A 60-year-old male presented to the emergency room complaining of fever and coughing that lasted for 2 days. He was working as a sailor around the southern coast of Korea and due to the uncooperative nature of the patient, obtaining a detailed medical history was difficult. His captain said that he drank alcohol every day and he was the only one of his crew with symptoms.
Neurological examination revealed disorientation with no focal findings. The patient scored a 9 on the Glasgow coma scale. His temperature was 37.5℃, blood pressure was 160/98 mm Hg, pulse rate was 96 beats per min, respiratory rate was 22 breaths per min and oxygen saturation was 95% at room air. Lung auscultation revealed coarse crackles in the right whole lung fields.
Complete blood cell count showed a white blood cell count of 11.97×103/µL (normal, 3.9~11.0×103/µL), a hemoglobin concentration of 12.8 g/dL (normal, 13~18 g/dL), and a platelet count 155×103/µL (normal, 140~440×103/µL). The differential count showed neutrophils at 96.4%, lymphocytes at 2.7%. The C-reactive protein level was 38.5 mg/dL (normal, ≤0.3 mg/dL). His blood urea nitrogen was 51 mg/dL (normal, 8~20 mg/dL), creatinine was 1.31 mg/dL (normal, 0.6~1.2 mg/dL), albumin was 2.6 g/dL (normal, 3.8~5.1 g/dL), alkaline phosphatase was 200 U/L (normal, 3~120 U/L), aspartate aminotransferase was 43 IU/L (normal, 7~38 IU/L) and alanine aminotransferase was 21 IU/L (normal, 4~43 IU/L). In the arterial blood gas analysis, PaO2 was 72.2 mm Hg, PaCO2 was 24.6 mm Hg and oxygen saturation was 95%.
Pleural fluid examination showed pH 7.0, glucose 2 mg/dL, protein 4.0 g/dL, white blood cell 137,000/mm3 (polymorphonuclear leukocyte 95%, lymphocyte 5%).
Both blood and pleural fluid cultures grew S. suis which was identified by using the automated Vitek2 system. Antimicrobial susceptibility testing using disc diffusion method showed that the isolate was sensitive to penicillin, erythromycin, clindamycin, cefepime and vancomycin but resistant to tetracycline ().
The initial chest X-ray showed diffuse hazy opacity on the right upper and lower portion (). Chest computed tomography scan demonstrated moderate consolidation in the right lung with pleural effusion (). Brain computed tomography showed moderate diffuse brain atrophy without meningeal enhancement ().
Empirical antibiotics with piperacillin-tazobactam and ciprofloxacin were administered. Because the patient's irritability was thought to be due to delirum of alcohol withdrawal, spinal tap was not performed. On the 3rd day of admission, blood cultures showed Gram-positive cocci in pairs and chains, which suggested streptococcus species. We used disc diffusion method while not utilizing automated system for antimicobial susceptiblity testing because brush dilution method was not available in our laboratory. The isolate was sensitive to penicillin, erythromycin and vancomycin. Empyema was drained through a percutaneous catheter. On hospital day 4, he had a grand mal seizure which was treated by anti-epileptic drugs. On hospital day 7, the isolated organism was identified as S. suis. Pleural fluid also grew the same organisms. A week later, the patient showed improvement with his fever and pneumonia. However, his mental status did not improve, the patient's Glasgow coma score was only was only 4 to 5 and electroencephalographic findings showed moderate cerebral dysfunction. Brain magnetic resonance imaging scans was similar with initial brain computed tomographic findings showing diffuse brain atrophy but many white blood cells were seen in cerebrospinal fluid from the patient. Cereobrospinal fluid (CSF) culture grew no organism. Those results suggested that he had meningitis and explained the reason why he did not regained consciousness. On hospital day 12, the patient acquired nosocomial pneumonia which required intubation and mechanical ventilation. On hospital day 14, multi-drug resistant Acinetobacter baumannii grew in the sputum of the patient and we switched antibiotics to intravenous colistin. On hospital day 30, pneumonia was improved so much () and the weaning from mechanical ventilation was done successfully. He was discharged without regaining consciousness.


A 59 year-old man without any history of cardiovascular disease was admitted to emergency service with the complaint of chest and back pain. ECG revealed sinus rhythm with a rate of 70/min, 2-3 mm ST elevations in V2 and V6 []. His blood pressure was 110/70 mmHg. He was on antihypertensive medication and smokes 20 cigarettes per day for more than 20 years. He was immediately taken into the cardiac catheterization laboratory with the diagnosis of acute anterior myocardial infarction. Coronary angiography demonstrated patent coronary arteries without significant stenosis. Ventriculography demonstrated systolic apical ballooning which is typical for TC []. Transthoracic echocardiography demonstrated apical akinesia with a dynamic LV outflow tract obstruction (peak resting gradient: 45 mmHg, peak gradient reaches to 177 mmHg and mean gradient to 81 mmHg with valsalva maneuver) []. ST elevations returned towards baseline and his complaints were improved progressively with medical treatment, which included antiplatelet agents and anticoagulation, beta adrenergic receptor blocker and renin-angiotensin system blocker agents. Troponin T level peaked at 0.71 ng/ml.
Patient had a cachectic appearance and had complaints of backache and dysphagia with weight loss of 25 kg during the last 12 months. Endoscopic examination revealed esophageal obstruction due to external compression. Computed tomography scan of the chest revealed a mass with 5 x 2.5 cm diameter at the level of right pulmonary upper lobe on the posterior segment, extending from retrotracheal to paravertebral space with bone invasion. There were also multiple mediastinal lymphadenopathies. Fine needle aspiration biopsy obtained from mass showed neoplastic cells and immunohistochemical analysis demonstrated that these cells were reactive with CK7, CK20, and TTF-1 antibodies. He was diagnosed with lung adenocarcinoma and whole body positron emission tomography (PET) demonstrated hypermetabolic subcarinal and paraosephageal lymphadenopathies and lytic/sclerotic lesions on thoracic vertebral bodies (T 3-4-5) and right sided ribs (from 4th to 9th), which were accepted as metastases.
Repeat transthoracic echocardiogram performed 10 days after admission revealed complete resolution of LV systolic dysfunction and disappearance of LV outflow gradient [].


A 15-year-old girl presented with 7 months history of intermittent occipital headaches that increased on walking, standing and was relieved by rest. There was no postural variation. She also gave a history of sustaining a road traffic accident 6 months prior to presentation after which she was apparently alright and from which she recovered uneventfully. She did not sustain any injury to the occipital region at that time. On examination, she had a small sinus in the region of the occipital protuberance with no active discharge or swelling underneath. Neurological examination was within normal limits and she did not have any cerebellar signs. MRI brain (Magnetic resonance imaging) [] showed a well defined lesion in the region of the vermis-hypointense on T1W, hyperintense on T2W with a patchy contrast enhancement and causing compression on the vermis. Fourth ventricle was normal in shape. There was no obstructive hydrocephalus. A thin tract was seen to extend from the skin surface, coursing downwards and entering the bone just to the left of midline at the level of the torqula. A provisional diagnosis of dermoid cyst with a sinus tract was made. Other possibilities like epidermoid or dermal sinus with an assosciated abscess were also considered. She underwent midline suboccipital craniectomy and excision of the cyst. The tract was followed. It was seen to be entering the dura just below the torqula and entering into the lesion beneath. It was excised. The external surface of the lesion had a smooth, pearly appearance with small lobulations. The cyst contained cheesy, pultaceous material. Grossly, no hair follicles or other ectodermal structures were encountered. The plane between the cyst and the surrounding structures was relatively good and total resection of the cyst with the sinus tract could be achieved. Post-operatively she recovered well without any fresh deficits, seizures or aseptic meningitis. Post-operative CT scan (computed tomography) showed no residual lesion []. Histopathological examination of the excised cyst wall revealed a thin fibro collagenous wall with overlying stratified squamous epithelium and focal areas of bone, dystrophic calcification, cholesterol clefts and foreign body giant cells. The cyst lumen showed keratin flakes and hair shafts, suggestive of a dermoidcyst [].


The first case was a 22-year-old female who presented with yellow plaques on the lips that had appeared 4 years prior to the current visit (). She had tried to manage her lip problem with topical corticosteroids but there was no improvement. We found that the patient habitually stimulated her lips with her teeth, and sucked her lips. There were no associated medical or dental problems. We performed KOH examinations, which were also negative. The biopsy specimen revealed that the epidermis had a focal hyperkeratosis with basophilic debris on the surface (). The gram stain showed many gram-positive cocci at the surface (). The periodic acid-Schiff (PAS) stain were negative for fungal infection (). Since the patient could not stimulate her lips any more because of pain at the biopsy site, the plaque lesions almost disappeared. The patient then recognized that her habitual behavior caused the lesion, and tried to refrain from lip stimulation. The lesions completely disappeared and there were no episodes of recurrence at one month of follow-up ().


The second case was a 21-year-old male patient who presented with yellowish plaques on the lips that had appeared 7 years earlier (). The patient had been treated with topical steroids with no response. The patient recognized that he chewed and sucked his lips habitually. The patient did not have any associated diseases or episodes of trauma. We performed KOH examinations, which were also negative. The biopsy specimen showed a marked acanthosis of the mucosal epithelium with surface exfoliation. In some areas, swollen epithelium was also seen (). On the gram stain, bacterial colonies were not seen (). The PAS stain was negative for fungal infection (). After the skin biopsy, we advised the patient to refrain from habitual licking, and the lesions nearly disappeared after three months ().


The third case was a 17-year-old healthy male who presented with a whitish surfaced plaque on the lower lip that had appeared 3 months earlier (). KOH examinations were negative. The patient recognized that he habitually stimulated his lower lip with his teeth. The biopsy specimen showed marked acanthosis of the mucosal epithelium, and an underlying retention cyst was found in the interstitium (). A gram stain was negative (). The PAS stain was negative for fungal infection (). We diagnosed this lesion as a 'morsicatio labiorum' with underlying mucocele. We removed the cystic lesion and advised the patient to cease his habitual licking. One month later, the lesion had almost completely disappeared ().


In October 2006, a 51-year-old female without remarkable medical, social, or family history was admitted for cough. On the chest posteroanterior (PA) radiograph, a 7.2 cm sized mass was identified in the left upper lobe (LUL). It was diagnosed as an adenocarcinoma by bronchoscopic biopsy (positive immunohistochemical staining for cytokeratin [CK]-20 and negative for CK-7 and p63). The disease stage was IV (T4N3M1) ().
Six cycles of docetaxel (75 mg/m2) and cisplatin (75 mg/m2) combination therapy was administered as a first-line chemotherapy. Erlotinib, an epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) was administered for 2 months as second-line therapy. Because of disease progression, subsequent treatment with pemetrexed (500 mg/m2) was initiated as third-line therapy from September 2007 at 3-week intervals. Positron emission tomography (PET)-computed tomography (CT) performed after nine cycles did not detect any metabolic evidence of cancer, and this was considered to indicate CR. Sixteen cycles of pemetrexed were administered as maintenance therapy. Chest CT and PET-CT, performed in September 2008, revealed a CR state (T0N0M0) (). Although increased glucose metabolism was not detected, abnormal findings were observed in the brain area. Brain magnetic resonance imaging (MRI) indicated a Schwanoma, which was removed using a gamma knife. After the operation, the patient complained of generalized weakness and stopped chemotherapy. Follow-up was performed regularly.
A recurred lung mass at the primary mass site was confirmed on a chest CT performed in June 2009, which was 15 months after CR and 9 months after therapy termination (). New lung and bone metastases appeared on PET-CT in September 2009 (). In October 2009, pemetrexed at the same dose was administered every 3-weeks. After four cycles in January 2010, no fluoro-2-deoxy-d-glucose uptake on PET-CT was observed (). This was deemed the second remission, and pemetrexed treatment has been subsequently maintained. The CR state was maintained on chest CT in July 2011.


In September 2005, a 58-year-old female with a tuberculosis history, and without a history of drinking, smoking, or special findings in the family history, was admitted for cough. A mass in the LUL was detected on a chest PA radiograph (). The mass was diagnosed as an adenocarcinoma by wedge lung resection (positive immunohistochemical staining for thyroid transcription factor-1 (TTF-1) and CK-7 and negative for CK-20, CK-5/6, and calretinin (). The disease stage was IIIB (T4N2M0) (). No brain or bone metastases were detected on brain MRI or a whole body bone scan. Gemcitabine (1,000 mg/m2) and cisplatin (75 mg/m2) combination therapy was administered at 3-week intervals as first-line chemotherapy. However, progression was detected on a chest CT performed after three cycles. Subsequently, treatment with daily 150 mg erlotinib as second-line therapy was initiated in December 2005. A partial response (PR) continued on every follow-up chest CT scan. The lesions had almost disappeared on a chest CT performed after 5 months (). A PET-CT performed after 13 months did not detect any metabolic evidence of cancer and this was considered to indicate CR (). Erlotinib was administered for 38 months as maintenance therapy. The patient complained of severe anorexia and nausea, and she wanted to stop the erlotinib treatment. Follow-up was performed regularly.
A chest CT and PET-CT were performed in July 2009, and a recurred lung mass at the primary mass site was confirmed (), which was 38 months after CR and 5 months after therapy termination. The mass was diagnosed as an adenocarcinoma by percutaneous needle lung biopsy (positive immunohistochemical staining for TTF-1 and CK-7 and negative for CK-20, CK-5/6, and calretinin). After confirming disease progression in August 2009, erlotinib was administered at the initial dose. The lesions had almost disappeared on the chest CT and the PET-CT after 2 months (). This was deemed the second remission, and erlotinib treatment has been subsequently maintained. A chest CT in July 2011 indicated that the CR state was maintained ().


A 20-year-old housewife presented with secondary amenorrhea for 2 years in July 2001. She had a history of headache for 1.5 years. There was no history of galactorrhea. She consulted neurosurgery department in this hospital, where she was found to have prolactin level of 150 ng/ml (normal 5–25 ng/ml, CLIA). Her magnetic resonance imaging (MRI) brain showed a microadenoma of about 4 mm in the left half of the pituitary gland. She was started on bromocriptine 2.5 mg daily, which was stepped up to 7.5 mg subsequently. At 3 months of treatment, she had two menstrual cycles and her prolactin was 25 ng/ml. Then, she did not follow-up for 1 year, but she continued the drug. She followed up after 1 year, when she had missed a period. Her urine pregnancy test was positive and she was advised to stop bromocriptine. She was asymptomatic during her pregnancy. She delivered a full-term baby on 18/06/03. She followed up after 3 months of delivery. She was breastfeeding the baby and was asymptomatic.
Repeat MRI in April 2004 showed microadenoma of size 4 mm, which was the same as previous scan. In February 2004, after 2 months of stopping breastfeeding, her prolactin was >150 ng/ml. She was restarted on bromocriptine 7.5 mg daily in divided doses. After that, she had regular menstrual cycles for 2 years. MRI (11/08/05) showed a microadenoma of size 2 × 3 mm. She had spontaneous abortion in February 2006. After that, her menstrual cycles were normal for the next 4 months. She stopped bromocriptine on her own in June 2006 and presented in September with headache, blurring of vision and amenorrhea of 3 months duration. Urine pregnancy test was positive. MRI showed pituitary macroadenoma of 1.2 × 1.6 × 1.1 cm in the sellar region with suprasellar extension abutting of left side of optic chiasma []. The patient was admitted in the hospital where she was started on low dose of bromocriptine and the dose was slowly increased to 7.5 mg/day. She tolerated the drug well and her headache and visuals symptoms subsided. Her thyroid function tests and serum cortisol were normal. She was monitored with visual field charting two monthly, which were normal. Repeat MRI after 6 weeks showed tumor of same size. The patient delivered in March 2007 uneventfully. Baby was normal. Bromocriptine was stopped and she was advised to breastfeed the baby under close monitoring of visual field and symptoms. She was asymptomatic during this period. MRI was repeated after 3 months of delivery, which showed almost complete disappearance of the tumor [Figures –].


A 46-year-old, 72 kg, man was scheduled for elective right knee replacement for post traumatic osteoarthritis. The patient was a known hypertensive, well controlled on oral amlodipine 5 mg OD. He was a non-smoker with no family history of CAD. The effort tolerance was mildly restricted since last 2 years due pain associated with osteoarthritis for which patient was on occasional non-steroidal anti-inflammatory drugs. There was no history of angina, palpitation, or diaphoresis on effort. There was no significant past medical or surgical history. Pre-operative hemoglobin level was 12.3 mg/dl and the biochemical profile, including lipid profile, was normal. Chest X-ray and electrocardiogram (ECG) showed no abnormality. Being an orthopedic surgery, intermediate risk was explained to the patient and a written/informed consent was taken. The patient was advised to remain nil per oral from midnight and 2 units of packed red blood cells were arranged.
On shifting to the operating room, standard monitoring was connected which showed an ECG with normal sinus rhythm with heart rate 74/min, blood pressure 116/70 mm/Hg, and oxygen saturation 100% on room air. A 16G intravenous (IV) line was secured.
A combined spinal-epidural (CSE) block was given in right lateral position with 12.5 mg of 0.5% hyperbaric bupivacaine along with 25 mcg fentanyl was given intrathecally through the L3-L4 interspace on the first attempt after confirming the backflow of cerebro-spinal fluid from the spinal needle. Epidural space was obtained at 5.5 cm depth and an 18G catheter was threaded into the space and fixed with the 10 cm on the skin entry point. The patient was turned to the supine position and the sensory level of block was found to have reached around T5 after 10 minutes.
After 15 minutes, the ECG monitor on “monitoring mode” started to show down-sloping ST depression. The monitor was shifted to diagnostic mode and it recognized a ST depression of 2 mm, which in next 5 minute progressed to 3.4 mm but was limited to lead II only. The automatic ST analysis on the diagnostic monitor showed a value of +0.2 and +1.2 in lead V5 and aVL respectively and the blood pressure was 106/62 mm/Hg with heart rate 117/min []. The patient was asked for any chest pain or heaviness, which the patient denied. Since the ECG pattern was indicative of inferior cardiac wall ischemia and there was increasing tachycardia, we decided to use a vasopressor besides augmenting the ongoing intravenous fluid. We used phenylephrine, rather than ephedrine or mephentermine, to avoid more tachycardia. 75 mcg bolus of phenylephrine was given IV. The ECG pattern changed to normal with heart rate dropping to 100/min and blood pressure picking up to 127/74 in next 5 minutes []. The diagnosis of myocardial ischemia remained uncertain as the lowest blood pressure recording was 106/62 mm/Hg, the patient had no history of CAD and had no clinical symptoms.
After 10 minutes, the ST depression, with similar lead involvement, began to reappear. A ST depression of 3.2 mm in lead II with a reciprocal ST elevation in aVL of +1.1 mm was seen []. The blood pressure dropped to 101/59 mm/ Hg with a heart rate 110/min. The patient had received 1l of crystalloid and 500 ml of colloid. Another phenylephrine bolus of 75 mcg was given IV and the rhythm again returned to normal in 5 minutes.
A similar episode reoccurred over next 20 minutes and a phenylephrine infusion was started @ 50 mcg/min. The ST segment values returned to normal for all leads with heart rate returning back to 84/min []. The surgeon was asked to withhold the surgery after 2nd episode as blood loss could precipitate MI. The surgery was deferred.
The patient was monitored in recovery and quantitative essay for troponins were sent immediately and a qualitative troponin after 4 hours both of which turned out to be negative for myocardial ischemia. Cardiology evaluation later revealed a 70% occlusion of right coronary artery. An elective coronary stenting was done subsequently.


A 25-year-old G2P1L1 woman with a 3-month history of amenorrhea presented to casualty with right hypochondriac pain and vomiting for the past 1 week. She had a normal vaginal delivery 9 months ago. On examination, her pulse rate was 96/min, blood pressure was 90/54 mmHg and she appeared mildly anemic. Abdomen was soft but diffusely tender. There was no guarding, rigidity, or palpable mass. On speculum examination, the cervix and vagina were healthy. On vaginal examination, the uterus was anteverted, bulky, mobile, and nontender, and bilateral fornices were free. Her urine pregnancy test was positive. On an ultrasound scan, the uterus was found to be enlarged with an endometrial thickness of 10 mm; bilateral adnexae were normal and free fluid was present in the abdomen. A sac with a live fetus corresponding to 17- to 18-week gestational age was seen attached to the inferior surface of the liver []. A provisional diagnosis of primary hepatic pregnancy was made. A decision was taken for laparotomy in view of suspected hemoperitoneum with borderline vitals. Her blood investigations showed Hb 9.4 g%, TLC 6000, platelets 237 × 103, and INR 1.18. LFT and KFT were normal.
Laparotomy was carried out with a midline vertical incision which was extended subcostally on the right side, and 500 cc of hemoperitoneum was drained. The uterus and adnexa were normal looking. On exposing the liver, a 10-cm sac was seen on the undersurface of the right lobe []. There was fresh bleeding from the site of placental attachment. After rupturing the sac through an avascular area, a 300-g fetus [] was extracted and the umbilical cord was ligated. The placenta was left in situ and attempts were made to secure the bleeding area with hemostatic sutures, but without any success. Finally, the area was packed and the abdomen was closed in a single layer. Perioperatively, there was a total blood loss of 2.5 l and four units of blood were transfused. Postoperatively, the patient was transferred to ICU on inotropes and ventilatory support. However, the patient continued to bleed through the dressings, and after consultation with the gastrointestinal surgeon and interventional cardiologist, a decision was made to proceed with embolization. Hepatic artery embolization was carried out 18 h after surgery. The patient continued to bleed despite embolization and further laparotomy was carried out to remove the packs to avoid the risk of sepsis.
At the time of the laparotomy, the abdomen was full of blood. Packs were removed slowly, but there was diffuse bleeding from the undersurface of the liver. The patient remained unstable, and it was decided to pack the abdomen again and to replace blood. She received a total of 76 units of blood and blood products at regular intervals.
On the fourth postoperative day, patient's urine output decreased markedly, coagulation became deranged, and the vitals were unstable despite the use of inotropes. A decision was made to proceed with liver resection but the patient was too unstable and sadly she passed away on the fifth postoperative day due to multiorgan failure secondary to hemorrhage.


An 11-year-old boy, a known case of chronic kidney disease (stage V) on maintenance hemodialysis, presented with one episode of generalized tonic–clonic seizure approximately 30 minutes prior to presentation to the emergency center. He was in altered sensorium following the episode of seizure. There was history of high-grade fever (upto 103°F) for 3–4 days.
On examination, he was found to be drowsy; however, he was moving all four limbs. His blood pressure in the emergency room was recorded to be 140/100 mmHg. Laboratory tests revealed a serum creatinine of 4.8 mg% and blood urea of 121 mg%. His total leukocyte count was 22,200 per mm3 with Hb of 10.2 gms. Serum calcium, sodium, and potassium were 7.8 mg%, 135 mEq/L, and 5.3 mEq/L, respectively.
MRI brain at admission showed T2W/T2 FLAIR hyperintensities, s/o oedema, involving the subcortical white matter of bilateral frontal, parietal, and occipital lobes, with few areas of cortical involvement []. Similar lesions were also noted involving bilateral basal ganglia, left thalamus, splenium of corpus callosum, as well as brainstem []. Diffusion-weighted imaging (DWI) showed increased signal intensity in the lesions in bilateral occipital lobes and in the splenium of corpus callosum. A diagnosis of PRES was made on the basis of these findings.
The patient was started on antiepileptics, antihypertensives, and antibiotics, with daily hemodialysis. He had four more episodes of seizures during his hospital stay; however, he slowly improved clinically and was discharged on antiepileptics and antihypertensives on biweekly hemodialysis.
Follow-up MRI brain was done after 2 weeks, which showed near-total resolution of the brain lesions [].


A 52-year-old male patient presented with a swelling over the right cheek area since 18 months. On clinical examination, a solitary well defined swelling measuring 3×2×1.5 cm extending from the distal surface of right maxillary canine to retromolar area of the hard palate was seen. Grade II mobility of all the involved molars were observed. The swelling was firm in consistency and the overlying mucosa was normal [].
On the radiographic examination, the occlusal radiograph showed complete obliteration of the sinus. Panoramic view showed radiolucent and radiopaque lesion involving the right alveolus and the maxillary sinus with erosion of lateral wall and floor of the sinus. Multiple foci of radiopacity simulating flecks of calcifications were seen giving it a “snow-driven appearance”. Computed tomography (CT) scan showed the right maxillary sinus involvement and demonstrated mixed radiolucent and radiopaque areas. The lesion extended toward the lateral wall of the nose [Figures and ]. The swelling was aspirated and a cytological smear was prepared. It showed clusters of epithelial cells with uniform basophilic centrally placed nuclei intermixed with RBCs and inflammatory cells. Epithelial cells were polyhedral in shape with well-defined borders having pale eosinophilic cytoplasm. Few cells showed nuclear and cellular pleomorphism [Figures and ]. A provisional diagnosis of CEOT was made and for further confirmation an incisional biopsy was performed.
The histopathological sections revealed varying sizes of epithelial islands surrounded by hemorrhagic areas in a fibrous connective tissue stroma. Some areas of circular amorphous eosinophilic hyalinized amyloid-like material were seen. [] Areas of clear cells having vacuolated cytoplasm were identified within the epithelial islands []. Few cells with pleomorphism and mild degree of variability in nuclear size were seen. As clear cell variant of CEOT was diagnosed, which being aggressive in nature, a hemimaxillectomy using Le Fort I surgical approach was performed. The excised tissue was further histo-pathologically diagnosed as CEOT with free margins. The patient was followed up for 3 years postsurgically. There was no evidence of recurrence during this period.


A 59-year-old white woman, SC, after being treated for pneumonia, returned to the doctor in January 2008, when he detected, at physical examination, a painless, fibroelastic lymph node of approximately 40 mm in the left cervical region. A biopsy was made after complete excision and a computed tomography (CT) was requested. The CT demonstrated mediastinal and retroperitoneal lymphadenopathy and calcified granuloma in the right lower lobe of the lung. The biopsy initially was performed using the immunoperoxidase technique and the PicTure MAXTM Polymer method; the results were suggestive of non-Hodgkin lymphoma. The material was analyzed in the Consulting Pathology Service of Botucatu, São Paulo with the results of an immunohistochemical study defining atypical histiocytic proliferation. Eventually a sample was sent to Washington, USA where morphological and immunohistochemical alterations compatible with histiocytic sarcoma were identified: large cells with irregular-shaped nuclei and nucleoli, showing some binucleate forms and eosinophilic cytoplasm; positive immunophenotype for the CD68, CD163 and CD4 antigens which establish histiocytic proliferation and negative for CD1a and Langerin, which exclude the differential diagnosis of giant cell lymphoma and dendritic cell sarcoma. ( & ).
In May 2008, the patient was referred to the oncology department of the Hospital Universitário Santa Terezinha (HUST). She was submitted to systemic staging with CT scans and laboratory tests which showed the following: enlarged retroperitoneal lymph nodes, measuring approximately 8 cm; some enlarged mediastinal, paratracheal, para-aortic, aortopulmonary window and subcarinal pulmonary lymph nodes, and a residual granuloma of 8 mm in the lower right lobe of the lung; Hb: 12.2 g/dL (11.5-16.5 g/dL); leukocytes: 5.8 x 106/L (4.0-11.0 x 106/L); platelets: 175 x 109/L (150-400 x 109/L); β2 macroglobulin: 1.85 mg/L (1.2-2.4 mg/L); and LDH: 307.0 (88-230 units/L). Thus, chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) was indicated and started in June with a total of eight cycles completed in November.
After two months, the patient returned for evaluation in the oncology department, asymptomatic, but at physical examination two lymph nodes smaller than 10 mm (left supraclavicular/cervical region) were detected. They had a fibroelastic consistency and were not adhered to surrounding structures. CT scans were performed that gave normal results and laboratory tests showed no significant alterations. Expectant management was chosen and the patient was requested to return after approximately five months.
On her return in May 2009, the left supraclavicular lymph nodes were enlarged; the largest was 40 mm and both were painless and fibroelastic. Radiologic studies showed: enlarged retroperitoneal retrocaval lymph nodes, the largest measuring 40 by 20 mm and some lymph nodes measuring 15 mm along the ascending aorta.
After 30 days, the patient remained asymptomatic. A physical examination revealed enlarged mobile and hard lymph nodes in the left anterior cervical/supraclavicular region. Another analysis of a cervical lymph node was performed with the following result: lymph node diffusely altered by neoplastic malignancy suggestive of histiocytic sarcoma. CT scans showed enlarged retroperitoneal retrocaval lymph nodes with the largest measuring 35 by 30 mm and some lymph nodes measuring 10-15 mm along the ascending aorta. Laboratory tests showed no significant alterations. Salvage chemotherapy using etoposide, cisplatin, cytarabine and methylprednisolone (ESHAP) was begun on October, 7, 2009 with a planned 4-6 cycles.
In spite of the patient having shown good initial clinical response, after being submitted to two cycles of chemotherapy, she evolved with febrile neutropenia triggered by an urinary tract infection. She was hospitalized for treatment with systemic antibiotic therapy. Even so, the patient evolved with hemodynamic instability and was transferred to the ICU where she died due to septic shock and multiple organ failure in December 2009.


A 35-year-old male patient reported with complaint of absence of teeth in upper and lower arches. His medical history was non-contributory. A detailed history ruled out any familial inheritance. His facial feature was characteristic with a sunken nasal bridge and frontal bossing. Brachycephalic head and hypertelorism were other salient features noticed on examination. He was able to adduct his shoulders when asked to bring his shoulders forward to the midline. This confirmed an anomaly in clavicle formation []; oral examination showed prolonged retention of deciduous teeth.
The patient was subjected to radiographic examinations of chest, skull, hand wrist, cephalometric, and panoramic radiographs. Panoramic radiographs revealed abnormally retained primary teeth, nine impacted permanent and supernumerary teeth (excluding second and third molars) []. Skull AP view showed open sutures with large wormian bones []. Lateral cephalogram showed shortening of cranial base anteriorly; in the posterior region The physiological mandibular angle was replaced by a rounded outer contour of the mandible. Supernumerary teeth were also seen []. Radiograph chest PA showed narrowing of thorax and ribs. Clavicles were absent []. Impacted teeth were removed and prosthetic rehabilitation was done.


A 52-year-old male patient was referred to the Dental Hospital of Kyung Hee University from a local clinic for the extraction of his left third molar. He had suffered some discomfort during mastication and dull pain on his left lower posterior area beginning about 10 days earlier. On intraoral examination, the overlying mucosa of the left impacted third molar was intact. The shape and texture of the gingiva surrounding the second molar were relatively normal. Neither tenderness nor pus discharge via gingival sulcus was observed during the palpation on the left lower posterior area. Percussion was positive on the second molar, but no mobility was observed. No cervical lymphadenopathy was detected on his left submandibular area. His medical history was noncontributory, revealing controlled hypertension for the past 5 years.
Panoramic and periapical radiographic examination were performed under the clinical diagnosis of pericoronitis. Conventional radiographs showed an ill-defined periapical rarefaction coinciding with the external root resorption related with the follicular space of the impacted third molar. However, there was no any etiologic factor on the left lower second molar such as dental caries or periodontitis (). CBCT examination was performed in order to evaluate the relationship with the mandibular canal and apical radiolucency of the left lower second molar. The CBCT scan described external root resorption on the distal root and extensive bony lysis over the apex of the second molar from the follicular space of the impacted third molar (). The initial radiographic impression was pericoronitis with an advanced lytic bone lesion involving the periapical region of the adjacent root.
He underwent a surgical extraction of his left lower third molar. Despite the continous treatment for 3 months, there was delayed extraction wound healing assuming a surface osteitis.
After one year, he presented to our dental hospital with a complaint of paresthesia in the lower chin area. Intraoral examination revealed that the extraction wound was quite well healed and covered by intact, normal-appearing mucosa on his left mandibular retromolar region. Neither tenderness nor pus discharge was observed during palpation of the extraction wound. No cervical lymph node enlargement was detected in his left submandibular area.
Panoramic radiograph and CBCT scan revealed an ill-defined bony destructive lesion with perforation of the buccal and lingual cortical plates. This lesion extended from the distal root of his left second molar to the ascending ramus and involved the cortical outline of the mandibular canal inferiorly (). The radiographic impression suggested osteomyelitis, and a primary intraosseous malignant tumor was also suspected. Partial sequestrectomy was performed under the tentative diagnosis of osteomyelitis, and a biopsy specimen was obtained for a histopathologic examination. Two specimens were drawn, one was the teeth with attached soft tissue and the other was a brown soft tissue. Microscopic examination revealed infiltrative growth of the neoplastic squamous cells. The tumor cells formed irregular epithelial islands with celluar atypia, nuclear hyperchromatism, pleomorphism, and mitosis ().
Contrast-enhanced CT scan found a heterogeneously enhanced soft tissue mass in the left retromolar region with extensive bone destruction. MR images revealed adjacent soft tissue involvement, extending laterally into the buccinater and masster muscle, with invasion into the medial pterygoid muscle and masticator space. The tumorous mass showed low signal intensity on the T1 weighted image, while it was detected to have a high signal intensity on the T2 weighted image. Gadolinium-enhanced MRI showed an ill-defined mass with internal heterogeneous enhancement ().
On the findings of CT and MRI, the cervical lymph nodes were found enlarged. As a result, positron emission tomography (PET) and a bone scan were considered to be necessary for evaluating the entity for a primary malignant lesion or long metastatic lesion. According to the results of PET using 18F-fluorodeoxyglucose (FDG), a focal hypermetabolic mass showing a 10.9 standardized uptake value (SUVmax) was detected on the retromolar region of his left mandible (). Furthermore, a hypermetabolic lymph node showing an SUVmax of 5.0 was also observed on his left cervical area. In addition, a Tc99m-MDP bone scintigram revealed an increased uptake of radionuclides in the left mandibular angle area, but no evidence of bone metastasis except the degenerative change of other joints. The patient underwent radiation therapy for three months before surgical intervention. Under general anesthesia, the patient underwent partial mandibulectomy and selective neck dissection. The surgical defect was also reconstructed by surgical plates and a radial forearm flap. The histopathologic examination of the surgical specimen proved that the tumor, measuring about 4 cm×3.5 cm×3 cm, invaded the cortical bone of the mandible and surrounding skeletal muscles. The tumor cells formed an atypical epithelial cell nest with hyperchromatism and pleomorphism, while the overlying oral mucosa had no connection with the tumor. Scetions of a regional lymph node showed no tumoral cells. The histological diagnosis was moderately differentiated squamous cell carcinoma most likely of central origin. No lymphatic metastasis was detected; however, tumor cells were very close to lingual and buccal resection margins. In conclusion, the diagnosis of PIOSCC was confirmed radiographically and histopathologically. Up to the present, there has been no evidence of local recurrence or distant metastasis during the six-month postoperative follow-up period.


A 35-year-old man presented with a three month history of coccygeal and gluteal pain. Furthermore, the pain was associated with numbness in the same region and difficulty walking. The pain had been gradual in onset and was worse on sitting and walking. There was no bowel or bladder incontinence. He reported no recent weight loss, reduced appetite, cough, or night sweats, and his respiratory, cardiovascular, and abdominal system examinations were normal. No paresthesia or muscle weakness was evident in the legs, which he was able to straighten and raise his legs. However, mild perianal and perineal anesthesia were present. The Mantoux test and radiographs of the chest were negative, and hematological studies, including erythrocyte sedimentation rate and C-reactive protein were normal. A computed tomography (CT) scan of the lumbosacral spine revealed lytic destruction of the coccyx with sporadic calcification (). Magnetic resonance images (MRI) of the lumbosacral spine depicted a coccygeal mass involving the anterior and posterior extension (). Under a preliminary diagnosis of a primary bone tumor or metastasis, radionuclide bone scintigraphy (99m TC MDP) and positron emission tomography-CT were performed, but both failed to depict any lesion in addition to the lesion in the coccygeal area. A CT-guided biopsy of the sacral lesion was performed, and the patient was given anxiolytic and analgesic injection before and during the procedure. After infiltrating the skin and soft tissues with 2% lidocaine, a 14-gauge biopsy needle was advanced into the lesion and soft tissue and involved bone were aspirated. The solid material aspirated was dark brown in appearance and was forwarded for cytologic and microbiological examinations. The pathologic examination revealed caseating granulomas containing multinucleated giant cells (). Acid-fast bacilli cultures were positive for tuberculosis. The patient was given anti-tuberculosis treatment for 9 months based on four drugs (isoniazid, rifampin, pyrazimide, and ethambutol), which is the standard anti-tubercular regimen used at our institute. Patient made a rapid pain relief under this regimen and was asymptomatic at his last follow-up at 9 months.


A 41-year-old male patient presented to our emergency department with abdominal pain. Exploratory laparotomy performed through a subumbilical incision showed perforated appendicitis with intraabdominal abscess of 1,500 mL. In addition, there was a large hemangioma occupying 80% of the liver. After surgery he developed intraperitoneal sepsis and in order to prevent abdominal compartment syndrome, he was reoperated and left with "open abdomen". Several open abdomen lavages were performed and his abdominal wall defect was allowed to granulate.
After epithelization of the defect approximately ten months later (), reconstruction of the abdominal wall was planned. Skin incisions were made 2 cm lateral to the defective area. Two rectangular tissue expanders (LS 82 2000, Laboratoires Sebbin, Boissy-l'Aillerie, France) of 2,000 mL volume (230 × 130 × 70 mm) were placed in the subcutaneous pockets created just above the anterior rectus sheath and adjacent to the abdominal wound bilaterally to reconstruct the defect of 23 × 37 cm in size. The ports of the tissue expanders were placed on the thoracic cage region.
Each of the tissue expanders were inflated with 200 mL of saline at the time of the initial operation. Over the next several weeks, the expanders were gradually inflated to a total volume of 2,350 mL each over a period of four months (). After four months, the patient returned to the operating room for definitive repair of the defect. The expanders were removed () and since the fascial defect was too large to close primarily, utilizing prosthetic mesh (expanded polytetrafluoroethylene; GORE-TEX soft tissue patch) () in conjunction with tissue expanders, the abdominal wall defect was reconstructed. Expanded skin flaps were advanced toward the midline and closed in layers without tension. A more acceptable midline scar was then obtained. Suction drains were placed bilaterally and removed three days later.
The postoperative period of the patient was uneventful and he was discharged on the 4th postoperative day. During follow-up for ten months, he showed no signs of mesh infection or extrusion, and did not develop recurrent hernia, ulceration or enteric fistula. The tissue expansion process was well tolerated by the patient ().


A 46-year-old pregnant woman at 31 weeks gestation was referred to the gynecology department of our hospital for premature membrane rupture with uterine atony and placenta accreta. She had no significant past medical history, except a previous caesarean section. After an emergency caesarean section, the patient presented severe postpartum hemorrhage secondary to uterine atony and was referred to our department (interventional radiology).
Embolization was performed using the single femoral artery approach with insertion of a 5-Fr introducer sheath (Terumo, Tokyo, Japan). At the beginning of the procedure, flush aortography () with a 5-Fr pigtail catheter (Cook, Bloomington, IN) positioned at the level of the celiac trunk showed a single aberrant artery arising from the right common iliac artery. Selective angiography of the aberrant artery using a 5-Fr Yashiro catheter (Terumo, Tokyo, Japan) revealed that it had a sinuous course and was tortuous (). This artery showed the typical ovarian blush and abundant collateral perfusion to the markedly enlarged uterine fundus ().
Both ovarian arteries could not be observed on pelvic aortography, and anastomosis with the uterine artery was not clearly defined. The diameter of the aberrant artery was larger than the diameters of both uterine arteries. Selective angiography of both the internal iliac arteries and both uterine arteries showed markedly increased uterus vascularity. The aberrant ovarian artery () and both uterine arteries () were embolized with 1 × 1 mm gelfoam pledgets (Johnson & Johnson, Skipton, UK) by using a 2.7-Fr microcatheter (Progreat®, Terumo, Tokyo, Japan). Vaginal bleeding ceased after this successful embolization procedure.
Three days after embolization, the patient underwent a contrast-enhanced abdominal-pelvic computed tomography (CT) scan, and no associated unusual findings such as anomalies of the kidney or renal arteries were noted.
The patient's condition rapidly stabilized after the embolization procedure, and she was discharged in a good condition.


A 52-year-old woman was referred to the outpatient clinic of rheumatology department with a 6-month history of dyspnea on exertion [New York Heart Association (NYHA) functional class II to III]. About 20 years ago, she visited a local clinic for non-healing toe wound and had a tentative diagnosis of TA. She had a previous history of vascular surgery for left carotid artery. Ten years later, she visited another local clinic with a complaint of dyspnea on exertion (NYHA functional class II). At that time, echocardiographic examination showed severe pulmonary hypertension with severe tricuspid regurgitation, based on which the attending physician prescribed diuretics and digoxin with a diagnosis of idiopathic pulmonary arterial hypertension. Despite the medications, however, she could not feel any improvement with regard to exertional dyspnea and she was advised to undergo surgery for severe tricuspid regurgitation. During preoperative work-ups, complete occlusion of right main pulmonary artery was incidentally detected. For further evaluation, she was referred to our hospital.
On physical examination, her blood pressure was 78/39 mmHg at right arm and 99/70 mmHg at left arm. Her chest radiography showed a prominent left hilar opacity and right atrial enlargement (). Her electrocardiogram showed right atrial enlargement and right ventricular hypertrophy. Laboratory parameters included increases in erythrocyte sedimentation rate (77 mm/hr) and C-reactive protein (2.14 mg/dL).
On echocardiography, right ventricle (RV) was severely dilated, its wall thickness was increased, and RV systolic function was decreased. Severe tricuspid regurgitation and severe pulmonary hypertension with maximal pressure gradient of 131 mmHg were noted, as well. On basal parasternal short axis view, the blood ejected from the RV to the main pulmonary artery appeared not to cross the right pulmonary artery. When we carefully traced the proximal right pulmonary artery, we could not clearly delineate its opening (). Lung perfusion scan showed the total absence of perfusion in the right lung with partial perfusion defects in the left lung (), but no pulmonary thromboembolism was clearly demonstrated on computed tomographic pulmonary angiography. The occlusion of right main pulmonary artery and left main pulmonary artery stenosis at the entrance were also clearly demonstrated on computed tomographic angiography (). According to the result of cardiac catheterization performed elsewhere, the mean right atrial pressure was severely elevated (18.4 mmHg), and catheter was impossible to go into the right pulmonary artery. Coronary angiography demonstrated a huge left circumflex coronary artery to right pulmonary artery fistula (). Arch aortography revealed total occlusion of the left subclavian and left common carotid artery in their proximities. Right subclavian artery showed near-total occlusion, as well (). The diagnosis of TA was established based on the criteria of American college of Rheumatology for classification of TA; age at diagnosis (less than 40 years), difference in systolic blood pressure between arms (exceed 10 mmHg), arteriogram abnormality.
The patient was treated with corticosteroid, methotrexate, bosentan and symptomatic medications for right-sided heart failure. She is now being followed in the rheumatology clinic on a regular basis and her symptoms showed slight improvement with these medications.


A 76-year-old male presented to our Emergency Department (ED) after an intentional overdose of insulin glargine (LANTUS®). He was found by his friend diaphoretic and anxious, but responsive. He reported that he attempted to suicide by injecting himself 500 units insulin glargine subcutaneously. There was no information about blood glucose level at the time of ambulance arrival.
On initial ED evaluation, he was conscious, Glasgow Coma Score was 15/15; and vital signs were as follows: Blood pressure 120/70 mmHg, pulse rate 98 bpm, body temperature 36 °C; and respiratory rate 18 pm. Diaphoresis was still continuing and physical examination revealed nothing pathological but tachycardia.
Finger-stick glucose was 30 mg/dl (Reference range: 70-106 mg/dl). Simultaneous chemistry revealed 41 mg/dl. He was started 50 cc 50 % dextrose IV and continued on 10 % dextrose at 50 cc/h. Over the next 96 h he received a 10 % dextrose infusion at 50 cc/h and he was needed to administer extra glucose boluses for several times because of hypoglycemia periods [].
Serum potassium level was 3.11 meq/l (Reference range: 3.5 – 5.2 meq/l). Other parameters such as sodium, phosphate, calcium and liver function tests were in the normal range. Oral potassium chloride was started since serum level was found as low as 3.17 meq/l. Oral potassium chloride was arranged as needed during follow up period.
In his past medical history, he emphasized insulin-dependent diabetes for 25 years, hypertension, parkinson disease, panic disorder; and dementia. Current medications included insulin glargine 14 units twice daily, Losartan plus, levodopa+carbidopa+entacapone and piracetam.
After 96 h, he was transferred to Internal Medicine ward for close monitoring; then consulted to psychiatry and endocrinology.
At the fifth day of follow up, hypoglycemia periods were terminated and he was discharged on appointed outpatient clinic.


A 65-year-old man presented with a hard mass measuring 4 × 3 cm in the supraclavicular region. Clinical diagnosis was secondaries in the lymph node. FNAC was performed. The smears were moderately cellular and showed proliferative spindle cells among the skeletal muscle fibers. Good number of uni and multinucleated cells having enlarged and atypical nuclei were seen. Giant cells were conspicuous [Figure and ]. A diagnosis of metastatic tumor was made. The patient underwent various tests, but no primary was detected. The mass was excised. Grossly, the mass was grey-white and measured 3×2 cm. On histopathology, there were skeletal muscle fibers and fibro-collagenous tissue with chronic inflammatory cells, proliferating fibroblasts and giant cells. Giant cells had abundant dense eosinophilic cytoplasm and vesicular nuclei with prominent nucleoli. The features were consistent with a diagnosis of proliferative myositis.


A 29-year-old man presented with a firm mass measuring 2.2 × 2 cm in the upper neck of one week duration. FNAC was done. The aspirate was cellular and showed a polymorphous population of isolated and sheets of spindle cells with inflammatory cells consisting of lymphocytes, plasma cells, eosinophils and neutrophils. The nuclei of some of the cells were slender with pointed ends, while others had round to oval nuclei, with evenly distributed fine chromatin. A few muscle giant cells and ganglion-like cells of triangular to polyhedral shapes were seen. The background was myxoid. [] A diagnosis of NF was made. The mass resolved after three weeks with no further treatment.


A 44-year-old male presented with severe sudden-onset headache. Computed tomography (CT) scan showed dense blood clot in the left Sylvian fissure, suggesting ruptured middle cerebral artery (MCA) bifurcation aneurysm; CT angiography (CTA) revealed another supraclinoid ICA aneurysm as well as left MCA bifurcation aneurysm (). For the treatment of ruptured MCA bifurcation aneurysm, considering the irregular shape, larger size, daughter sac and the location of the hematoma in preoperative CT scan, the patient underwent aneurysm clipping surgery via a left pterional craniotomy. A clip was successfully placed on the neck of the aneurysm, which was confirmed as ruptured in the surgical field. Although a paraclinoid aneurysm existed on the same side and could be clipped via the same approach, we planned endovascular treatment for the unruptured supraclinoid ICA aneurysm because of potential optic nerve injury attributable to anterior clinoidectomy or unroofing of the optic canal during clipping. The three-dimensional rotational angiography (3DRA) at 20 days after surgery demonstrated a fenestration of the left supraclinoid ICA with an aneurysm arising from its proximal end, which was not delineated clearly on 2D cerebral angiography and CTA, and the well-clipped state of the ruptured MCA bifurcation aneurysm. The fenestration of the ICA occurred from the origin of the ophthalmic artery (OphA) to the origin of the posterior communicating artery (PCoA). A saccular aneurysm was oriented postero-laterally, arising from the posterior aspect of the left supraclinoid ICA segment, which was proximal to the fenestration (). The aneurysm was 4.5, 3.4 and 3.5 mm in length, dome and neck diameter, respectively. From post-operative day 20, dual anti-platelet medication (aspirin 200 mg and clopidogrel 75 mg) was administered for about seven days for the coil embolization of the supraclinoid ICA aneurysm. At 27 days after the surgical clipping, because of the wide-neck and vessel incorporation at the neck of the aneurysm, balloon-assisted endovascular coiling was performed to occlude the aneurysm and preserve both fenestration channels. Under local anesthesia, the 7F femoral sheath was inserted through the right-sided femoral artery. Then the 7F guiding catheter (Vista Brite; Cordis Neurovascular, Miami, FL) was advanced to the distal cervical ICA segment. The Excelsior SL-10 microcatheter (Boston Scientific, Natick, MA) was placed into the neck of the aneurysm. Balloon-assisted coil embolization was done with Hyperglide [Microtherapeutics (MTI), Irvine, CA]. We used five bare-platinum coils for the obliteration of the aneurysm. The aneurysm was obliterated successfully, and both limbs of the fenestration were preserved (). The patient had an uneventful postoperative course and was discharged without any neurological deficits.


A 40-year-old nondiabetic man was diagnosed with CKD in March 2006. He was initiated on hemodialysis through left brachiocephalic arteriovenous fistula (AVF). He underwent surgical placement of double-cuffed, swan-neck, Tenckhoff catheter under local anesthesia in December 2008. He was initiated on regular CAPD exchanges after 2 weeks of break-in period. His peritoneal equilibration test showed high-average transporter status. His residual urine output was 250 ml per day. He was on three exchanges per day with 2.5% dextrose solution and achieved around 1500 ml ultrafiltration daily. After 2 months of initiation of CAPD, he noticed a small swelling at the umbilicus which reduced in size in lying posture and increased on standing. After 4 months, he presented with complaints of pain abdomen and vomiting of 5 days’ duration. Pain abdomen was severe in intensity, colicky in nature, periumbilical, and nonradiating. He had bilious vomiting 4–5 episodes a day. He also complained of progressive abdomen distension and constipation of 2 days’ duration. There were no complaints of fever, loose motion, or cloudy PD fluid. There were no previous episodes of peritonitis. He also denied history of abdominal surgeries or hernias prior to CAPD initiation. On physical examination, he was dehydrated and blood pressure was 100/70 mmHg. Abdominal examination showed irreducible umbilical hernia of 6 cm in size. The swelling was tense and tender. There was no expansile cough impulse. Bowel sounds were absent. Rectal examination showed empty rectum. Cardiovascular and respiratory system examination were unremarkable. Investigations revealed hemoglobin 8.6 g/dl, total leukocyte count 11,000/mm3, blood urea 70 mg/dl, serum creatinine 11.2 mg/dl, serum sodium 136 meq/l, potassium 4.2 meq/l, chlorides 94 meq/l, total proteins 7.0 g/dl, serum albumin 3.2 g/dl, serum alkaline phosphatase 196 IU/L, alanine aminotransferase 10 U/L, and aspartate aminotransferase 13 U/L; viral markers were negative; chest radiograph was normal; and abdominal radiograph showed dilated small bowel loops with multiple air fluid levels. A diagnosis of obstructed umbilical hernia was made. CAPD exchanges were continued till a day before surgery. He underwent laparotomy under general anesthesia. On opening the abdomen, hernial sac of 6 cm was found and there was 4 cm defect in the rectus. The rectus defect was enlarged on either side and the peritoneum over the umbilical hernia was opened. Ileal gangrene of 15 cm was noted, proximal small bowel loops were mildly dilated []. He underwent resection of the gangrenous ileum and end-to-end anastomosis in two layers. After reducing the peritoneum of the hernial sac, the rectus defect was closed. Tenckhoff PD catheter was not disturbed []. He was on Ryles tube aspiration for 2 days, and antibiotics for 10 days. Sutures were removed on the 10th postoperative day. He was temporarily shifted to hemodialysis through left brachiocephalic AVF on the second postoperative day and was continued on hemodialysis three times a week for 2 weeks. On the third week, he was initiated on CAPD exchanges with 1 L of 2.5% dextrose three times a day. Initially the PD fluid was slightly hemorrhagic. Gradually by the fourth week, he returned to normal CAPD exchanges with 2 L of 2.5% dextrose and around 1 L clear ultrafiltration. There was no leakage either from the incision site or the exit site.


Two female Afghans refugees of a family (a 34 years old mother and her 12 years old daughter) that live in Borkhar, Khorzogh a rural area of Isfahan city of Iran admitted to the Dr. Enayatinia private medical office, with nasopharyngeal symptoms. They stated that their clinical symptoms started 2-3 hours after eating raw goat liver. The symptoms described were discomfort and pricking sensation in throat with expansion to the ears. Symptoms like coughing, sneezing, yellow nasal and ear discharges were appeared; and after several days, patients felt epigastric pains and movement of something in their nose and ears, and several organisms were removed after coughing and sneezing.
Then, patients referred to the Souroosh Diagnosis Medical Laboratory in Khorzogh, using forceps, 3 worm-like and white colored organisms were detected from tongue and due to coughing and sneezing, 4 other organisms were exited. Using stereo microscope and direct microscopy with normal saline, the nymph of Linguatula serrata was diagnosed in Parasitology and Mycology Department, School of Medicine, Isfahan University of Medical Sciences []. In the anterior end of parasite 4 large hooks surrounded its mouth [], and its segmented membrane covered with prominent spines [].


A 40 year old female who was brought to the emergency room was suspected to have ingested PPMT oil. A strong smell of mint was emanating from her body. The exact amount ingested could not be ascertained. Clincal examination revealed that the patient was comatosed, had a heart rate of 60/minute, blood pressure not recordable, respiratory rate of 6-8/ minute, oxygen saturation of 30%. Her peripheral pusles were absent and extremities were cold and clammy. Auscultation of chest and precordium revealed normal vesicular breath sounds and normal heart sounds. Patient was immediately intubated without any resistance. Mechanical ventilation (SIMV mode) was instituted (FiO2-1). Gastric lavage was done with warm normal saline. Rapid intravenous infusion of crystalloid was started but her blood pressure did not improve. Thus, intra-venous infusion of dopamine was started, which was gradually increased to 10 μg/kg/min. In the mean time all her clothes were changed and wet sponging was done. Warming blanket and radiant warmer were applied. A 7.0 Fr triple lumen central venous catheter was inserted through right subclavian vein. Her urinary bladder was catheterized. The medication administered include inj ranitidine intravenous (iv), inj ceftriaxone iv, inj gentamycin iv, inj metoclopramide iv and antacid through naso-gastric tube. Since chest skiagram showed no evidence of aspiration and considering the possibility of peppermint oil ingestion causing nephrotoxicity, further dose of gentamycin was stopped. Her vital parameters [], blood investigation reports [] and arterial blood gas analysis [] is given below.
Dopamine infusion was gradually tapered and finally stopped after 8 hours. She started responding to physical stimuli (light glabellar tap) after eight hours and to her name at 24 hours. She was weaned from ventilator after 24 hours. Finally, after 36 hours, patient was conscious, maintaining vitals without support. Chest and cardiovascular examination was unremarkable. Her room air saturation was 100%. She was discharged from intensive care unit.


An 11-year-old boy presented to us in December 2009 with fever, headache and seizures. In July 2008, he had headache with vomiting and photophobia. He was evaluated elsewhere and was found to have aneurysmal dilatation of intracranial segments of anterior, middle and posterior cerebral arteries on magnetic resonance imaging (MRI) and catheter angiogram of brain []. With the possibility of CNS angitis, he was treated with one pulse of intravenous Methylprednisolone and intravenous Cyclophosphamide, which was not continued further. He continued to have intermittent headache and fever. In November 2009, he had worsening of headache with seizures. He was admitted elsewhere and again received pulse intravenous Methylprednisolone and intravenous Cyclophosphamide, followed by a tapering course of oral steroids. In December 2009, he presented to us with headache, fever and recurrent right-side focal seizures with secondary generalisation. He was the first child of two siblings, born to nonconsanginous parents. There was no history of similar illness in the other sibling, with no other remarkable family history. MRI brain showed fusiform aneurysmal dilatations of arteries of anterior and posterior circulation with ectasia of the terminal internal carotid arteries (ICAs), proximal anterior cerebral arteries (ACAs), proximal middle cerebral arteries (MCAs) and their cortical branches. There was loss of flow void in right vertebral artery suggesting thrombosis. There was leptomeningeal enhancement [Figures –]. Cerebrospinal fluid (CSF) analysis showed 200 WBC/mm3 (100% lymphocytes), protein of 2.2 g/dL and sugar of 29 mg/dL. CSF cultures (bacterial and fungal) were negative. CSF multiplex polymerase chain reaction (PCR) was positive for EBV and negative for other viruses screened (herpes simplex 1 and 2, adeno, varicella and CMV viruses). Blood virus screening (HIV, hepatitis B and C viruses) was negative. Work up for lymphoproliferative disorder including screening for lymphadenopathy, CSF flow cytometry and bone marrow examination were negative. Quantitative immunoglobulin assay was normal (IgG – 1275 mg%, IgA – 201 mg% and IgE – 12.5 IU/ml). His peripheral blood lymphocyte subset analysis showed CD4+ T cells - 1091/μL and CD3+ T cells - 6060/μL. Positron emission tomography (PET) scan was unremarkable. The markers for systemic vasculitis were negative. Nerve conduction study and a muscle, nerve and skin biopsy were normal. During the hospital stay, he had worsening of headache; repeat MRI brain showed T2 hyperintensity in right caudate nuclei, bilateral frontal and hippocampal areas [Figure and ]. Repeat CSF analysis showed persistent lymphocytic pleocytosis, raised proteins, low sugars and EBV PCR positive status. He was discharged on oral anticoagulation and oxcarbamazepine. In June 2010, he had fever, pancytopenia and bone marrow aplasia, probably due to EBV-associated X-linked lymphoproliferative disorder (XLP). His peripheral blood lymphocyte subset analysis showed CD3+ T cells - 3888/μL, CD4+ T cells -756/μL, CD8+ T cells - 3074/μ L, CD19+ T cells - 108/μL and CD56+ T cells - 150/μL, suggestive of mild B cell deficiency. He was treated with antibiotics for respiratory infection and also growth factors. He continued to deteriorate and succumbed to sepsis within 2 weeks. A molecular diagnosis looking for mutation in the SH2D1A/DSHP/SLAM-associated protein (SAP) gene could not be done for the lack of availability of the test.


A 75-year-old male patient presented with rapidly progressive weakness of both lower limbs since past 3 months. At the time of presentation, he was bed ridden with grade 0 power in both lower limbs. Bladder involvement in form of urinary retention occurred 1 month back with patient on a indwelling Foley's catheter. There was a definite sensory level at L2 level for all modalities of sensation. Patient was known hypertensive and had ischemic heart disease with one episode of myocardial infarction and had undergone angioplasty 8 months back. Plain X-ray of lumbar region showed erosion of L3 vertebral body. Magnetic resonance imaging (MRI) pictures showed a large mass lying in paraspinal and retrospinal region []. The retrospinal extension was so massive that it almost extended to lie just beneath the skin. There was a small intraspinal component compressing the cord. L3 vertebral body was collapsed with tumor seen communicating into it. The intraspinal component extended outside only through one intervertebral foramen. However, the extraspinal component was seen extending several corresponding spinal levels from L1 to L4. The metastatic workup for the patient was negative. Another location of the tumor in the body could not be found out even after thorough work-up.
A linear incision given on the back from L1 to L4 spine. The tumor was found to lie just beneath the skin []. The extraspinal part of the tumor was removed. The tumor was reddish brown, fleshy, vascular [] with infiltration into the surrounding tissue. L3 laminenctomy was performed and the intraspinal part excised. The tumor did not have any obvious connection with any nerve root or dura. There was no plane of demarcation between the tumor and the vertebral body. Vertebral body excision, grafting, and fusion procedures were not done because gross of co-morbidities with anesthetic risk.
Histopathology showed densely cellular fascicles alternate with hypocellular myxoid zones []. The cellular areas showed large number of spindle cells arranged in a storiform pattern []. Each of the spindle cells have irregular contours with abundant eosinophilic cytoplasm and gross cellular atypia, mitotic figures, pleomorphism. Nuclei were wavy, buckled, comma shaped [] with prominent nucleoli [] suggestive of malignant variety of peripheral nerve sheath tumor. Histopathological evaluation was done by two independent pathologists and their impression were same. There were occasional areas of epithelioid differentiation and perivascular accentuation of tumor cells []. Negative glial fibrillary acidic protein (GFAP) immunohistochemistry ruled out astroglial origin []. Ki-67 proliferative index was 5.5%, suggestive of malignant nature of the tumor [].


A 50-year-old female complained of a swelling in her perianal region for the last two months and all the relevant biochemical and hematological investigation were found to be normal. On peripheral blood film examination patient was mildly anemic with a total leukocyte count of 4000/cmm and differential leucocyte count of P 50 L48 M1 E1 B0 with normal platelet count. Clinical diagnosis of perianal abscess [] was made. The abscess was drained, but it didn’t heal and persisted in the perianal region. After two months, wedge biopsy was taken and submitted for histopathological examination. Macroscopically, a partially skin covered soft tissue piece measuring 1.0 × 0.8 × 0.3 cm was received. The biopsy revealed skin and subcutaneous tissue with dense infiltration by small round cells in sheets and trabeculae, enveloping the adnexal structures and infiltrating the subcutaneous fat []. A provisional diagnosis of malignant small round cell tumor was given and the biopsy was subjected to panel of immunohistochemical markers. The initial panel of cytokeratin, neuron specific enolase synaptophysin, chromogranin was negative and LCA was positive []. Subsequent IHC showed that cells were negative for CD 20 and tdt; (Terminal deoxynucleotidyl transferase) positive for myeloperoxidase [] and focal positive for CD3. The peripheral blood film examined showed pancytopenia. Bone marrow showed a cellular marrow with a blast count of approximately 50%. Finally, the diagnosis of Acute Myeloid Leukemia with granulocytic sarcoma (GS)/chloroma of the perianal region were given. To our knowledge, there has not been a previous report of acute leukemia presenting as granulocytic sarcoma masquerading as perianal abscess.


Case 1: A 13-year-1-month old boy weighing 50.5 kg was admitted to our hospital on September 15, 2008 because of 2 weeks of fatigue and pallor associated with 1 week of chest distress. Bone marrow aspiration was carried out immediately. The complete blood count (CBC) of emergency showed white blood cells (WBC) 16.2×109/L, N 11.4%, Hb 75 g/L, Plt 79×109/L. The diagnosis was acute lymphocyte leukemia (ALL) with L2, common-B and middle risk according to the results of bone marrow cytomorphology examination, flow cytometry immunophenotyping (FCMI) and CBC. From September 17 to December 17, 2008, the chemotherapy was carried out sequentially. During the chemotherapy, when the hemoglobin was below 70g/L and/or platelets below 20×109/L, red blood cells (RBC) and/or platelets were transfused respectively, and fresh frozen plasma was used when dysfunction of blood coagulation was detected. He was multi-transfused with 16 U RBC, 20 U platelets and 820 ml fresh frozen plasma. During each hospitalization, screen tests of rapid plasma reagin (RPR), antibody of HIV (HIV-Ab) and hepatitis viruses were carried out. On February 1, 2009, he was admitted again for consolidation chemotherapy. Before transfusion, his blood sample was positive for HIV antibody [human immunodeficiency virus antibody diagnosis reagents (double antigen-binding enzyme-linked immunosorbent assay), INTEC (Xiamen) technology Ltd. LOT: 2008066607]. The result was confirmed by the Center for Disease Control (CDC) (HIV 1/2 Antibody Immunoblot Kit, MP Biomedicals Asia Pacific Pte. Ltd. Lot: AE8034). After retesting of blood products that this patient had received before, it was confirmed that the first used FFP carried the HIV. There was no transfusion before the diagnosis of ALL, no operation and infectious disease in his past history. The history of preventive vaccinations was normal. His parents and elder brother were healthy, with negative HIV screen tests.


Case 2: A 4-year-9-month old girl weighing 21 kg was admitted to hematology department of our hospital on December 8, 2009 because of 20 days of abdominal discomfort and anorexia. The initial CBC showed WBC 0.83×109/L, N 7.2%, Hb 90 g/L, Plt 202×109/L. The diagnosis was ALL (L2, common-B, low risk) according to the results of bone marrow cytomorphology examination, FCMI and CBC. During the first hospitalization from December 8, 2009 to January 22, 2010, she formally underwent chemotherapy. During the second hospitalization from February 16, 2010 to April 3, 2010, sequential chemotherapy was carried out. Totally, 2 U RBC, 5 U platelets and 1500 ml fresh frozen plasma were transfused during the two hospitalizations. During the third hospitalization, her blood test for HIV-Ab was positive [human immunodeficiency virus antibody diagnosis reagents (double antigen-binding enzyme-linked immunosorbent assay), INTEC (Xiamen) technology Ltd. LOT: 2010046607]. The result was also confirmed by CDC (HIV 1/2 Antibody Immunoblot Kit, MP Biomedicals Asia Pacific Pte. Ltd. Lot: AE9015). Later, tests of blood products transfused showed that the fourth RBC carried the HIV. There was no transfusion before her diagnosis of leukemia, no operation and infectious disease in her past history. Her history of vaccinations was normal. Her parents were healthy, and their blood sample was negative for HIV-Ab.


The patient is a 67-year-old Korean woman with no previous history of psychiatric problems serious enough to require psychiatric treatment. She had been an active female shaman for more than 30 years, but this work had not affected her judgment or reality. No one in her family had received medical services from the psychiatric department, and alcohol abuse was not suspected. With the exception of behaviors manifested during the performance of exorcisms, the patient did not exhibit improper behavior or elevated mood; therefore, a mood disorder could not be diagnosed.
In October 2009, she was diagnosed with buccal cancer and underwent oral cavity excision surgery. After the operation, adjuvant radiation therapy was recommended, but she refused further treatment due to a rumor that radiation therapy causes great harm. Unfortunately, in January 2010, pain in the oral cavity was aggravated, and she became anxious about dying from cancer. At the same time, she began to hear a male voice whispering about her every movement and developed a persecutory idea that neighbors would steal her house after her death.
When she visited the Psychiatry Department in July 2010, she complained of auditory hallucinations in the form of voices about her movements. She reported that several cameras in her house watched her and that she would be killed by neighbors while she was sleeping. Based on these reports, we suggested hospitalization for close observation and correct diagnosis.
During the patient's psychiatric interview, she reported auditory hallucinations, ideas of reference, and persecutory delusions. No abnormalities emerged from a physical examination, a blood test, or electroencephalography. The brain MRI showed mildly diffuse brain atrophy ().
Neuropsychological testing was difficult to complete due to the patient's inattention and evasiveness. shows the results of the patient's neuropsychological assessment. The results of the Korean Consortium to Establish a Registry for Alzheimer's Disease assessment (CERAD-K; ) did not meet criteria for cognitive impairment.
In summary, we diagnosed this patient with VLOSLP on the basis of her psychotic symptoms and test results.,
The patient was initially treated with 10 mg of olanzapine, which she tolerated well, and the dose was increased to 20 mg. During her admission, her perceptual disturbance was reduced. However, residual persecutory ideas remained at the time of her discharge, so we changed medication from olanzapine to amisulpride. After 3 months, we increased her amisulpride dose to 400 mg, and her residual symptoms almost disappeared.


A 59-year-old man visited the emergency department due to severe epigastric pain. A perforated duodenal ulcer was diagnosed, and a primary closure with omentopexy was performed. However, radiocontrast study 6 days later revealed leakage from the primary closure site (). A partially covered SEMS (HANAROSTENT® duodenum/pylorus (NCN), 2.0×11.0 cm; M. I. Tech Co., Ltd., Pyeongtaek, Korea) was applied to the leakage site through the scope. Five days later, follow-up radiocontrast study did not reveal any leakage (), and the amount of peritoneal drainage decreased to less than 15 mL/day. Oral feeding was permitted immediately, and the stent was removed 13 days after the insertion. Balloon dilation was required due to duodenal stricture after 2 months. The patient was in good condition during a 2-month follow-up after the dilatation.


A 55-year-old man underwent total gastrectomy with lymphnode dissection and end-to-end Roux-en-Y esophagojejunostomy for advanced gastric cancer. Pneumoperitoneum was observed 8 days after the surgery, and a second operation revealed extensive leakage from the esophagojejunal anastomosis. Only irrigation and drainage could be performed, because a primary closure was impossible due to the friability of the operated tissue. However, most of radiocontrast still leaked out 10 days after the second surgery.
Endoscopy revealed near-total dehiscence of the anastomosis (). Completely covered SEMS (Niti-S esophageal covered stent, 1.8×6.0 cm; Taewoong Medical Co., Goyang, Korea) was applied. However, the stent migrated distally 2 days after the insertion. Thus, we placed an anti-migration stent with 1.0-cm-wide uncovered proximal flanges and silk threads that linked its upper edge with the patient's earlobe (CHOOSTENT® esophageal ST (CCN), 2.2×12.0 cm; M. I. Tech Co., Ltd.) after removing the migrated stent. Oral feeding was started after 2 weeks, and the drainage from the catheter stopped 4 weeks after the insertion of the stent. A follow-up radiocontrast study revealed no leakage, and the stent was removed 5 weeks after the second stent insertion. Minor bleeding occurred after the removal because the uncovered portion of the proximal flange was embedded in the mucosa. Follow-up endoscopy 10 days after the removal revealed complete healing of the dehiscence and bleeding site (). The patient died 3 months later from the progression of gastric cancer.


A 58-year-old man received a thoraco-laparoscopic esophagectomy with a cervical esophagogastrostomy due to submucosa-invasive esophageal cancer. Hypovolemic shock and acute renal failure occurred 2 days after the surgery, and continuous renal-replacement therapy followed. Three weeks after the surgery, a radiocontrast study revealed leakage from the esophagojejunostomy, and endoscopy revealed a 1.2-cm dehiscence of the anastomosis that was located 18 cm from the incisors (). The radiocontrast that was injected into the working channel of the endoscope was discharged to the cervical drainage. We applied an anti-migration stent with 0.5-cm-wide, uncovered proximal flange and silk threads (CHOOSTENT® esophageal ST, 2.2×12.0 cm; M. I. Tech Co., Ltd.). However, the attempt to perform a fixation to an earlobe failed because the threads were broken during the insertion. A nasojejunal tube (ENBD-7-LIGUORY, 7 Fr, 250 cm; Cook Medical Inc., Winston-Salem, NC, USA) was inserted through the scope for feeding. The stent did not migrate, but a follow-up endoscopy revealed that a fistula was present at the anastomosis site 4 weeks after the insertion of the stent. Repeated endoscopic examination revealed the complete closure of the fistula 7 weeks after the insertion, and the stent was removed (). The patient remained stable over a 1-year follow-up period.


A 55-year-old male underwent laparoscopic transhiatal esophagectomy with a cervical esophagogastrostomy because of submucosa-invasive esophageal cancer. Pneumonia and a wound infection developed, and intensive care for the complications followed. Eight days after the surgery, exudative discharge was observed at the cervical drainage site. Endoscopic examination was performed 4 weeks after the surgery because the patient's vital signs were unstable, and it revealed a 1.4-cm fistula opening with necrotic material at the esophagogastrostomy, 17 cm from the incisors. We applied a fully covered stent with a funnel-shaped proximal flange (Choo Cervical Stent cervical type, 1.8×8.0 cm; M. I. Tech Co., Ltd.) because the fistula was very close to the upper esophageal sphincter (). Silk threads that were attached to the upper edge of the stent were successfully fixed to the patient's earlobe. Oral feeding was started 5 days after the insertion of the stent. Three weeks after the insertion, a radiocontrast study still revealed minor leakage. Thus, the stent was maintained for an additional 2 weeks and then removed. The patient improved and remained in good condition for 1 year.


A 33-year-old male presented with multiple, reddish-brown plaques, and nodules involving the face for last 14 years. The lesions were insidious in onset, starting from the cheek, slowly increasing in size and number to involve forehead, nose, chin and had progressed to involve the left shoulder in last 1 year. The patient did not have any other complaints, except mild itching at times in the lesions. He did not give any history of trauma.
On examination, multiple, reddish-brown plaques and nodules, firm in consistency, were present on bilateral cheeks, forehead, nose, chin and left shoulder ranging in size from 0.5 × 0.5 cm to 2.5 × 2 cm. There was no systemic involvement [Figures and ]. The clinical differential diagnoses considered were keloid, lupus vulgaris, nodular sarcoidosis, cutaneous leishmaniasis, granuloma annulare, and erythema elevatum diutinum.
Biopsy was taken from the lesion on the forehead and shoulder and both showed similar histology. Biopsy showed a diffuse dense infiltrate in most of reticular dermis, mainly consisting of neutrophils and histiocytes, with scattered lymphocytes and occasional plasma cells. The infiltrate surrounded small thickened vessels and extended extensively into the interstitium, and small amount of nuclear dust also was seen. Overlying epidermis and dermo-epidermal junction was completely spared [Figures –].
The above findings were consistent with a diagnosis of granuloma faciale. The patient received intralesional triamcinolone acetonide 40 mg/ml every 4 weeks for 6 months, but there was no response. The patient is currently on intralesional triamcinolone 40 mg/ml every 4 weeks with topical tacrolimus. There is slight flattening of few lesions.


A 45-year-old male consulted a general practitioner for his pedal edema of 1 week duration. He was detected to have renal dysfunction and was referred to us. The patient was unwell, 2 months after a tooth extraction and had consulted three doctors for his clubbing and generalized feeling of lassitude. He never had any medical illness in the past and was told to be normal after evaluation. The details of those evaluations were not available. The patients also had dyspnea on doing more than ordinary work for 6 months and had paroxysmal nocturnal dyspnea (PND) of 1 month duration. The clinical examination showed pallor, pan-digital clubbing and pedal edema. The blood pressure was 110/70 mm Hg, pulse rate 98/min, and respiratory rate 26/min. The kidneys were 9.5 cm long on both sides with increased cortical echogenicity, hemoglobin was 6.5 g/dl, serum urea 107 mg/dl, serum creatinine 4.5 mg/dl, Modified Diet in Renal Disease estimated glomerular filtration rate (MDRD e-GFR) 23 ml/min/1.73 m2), and normal WBC count (total count 5600/mm3). The urine showed microscopic hematuria (RBC > 100/hpf), hyaline, granular casts, and 24-h proteinuria was 650 mg/day. The chest X-ray film showed normal findings. The dyspnea and PND improved with blood transfusion and diuretics. The renal biopsy showed pauci-immune fibro-cellular crescentic vasculitis [Figures and ] with vessel necrosis and inflammation [].
The c-ANCA and p-ANCA were elevated, and the C3 complement was repeatedly low and C4 was low normal. Three doses of 0.5 g of injectable methylprednisolone were given followed by oral steroid (0.5 mg/kg/day) along with oral cyclophosphamide (1 mg/kg/day). The renal functions improved and the serum creatinine stabilized at 1.8 mg/dl. Echocardiography showed small vegetations in the mitral leaflets with severe mitral regurgitation, moderate severe mitral stenosis, and severe pulmonary arterial hypertension. The patient was characterized as “possible infective endocarditis” as per the modified Duke's criteria for infective endocarditis with one major criteria – positive echocardiogram for infective endocarditis with an oscillating intra-cardiac mass on the mitral valve, and two minor criteria: (1) predisposing rheumatic mitral valve disease with a recent history of tooth extraction and (2) immunological renal involvement in the form of dual ANCA-positive vasculitis. The cyclophosphamide was stopped and steroids were rapidly tapered and stopped. The vegetations grew in size over the next 4 weeks despite empirical antibiotics for culture-negative endocarditis. Due to absence of history of fever or leukocytosis and as all the blood cultures were negative, it was not clear if the patient had infective endocarditis or the small vegetations were secondary to vasculitis. The vegetation continued to grow despite vancomycin, cefaperazone/sulbactum therapy, and hence the valve was replaced with a bioprosthetic valve. The abnormal valve with the vegetation is shown in . The C3 normalized within a month after valve replacement, c-ANCA was negative after 2 months, and p-ANCA normalized when it was tested after 4 months. The immunosuppression was stopped within 2 weeks after diagnosis and the patient continues to be stable over the 4 months follow-up now.


A 26-year-old female presented to the dental Outpatient Department (OPD) with complaints of toothache. The dentist found that her teeth were abraded with irregular surfaces. She had the habit of eating uncooked rice and wheat for the last one-and-a-half years, hence, she was referred to the Psychiatry OPD. This habit started during fourth month of her pregnancy. She had an intense and irresistible urge to eat these substances despite being aware of their non-edible nature.
Every attempt of resistance was leading to a feeling of restlessness and anxiety, which resolved only after eating. Initially she was expecting it to subside within few months after delivery like earlier pregnancies, but it persisted with similar intensity. She never ate any other non-edible substance. Her choice between rice and wheat was determined by their availability and there was no preference for either. She always had abdominal discomfort because of her eating patterns. During the last six months she was subjected to multiple religious practices by faith healers, for treatment of the said supernatural illness, but without any result. Pregnancy was reported as uneventful except for swelling of the lower limbs. She delivered a healthy male baby vaginally at home. No other precipitating factor or stress was found.
There was no history of any other abnormal behavior or irrelevant talks, although wasting of time due to her eating habit resulted in inadequate care of the children. There was no history of other repetitive action, ritual or mental repetitions.
She had revealed a similar habit during her previous pregnancies four and six years prior. Every time it started during the third or fourth month and resolved spontaneously two-to-three months after delivery. Both the earlier pregnancies were uneventful and she delivered healthy male and female babies, respectively. There was no past history of psychiatric illness, medical illness, or substance abuse. She and her husband were farmers, living with their three children. Her paternal grandmother had a habit of excessive washing and cleaning. The patient was an illiterate tribal, unable to understand Hindi or English. All communications were mediated by her husband who understood Hindi with some difficulty. On mental status examination she had a depressed mood, in addition to preoccupation with ideas of eating raw rice or wheat. She acknowledged that these repetitive, irresistible thoughts were her own, but she could not describe any reason for her habit, except intense urges for it. No other obsession or compulsion was found. She was considered as a case of OCD presenting as pica. All routine investigations including hemoglobin level were normal. The serum micronutrient assay was not done, as it was not available at our center, it being a new medical institute. Behavior therapy was not considered because of the patient's language problem and reluctance of her husband. She was started on fluoxetine 20 mg once a day along with alprazolam 0.25 mg per day. After one month she reported mild mood lifting, although the craving and subsequent eating was unchanged. Fluoxetine was increased to 40 mg per day and alprazolam stopped. Significant improvement was noted in her eating habits and depression after taking 40 mg / day for two months. She was maintained on the same dose for six months, after which she was lost to follow-up.


A 56-year-old female presented to the Schizophrenia Foundation Hospital (SCARF) outpatient services with a seven-year on and off history of sub syndromal anxiety and depressive symptoms related to marital stressors and a one-month exacerbation of symptoms following her son's marriage. Patient was diagnosed as a case of mixed anxiety and depression as per International Classification of Diseases (ICD)-10 criteria. Treatment was initiated with escitalopram 10 mg for a week and discontinued due to gastritis. Subsequently patient was started on amisulpride 50 mg/day and hiked to 100 mg when she gradually reported improvement in mood in 6 weeks. During the next follow up at week 12 of 100 mg amisulpride therapy, she was first noticed to have orofacial dyskinetic movements and amisulpride was discontinued. However, patient was prescribed fluvoxamine 25-50 mg for 8 weeks because of worsening of anxiety and depressive symptoms. During her subsequent hospital visits, patient reported progressively severe dyskinetic movements of the face, neck, right forearm, wrist, and fingers and opisthotonic posturing of the chest. She was evaluated in detail and diagnosed with dyskinesia (drug induced) as per ICD-10. Her Abnormal Involuntary Movement Scale (AIMS) score was 15. A score of 4 on the Naranjo adverse drug reaction probability scale indicates a possible cause of dyskinesia related to amisulpride. Her medical co morbidity also included diabetes mellitus, which was not well controlled. There was no past or current history of substance use or neurological disorder, or any family history of movement disorders or any previous antipsychotic use. Magnetic resonance imaging (MRI) done did not reveal any abnormal finding. To treat drug-induced dyskinesia, fluvoxamine was stopped and patient was started on tetrabenazine. Two months later, tardive dyskinesia persisted and there was no improvement in dyskinetic movement. Patient has recently been started on clozapine for dyskinesia.


An 80-year-old gentleman presented to A&E department for general weakness and paralysis of all four limbs. His past medical history includes Type 2 diabetes mellitus, spinal stenosis at the level of L2/L3, L3/L4 and L5/S1. His drug history includes aspirin, simvastatin and omeprazole.
The initial diagnosis was thought to be Guillan–Barre syndrome. However, he denied any recent flu-like symptoms or dysphagia. He said that he had become unwell since his cystectomy operation 4 months prior to his attendance at A&E. He also denied any loin pain. On examination, his abdomen was soft, a draining ileal conduit stoma was observed, sensation and reflex at all limbs were intact, but motor power of all limbs was diminished.
His initial blood test shows the potassium level of 9.1 mEq/l, serum urea of 20.1 mM/l, creatinine of 521 µM/l. He was immediately treated with calcium gluconate 10%, insulin-sliding scale and salbutamol nebulisers. An ultrasound scan of the renal tracts was carried out and subsequently shows bilateral hydronephrosis. Computed topography of the head revealed no intracranial bleed or infarct for the cause of paralysis. Due to his worsened renal function, a loopogram was performed and showed a stricture 4 cm proximal to the skin opening of the ileal conduit (see Fig. ).
The patient was treated conservatively with 2 weeks of intravenous Ciprofloxacin antibiotics and nephrostomy tubes were inserted as a diversion. He underwent a laparatomy and revision of ileal conduit 2 months later. The surgical exploration revealed a small fibrous tissue band of mesenteric origin 4 cm proximal to the skin opening of the ileal conduit. The patient recovered uneventfully, his renal function improved remarkably and he was discharged back to community care after a stormy hospital stay.


A 19-year-old girl presented to the Emergency Department at 1 am after having a football kicked from a distance of 5–10 m into her abdomen 7 h previously whilst watching a game. She complained of worsening diffuse abdominal pain and vomiting. Her observations were stable; however, on examination, her abdomen was diffusely tender and there was evidence of generalized peritonism. She had a white cell count of 18.8 × 109/l, but the rest of her blood tests, including amylase, was normal. Her chest radiograph did not show any evidence of free air under the diaphragm. A computed tomographic (CT) scan of her abdomen and pelvis was arranged, which showed abnormal areas of low attenuation and multiple pockets of air in the right flank, surrounding the right kidney and in the right sub-hepatic space, consistent with a perforation of either the ascending colon or the duodenum (Fig. ). A laparotomy was performed and a 0.5 cm perforation was seen in the antero-lateral border of the duodenum at the junction of the first and second parts of the duodenum following kocherization. The perforation was oversewn and repaired with an omental patch. She recovered well from the operation and was discharged 4 days later.


A 3 year old girl was referred to our department with complaints of double lower lip with drooling of saliva from angle of mouth []. There was no history of consanguity and no significant antenatal history. There was no history of other similar anomalies in the family. The child was born full term by normal vaginal delivery with no other detectable associated anomalies. Though the child was able to feed normally and achieved normal developmental milestones, there was constant drooling of saliva from the mouth. The child came for this drooling of saliva and correction of the deformity. The child underwent all routine investigations which were within normal limits. Lateral and Antero Posterior X- ray views of face showed duplication of right half of mandible with an extra row of tooth buds [Figures and ].
The child was planned for surgery with the goal to correct both the anomalies in a single stage. Patient was operated under general anaesthesia with nasal intubation. Plan was to preserve the right commissure with vermillion and excise the remaining tissues with the duplicated vermillion. Elliptical incision was given encircling the duplicated odontogenic material extending to the left of chin along the relaxed skin tension line []. The incision was deepened to the anterior surface of mandible. The excess odontogenic tissues along with the inferior row of extra dentition was removed [The Hypoplastic vermillion was augmented by vermillion sharing and the lower lip was thus reconstructed []. The patient was discharged after seven days [].