (TAC) as a delivery guide. After wiring the fistula with the 0.014-inch guidewire, TAC was advanced over the guidewire. After the optimal position of aspiration catheter was obtained (), amplatzer vascular plug (AVP) was loaded into the aspiration cathater and advanced carefully. After the optimal device position was assured, vascular plug was released and control image demonstrated completely closure of fistulae and significant LAD stenosis just distal to the origin of fistulae that was not seen in previous coronary angiography (, ). We gave nitroglycerine in order to be sure that this image was not due to the spasm. There was no effect of nitroglyserine and lesion was stented with 3.5 mm × 15 mm bare metal stent and postdilated with 4 mm × 12 mm noncompliant balloon. Final image was satisfactory. Because of high dose use of contrast media (about 300 mL) and patient renal function (creatine was 1.6), the other CAF was untreated.\nAfter a month later, patient was taken to the catheter laboratory for occlusion of second coronary to pulmonary artery fistulae. Control image demonstrated patent LAD stent and occluded fistulae (). Vascular plug 2 was loaded in guiding catheter and was advanced as further as possible. After confirming the correct positon of device (), it was released. Control image demonstrated totally occlusion of fistulae ().

[[83.0, 'year']]

M

{'19743489': 1, '2050921': 1, '7753702': 1, '16909054': 1, '2248189': 1, '2283196': 1, '22560322': 1, '11330735': 1, '12220072': 1, '2009563': 1, '1607526': 1, '21777892': 1, '24748888': 2}

{}

3982239-1

noncomm/PMC003xxxxxx/PMC3982239.xml

Effect of Rivaroxaban on Fibrinolytic Therapy in Massive Pulmonary Embolism: Two Cases

A 61-year-old woman was admitted to our hospital with a 4-day history of repeated syncope. She had felt dyspnea on exertion even in daily life since the last 2 weeks. The loss of consciousness was accompanied by syncope but abnormal neurologic sign was not shown. She was never a smoker and had been on hormone replacement therapy for abnormal uterine bleeding since the last 3 months. On admission, blood pressure was 104/70 mm Hg, heart rate was 94 beat/min, respiratory rate was 20 breath/min, and body temperature was 36.8℃. All of a sudden, her blood pressure decreased to 80/40 mm Hg for over 15 minutes on the same day. The physical examination was grossly normal. Arterial blood gas analysis (aBGA) on room air was 7.442 in pH, 27.7 mm Hg in PaCO2, 51 mm Hg in PaO2, 18 mmol/L in HCO3-, and 87% in O2 saturation. Echocardiography showed right ventricular (RV) hypokinesia with a D-shaped left ventricle (LV) and pulmonary hypertension. Computed tomographic (CT) pulmonary angiogram with lower extremity CT venogram showed extensive bilateral acute PE with deep vein thrombosis (DVT) in the right lower extremity and enlarged right cardiac chambers (). The brain CT was normal. D-dimer, N terminal-pro-brain natriuretic peptide (NT-pro-BNP), and high sensitive troponin-T was 2,923 ng/mL (range, 0-243 ng/mL), 316 pg/mL (range, 0-97.3 ng/mL), and 0.029 ng/mL (range, 0-0.015 ng/mL), respectively.\nAccording to the known protocol for massive PE, a high dose of unfractionated heparin (UFH) with 10,000 U was intravenously injected once. The maintaining dose of UFH was continuously infused at the rate of at least 1,250 U/hr until the activated partial thromboplastin time (aPTT) reached 80 seconds. Then, recombinant tissue plasminogen activator (rt-PA) of 100 mg was administered via a peripheral vein for 2 hours while a high dose of UFH was withheld. The aPTT was checked every 4 hours until aPTT reached below 80 seconds. Rivaroxaban with 15 mg twice daily was administered instantly without resumption of the high dose UFH after aPTT reached below 80 seconds. Her hospital stay was 4 days. The dose of rivaroxaban was changed from 30 mg/day to 20 mg/day after 3 weeks. Two months passed and she denied dyspnea on exertion even during hard work and any bleeding complications.

[[61.0, 'year']]

F

{'20926501': 1, '22449293': 1, '21422387': 1, '22315268': 1, '21128814': 1, '24734100': 2}

{'3982239-2': 2}

3982239-2

noncomm/PMC003xxxxxx/PMC3982239.xml

Effect of Rivaroxaban on Fibrinolytic Therapy in Massive Pulmonary Embolism: Two Cases

A 73-year-old woman was admitted to our hospital with a 1-month history of dyspnea and poor oral intake. She had felt mild dyspnea on exertion without progression since last year. The aggravation of dyspnea on exertion started 1 month ago. She had a disability in walking because an event of cerebral hemorrhage occurred 2 years ago and an event of cerebral infarction occurred 1 year ago. She was never a smoker and was on medication due to hypertension for 2 years. On admission, blood pressure was 100/60 mm Hg, heart rate was 81 beat/min, respiratory rate was 18 breath/min, body temperature was 36.4℃. Her blood pressure decreased to 80/50 mm Hg and lasted over 1 hour on the next day. aBGA on room air was 7.505 in pH, 23.1 mm Hg in PaCO2, 64.6 mm Hg in PaO2, 17.8 mmol/L in HCO3-, and 94.8% in O2 saturation. Echocardiography showed RV hypokinesia with a D-shaped LV and pulmonary hypertension. A CT pulmonary angiogram with a lower extremity CT venogram showed massive bilateral PE with lung infarction and DVT in the right superficial femoral vein extending to the popliteal vein (). A brain CT showed an old infarction sequelae in the right frontal lobe, basal ganglia and cerebellum. D-dimer, NT-pro-BNP, and high sensitive troponin-T were 1,190 ng/mL (range, 0-243 ng/mL), 17,481 pg/mL (range, 0-97.3 ng/mL), and 0.036 ng/mL (range, 0-0.015 ng/mL), respectively. Since previous intracranial hemorrhage is one of the major contraindications to the use of fibrinolytic therapy, high dose UFH alone was administered instead of a fibrinolytic agent. On the day following the high dose UFH injection, dyspnea was much improved in spite of no change in hemodynamic parameters. High dose UFH was replaced with rivaroxaban 15 mg twice daily. After 3 days of medication with rivaroxaban alone, the dyspnea was worsened and repeated aBGA on oxygen 6 L/min with an oxygen mask with a reservoir bag was 7.455 in pH, 19.3 mm Hg in PaCO2, 54.3 mm Hg in PaO2, 13.3 mmol/L in HCO3-, and 90.7% in O2 saturation. A high dose of UFH was administered again after the rivaroxaban was stopped for 4 days. Dyspnea was slightly improved without a change in the thrombus burden on follow-up CT scan and hemodynamic parameters (). We assumed that reversal of the RV failure outweighed the increased bleeding following fibrinolytic therapy. On the next day, rt-PA with 100 mg was administered via a peripheral vein for 2 hours while a high dose of UFH was withheld. Dyspnea was much improved without major bleeding complications and hemodynamic parameters showed marked improvement (). She has been taking warfarin after fibrinolytic therapy and denied dyspnea on exertion.

[[73.0, 'year']]

F

{'20926501': 1, '22449293': 1, '21422387': 1, '22315268': 1, '21128814': 1, '24734100': 2}

{'3982239-1': 2}

3982240-1

noncomm/PMC003xxxxxx/PMC3982240.xml

Endometrial Stromal Sarcoma Presented as an Incidental Lung Mass with Multiple Pulmonary Nodules

A 42-year-old woman was referred to Korea University Ansan Hospital for evaluation of suspicious lung mass with multiple pulmonary nodules. The lung lesions were incidentally found in a simple chest roentgenography during a routine medical inspection performed a month ago. She had a history of myomectomy seven years ago in local clinic in China, and the pathologic result was known to be as a benign uterine tumor, leiomyoma.\nAt admission, she was asymptomatic and physical examination showed unremarkable findings. A chest X-ray revealed a right perihilar lung mass with tiny peripheral nodules on right middle lung field. Chest CT scan showed a 4.5-cm sized well demarcated right perihilar mass with various sized multiple peripheral nodules on both lungs (). Her complete blood cell counts showed hemoglobin level of 14.0 g/dL, total leukocyte count of 7.50×109/L with 50.4% neutrophils and platelet count of 290×109/L. Blood biochemical results including blood urea nitrogen, creatinine, and liver function tests were unremarkable. Carcinoembryonic antigen, squamous cell carcinoma antigen, alpha-fetoprotein and beta human chorionic gonadotrophin also revealed values within normal range.\nInitially, she was suspected of primary lung malignancy with lung to lung metastasis, but radiologic findings of the mass and nodules were well demarcated without remarkable lymph node enlargement in mediastinum and hilum. These features also suggested a possibility of metastatic lung tumor from extrathoracic origin. Thereby, locoregional and systemic evaluations were undertaken to discover potential extrathoracic metastatic lesions and concealed primary malignant origin. Because she had a history of surgical resection on leiomyoma, systemic evaluations to search possible primary origin included a gynecologic inspection on the preferential basis. Through pelvic examination by the gynecologist, firm, non-tender, smooth intrapelvic mass was palpated over the symphysis pubis, and transvaginal ultrasonography revealed a mixed echogenic mass sizing approximately 16-week pregnant uterus. Further radiologic evaluations were undergone to characterize detailed structural features of the intrapelvic mass.\nAbdomen-pelvis CT scan discovered a 6.9×5.8-cm sized pelvic mass, and the mass showed a heterogeneous enhancement pattern with possible attachment to the adjacent intrapelvic structures. Magnetic resonance imaging was conducted for further delineation and characterization of the intrapelvic mass, and the lesion showed moderate enhancement in T1 weighted image with internal fibrovascular septum (). The mass was partially abutting to the uterine fundus in a possible outgrowing fashion. Initial radiologic impression of the intrapelvic mass was neoplasm from uterine origin including subserosal myoma or fibrous tumor such as malignant fibrous histocytoma. In positron emission tomography-CT scan, neither pulmonary lesions nor pelvic mass expressed hypermetabolisms typical of malignancy (). Maximum standardized uptake values of the intrapelvic mass and the right perihilar mass were 1.32 and 1.02, respectively. This finding was generally discordant with the initial impressions suggesting either primary pulmonary or metastatic malignancy. Furthermore, this feature potentially implied that both lung and pelvic mass were mutually sharing identical characteristics. Therefore, pathologic evaluation on both lung and pelvic mass was planned to confirm the diagnosis.\nBronchoscopic examination for the right perihilar mass showed no definite endobronchial lesion. Percutaneous needle biopsy for the right perihilar mass could not be performed because the location of the mass was just beside the right pulmonary artery and its branches. Therefore, surgical biopsy under general anesthesia was decided for the simultaneous pathologic diagnosis of both pelvic and lung mass.\nDiagnostic pelviscopy for intrapelvic mass and thoracoscopic right perihilar mass biopsy with wedge resection for right peripheral nodules were conducted. Intraoperative frozen biopsies showed small round malignant cells from pelvic and lung specimens, which was not compatible for typical non-small cell lung cancer. Intraoperative gross finding of the pelvic mass exhibited bulging appearance from the anterior side of the uterine fundus, and this suggested higher probability of uterine origin malignancy. Subsequently, diagnostic pelviscopy was converted into total abdominal hysterectomy with both salphingo-oophorectomy.\nHistopathologic examination for specimens from lung mass, uterus, both ovary and salpinx, and omentum showed same features to each other (). Bland looking small oval to spindle shaped cells with scanty cytoplasm and perivascular arrangement were observed on hematolxyline and eosin stain. These cells were infiltrating adjacent normal myometrium and pulmonary parenchymal structures. Immunohistochemical stain of the uterine specimen revealed positivites on estrogen and progesterone receptors, and CD10 (). However, cytokeratin, chromogranin, smooth muscle actin, and p53 were negative. These immunohistochemical features, especially positive to CD10, were identical to the findings of the right perihilar lung mass (). Based on these histopathological and immunohistochemical findings, the diagnosis of low-grade ESS with pulmonary metastasis was confirmed.\nAfter recovery from post-operative period, palliative chemotherapy with paclitaxel, adriamycin and cisplatin was initiated. Abdomen-pelvis CT scan after two cycles of chemotherapy showed no significant evidence of recurrence in the pelvic cavity. From the chest CT scan taken at this point of time, remnant right perihilar mass remained to be unchanged without any sign of disease progression, and there was no newly developed pulmonary nodule suggestive of metastasis.

[[42.0, 'year']]

F

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{'3545911-1': 1, '5729316-1': 1}

3982241-1

noncomm/PMC003xxxxxx/PMC3982241.xml

A Case of Pulmonary Artery Sarcoma Presented as Cavitary Pulmonary Lesions

An 18-year-old man was referred to our institution from a primary clinic for further evaluation and management of cavitary pulmonary lesions. He had no significant medical history and had visited the primary clinic 3 months before he was referred to our institution. He presented with complaints of cough, blood-tinged sputum, and right chest wall pain. The initial chest radiography at the primary clinic showed patchy consolidations in the right upper lobe (), and non-enhanced chest CT was performed. A 5-cm cavitary consolidation and multifocal nodular consolidations were observed in the right lung, mainly in the right upper lobe posterior segment and the right lower lobe (). The patient was treated with medication, including empirical antibiotics, and follow-up non-enhanced chest CT was performed every month for the next 3 months. Despite medical treatment, his symptoms did not improve and the lung parenchymal lesions persisted. Follow-up CT showed changes in the pulmonary lesions, decrease in the size of the main cavitary consolidation and increase in the number and size of adjacent nodular consolidations (). Eventually, the patient was referred to our institution for further diagnosis and treatment.\nWe suspected the possibility of various conditions that can cause cavitary lesions, including bacterial infection, fungal infection, tuberculosis, autoimmune disease, vasculitis, malignancy, and other rare diseases. The findings of laboratory examinations were unremarkable. The patient's leukocyte count was 7,870/µL with a C-reactive protein level of 0.44 mg/dL. We could not detect any microorganisms on the microbiologic studies including sputum culture, acid-fast bacilli stain, interferon-gamma release assay and aspergillous antigen test. The tests of autoantibodies such as antinuclear antibody and antineutrophil cytoplasmic antibody were negative. Further, no endobronchial lesion was observed on bronchoscopy. Percutaneous needle aspiration was performed, targeting the cavitary consolidation of the right upper lobe, but the pathologic results were unremarkable. Pathology examination showed parenchymal necrosis and fibrosis, interstitial lymphocytic infiltration, and type II pneumocyte hyperplasia. We did not detect granuloma, evidence of vasculitis, or any other possible causes of the pulmonary lesions.\nNext, the patient underwent contrast-enhanced chest CT, which showed a filling defect within the lumen of the right interlobar pulmonary artery, raising the possibility of either pulmonary thromboembolism or PAS (). The patient received low molecular weight heparin, considering the possibility of pulmonary thromboembolism. Deep vein thrombosis was not detected on venous duplex examination of the lower extremities. Positron emission tomography (PET)-CT with 18F-fluorodeoxyglucose (FDG) showed increased FDG uptake, with a maximum standardized uptake value of 9.6 along the right interlobar pulmonary artery, suggesting the presence of a malignant lesion ().\nTo confirm the diagnosis, open thoracotomy and excisional biopsy were performed. At surgery, frozen biopsy specimens obtained from the right interlobar pulmonary artery revealed a PAS. Accordingly, the patient underwent subsequent curative right pneumonectomy.\nGrossly, a 1.5×1 cm gray-tan soft tumor was detected in the lumen of the right interlobar pulmonary artery (). The distal pulmonary artery was occluded with thrombus. A gray-tan-yellow infarct, measuring 4×2×2 cm, was observed in the right upper lobe, and multiple, small gray-tan nodules were scattered in the remaining lung.\nHistopathologic examination of the intravascular tumor revealed abundant spindle cells with high cellularity, frequent mitoses, and nuclear pleomorphism (). Immunohistochemical staining was positive for smooth-muscle actin and desmin (). Staining for CD34 and CD56 was negative. Pathologic finding of the distal parenchymal lesions were ischemic necrosis and fibrosis, indicated pulmonary infarct. Also, there were hematogenous spread of occlusive tumor emboli and multiple parenchymal involvements within the right lung.\nThe patient recovered uneventfully and received 3 cycles of adjuvant chemotherapy with ifosfamide and doxorubicin. However, treatment was terminated because of side effects, which included severe gastrointestinal symptoms and neutropenia. There was no evidence of local recurrence or distant metastasis 6 months after surgery.

[[18.0, 'year']]

M

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{}

3982242-1

noncomm/PMC003xxxxxx/PMC3982242.xml

Two Cases of Diagnosis and Removal of Endobronchial Hamartoma by Cryotherapy via Flexible Bronchoscopy

A 49-year-old man was referred to our hospital for bronchoscopic evaluation for obstructive pneumonia on superior segment of right lower lung (RS6) on chest X-ray and chest computed tomography (CT) (). The bronchoscopic examination with autofluorescence bronchoscopy (system: Onco-Life for Improved Cancer Detector; Xillix, Richmond, Canada and bronchoscope: BF-1T40; Olympus, Tokyo, Japan) showed the superior segmental bronchus of right lower lung (RB6) was obstructed by pedunculated mass. The cryotherapy was performed for endobronchial biopsy and tumor cryodebridement. Flexible cryoprobe (length 80 cm, length of probe tip 7 mm, diameter 2.2 mm) with cryomachine (ERBE, Tubingen, Germany) was passed through the working channel of the flexible bronchoscopy (system: ELVIS LUCERA CV-260 and CLV-260; Olympus and bronchoscope: BF-1T260; Olympus) into the tumor. The tip of flexible bronchoscope was positioned 1.0 cm from the tumor. The cryoprobe was kept about 4 mm away from the tip of the bronchoscope. Then, the tip of the cryoprobe that was placed in direct contact with the tumor was cooled to approximately -89℃ with cryogen (nitrous oxide; N2O) for 10 seconds using the foot pedal. After that time, the probe was pulled, the probe with frozen tissue was withdrawn with bronchoscope (pull-out method). The mass was successfully removed with several repeated procedures with small amount of bleeding (). The bleeding was controlled by iced saline. The biopsy result of removed mass was chondroid hamartoma (). Imaging study at 3 months after removal of endobronchial hamartoma showed completely resolution of previous obstructive pneumonia on RS6 (). And bronchoscopic examination after 3 months after removal showed good patency without any obstruction of RB6 ().

[[49.0, 'year']]

M

{'29317836': 1, '15187010': 1, '8538225': 1, '19246874': 1, '25208559': 1, '2011801': 1, '15059020': 1, '20226474': 1, '19947992': 1, '27621844': 1, '12114359': 1, '23328141': 1, '16816349': 1, '8797417': 1, '24734103': 2}

{'3982242-2': 2}

3982242-2

noncomm/PMC003xxxxxx/PMC3982242.xml

Two Cases of Diagnosis and Removal of Endobronchial Hamartoma by Cryotherapy via Flexible Bronchoscopy

A 53-year-old man was referred to our hospital for bronchoscopic evaluation for abnormal density in front of superior segmental bronchus of left lower lung (LB6) on chest CT on personal health examination (). The bronchoscopic examination with autofluorescence bronchoscopy showed LB6 was obstructed by pedunculated mass. The cryotherapy was performed for endobronchial biopsy and tumor cryodebridement with same above described procedures. The mass was successfully removed with small amount of bleeding (). The bleeding was controlled by iced saline. The biopsy result of removed mass was hamartoma (). Chest X-ray at 1 month after resection of endobronchial hamartoma showed normal chest X-ray finding (). And bronchoscopic examination after 1 month after removal showed good patency without any obstruction of LB6 ().

[[53.0, 'year']]

M

{'29317836': 1, '15187010': 1, '8538225': 1, '19246874': 1, '25208559': 1, '2011801': 1, '15059020': 1, '20226474': 1, '19947992': 1, '27621844': 1, '12114359': 1, '23328141': 1, '16816349': 1, '8797417': 1, '24734103': 2}

{'3982242-1': 2}