In May 2008, a 67-year-old woman residing in the United States of America presented with a history of postmenopausal bleeding since January 2008. She had been using local estrogen treatment for vaginal dryness without any systemic hormonal therapy. She had been diagnosed with an endometrial carcinoma and was advised to undergo surgery. As she wanted to avoid surgery, she sought an alternative treatment and consulted DW. The clinical examination was normal, with normal body weight, and a transvaginal ultrasound scan showed normal appearance of the myometrium and endometrium. An outpatient endometrial pipelle biopsy was performed which revealed a moderately differentiated adenocarcinoma () with minimal myometrial invasion (Clinical FIGO stage I). An LNG-IUS (Femilis, Contrel Research, Ghent, Belgium) releasing 20 μg of LNG/d was inserted (), and advice was given to request a repeat biopsy within the next 3 to 6 months. Spotting continued for several weeks and then stopped. As the patient was completely free of symptoms 6 months after insertion of the LNG-IUS, a pelvic transvaginal ultrasound was performed, including a 3D-ultrasound and a Duplex Doppler with Color Flow Mapping. The uterus appeared completely normal, and there was no evidence of any pathology. The endometrium showed normal thickness, and there was no evidence of any endometrial abnormality or myometrial invasion (Figures and ). The LNG-IUS was identified in situ, as expected. Three months later, in order to ascertain complete remission, the LNG-IUS was removed, and a full D&C was performed. The uterine sound length was 6 cm. The whole cavity was explored, and very scant tissue was removed. Histological examination of the specimen revealed a secretory endometrium without signs of hyperplasia or atypia (). A mini Femilis LNG-IUS (crossarm 24 mm long and 28 mm long and 2.0 wide drug compartment) was inserted as a precaution.
The patient was again examined two years following initial treatment. She had no symptoms, and vaginal ultrasound showed a very thin endometrium and normal position of the LNG-IUS in the uterine cavity.


A 50 year old asymptomatic woman was referred to our out-patient clinic following occasional detection of a mediastinal mass. On routine chest x-ray performed before orthopaedic surgery, the suspicion arose of a mediastinal mass. A computed tomography (CT) scan showed a cystic mass in the posterior mediastinum between the aortic arch and the vertebral bodies (Figure ). The cyst extended from the 3rd thoracic vertebral body to the tracheal carina plane, with a length of 4 cm and a transversal diameter of 2.5 cm. The lesion appeared cystic with a well defined capsule and lacking enhancement after intravenous contrast injection. Surgical treatment was decided upon. Preoperative bronchoscopy excluded any communication between the cyst and the tracheobronchial tree. After double lumen intubation, the patient was placed in a right lateral position on the operating table. Three trocars were used: one on the fifth intercostal space along the anterior axillary line; one on the fifth intercostal space along the posterior axillary line; and the last one on the 7th intercostal space along the midaxillary line. The cyst was visualized by thoracoscopy, appearing with a major adhesion on the distal portion of the aortic arch (Figure ). To facilitate surgical dissection of the cystic lesion from the aorta, fluid aspiration was performed (Figure ). Once the cyst was empty, complete resection from the adherent aorta was easily completed (Figure ). However, despite total lesion excision, we completed the surgical procedure by passing the electrocautery on the pleural area where the cyst was adherent (Figure ). The procedure was completed with insertion of a chest tube. Histology examination confirmed the diagnosis of benign bronchogenic cyst with the typical feature of a ciliated columnar epithelial lining. The postoperative (PO) course was uneventful and the patient was discharged home on the 5th PO day. At 12 months follow-up the patient remains well with no recurrence on control CT scan.


A 9-year-old boy presented with progressive gait disturbance and right-sided weakness of 1 year’s duration. His past medical history was significant for hydrocephaly, and he had experienced several episodes of tonic-type seizures prior to the age of 3 years. He had demonstrated clinical improvement without specific antiepileptic therapy.
Upon admission, he was diagnosed with a pineal gland tumor on the basis of the physical examination and radiologic findings []. The tumor was resected by the supracerebellar infratentorial approach, with the patient in the Concord position. A preoperative extraventricular drainage to the right side of Kocher’s point was performed and cerebrospinal fluid (CSF) was noted to drain slowly. The dura was opened, the cisterna magna was dissected, the bridging veins draining to the transverse sinus were removed, and the cerebellum was allowed to move inferiorly. The mass was then completely resected without complication. Pathology confirmed the presence of a mature teratoma.
The patient was noted to be lethargic postoperatively and, when a subsequent brain CT scan showed bilateral parietal EDHs, emergency craniotomy was performed for their removal []. Follow-up brain CT after reoperation demonstrated the presence of small bifrontal EDHs []. The mentality was recovered but the patient complained of continuously headache and gait disturbance and, therefore bilateral frontal twist trephination and hematoma removal was performed 2 weeks later. The headache, gait disturbance, and right hemiparesis improved following this and there has been no evidence of tumor recurrence during the 3-year follow-up period [].


We report the case of an 84-year-old Caucasian woman with a previous history of arterial hypertension controlled with an angiotensin converting enzyme (ACE) inhibitor. She had no other known personal or family history. She was referred to our hospital after consulting another hospital for epigastric abdominal pain. An upper gastrointestinal (GI) endoscopy had revealed an extensive ulcer of the gastric antrum with signs of recent bleeding and the biopsy was not representative of the lesion, so the result was negative for malignant cells.
Upon arrival at our hospital, she was pale and underweight. She presented with black stools and early satiety. A hard, well-defined abdominal mass was felt in her epigastrium. Laboratory tests revealed a hemoglobin of 7.1 g/dL, so she had a blood transfusion and was admitted to our hospital. An upper GI endoscopy with biopsy was performed, again with the same results.
The upper gastrointestinal series was consistent with a mass in the antrum and the abdominal computed tomography (CT) scan revealed a thickening of her gastric wall and a mass without a clear interface with her liver. She underwent a sub-total distal gastrectomy with a Billroth type-2 anastomosis. Intra-operatively, she was found to have a perforated mass with extraluminal growth and adherent to the liver (Figure ), which led to a resection of the liver parenchyma adjacent to the tumor. In the post-operative period, she developed systemic inflammatory response syndrome (SIRS) with multiple organ failure and died on the 23rd post-operative day.
A macroscopic exam of the specimen revealed an ulcero-infiltrative lesion occupying most of the antrum, measuring 8 × 5 × 1.1 cm, and infiltrating her gastric wall to the serosal layer. On cutting the adherent liver fragment, a tumor was identified as a whitish nodular sub-capsular lesion of well-defined limits with a major diameter of 1.5 cm.
A pathological exam revealed a poorly-differentiated malignant epithelial neoplasia of solid pattern (polygonal cells bound by Schultz bridges) and focally glandular with expansive growth (Figure ). The lesion was perforated, with bacterial infection and significant inflammatory reaction which was responsible for the adhesion to her liver tissue. Venous and lymphatic invasion were identified, as well as peri-neural growth.
The remaining mucosa had active atrophic chronic gastritis with intestinal metaplasia and Helicobacter pylori infection. No squamous metaplasia was identified. There was metastatic neoplasia in one of the eight identified lymphatic nodes, as well as in her liver fragment (without infiltration of the Gleeson capsule). A histochemical study with Periodic acid-Schiff (PAS) revealed (intracytoplasmic and extracellular) mucopolysaccharides (Figure ). Keratinization was found in the primary tumor and on the metastasis. An immunohistochemistry panel with AE1 AE3, CAM 5.2, Chromogranin A, Sinaptophysin, HMB-45, S100 protein and c-Kit (CD117) was performed, being strong and diffusely positive for AE1 AE3 and CAM5.2 in the neoplastic cells, and negative for the remaining antibodies. A specific squamous cell staining with 34βE12 was positive (Figure ).
This allows us to classify the tumor as a carcinoma of the gastric antrum (AE1 AE3 and CAM5.2 positivity) with a glandular component, but predominantly epidermoid (approximately 80 percent). No neuroendocrine differentiation was observed (Cromogranin A and Sinaptophysinwere negative) and gastrointestinal stromal tumor (GIST) and melanoma were excluded (c-Kit, HMB-45 and S100 protein were negative). The tumor extended to her serosa with lymphatic and venous invasion, and presented with nodal and hepatic metastasis. The nodal (Figure ) and hepatic (Figure ) metastasis presented both cellular lines (squamous and glandular) but the majority was occupied by the squamous component.


A 16-year-old Caucasian boy was brought to the emergency department of our hospital after a motor vehicle accident. According to the description of the accident, the young man was hurled from his motorcycle and hit an immobile obstacle, impacting on it with his anterior abdominal wall. He had no apparent external injuries. When he arrived at the hospital he was haemodynamically stable with a blood pressure reading of 120/80 mmHg, a heart rate of 88 pulses/minute and a Glasgow Coma Scale(GCS) score of 15. The patient experienced pain and tenderness on palpation of his right upper abdominal quadrant; the rest of his abdomen was soft and nontender to palpation.
The patient underwent laboratory and radiological examination consisting of x-rays of his head, cervical spine, lumbar spine, chest and abdomen. His blood was cross-matched and an ultrasound examination of his abdominal region was performed in the emergency department to rule out any intra-abdominal haemorrhage and/or any organ injury. Laboratory results showed no specific pathological values (haematocrit of 41% and a white blood cell count of 9,500K/μl). The initial workup did not include serum amylase levels, since a basic serum biochemistry was examined at that time. Plain radiological and ultrasound examinations of the patient showed no pathological findings either. Soon after being admitted to hospital, the patient presented haematemesis and his clinical condition deteriorated. His abdominal pain increased at this time. An abdominal computed tomography (CT) scan without contrast agent administration was subsequently performed. This revealed a retroperitoneal haematoma at the level of the duodenum (Figure ).
Due to the patient's clinical condition worsening and the CT findings, we did not deem it necessary to perform an upper gastrointestinal endoscopy, and decided to proceed to an immediate exploratory laparotomy. The patient's peritoneal cavity was approached through a midline supra-umbilical incision. No solid organ bleeding or injury was found intraperitoneally. In the region of the head of the pancreas and the second part of the patient's duodenum, there was a retroperitoneal haematoma, which upon investigation was found to contain a fully circumferential rupture of the second part of the duodenum. There was also an apparently superficial rupture of the head of the patient's pancreas.
Both stumps of the patient's injured duodenum were dissected and Vater's papilla was found to be next to the distal stump. The major pancreatic duct was catheterised through the papilla of Vater and saline was injected to check for the presence of a rupture and none was found. The bile duct was also catheterised - as in the case of the pancreatic duct - but no rupture was found along it. Debridement of the stump edges followed, as far as was possible. Due to the position and the extent of the lesion, the risk of disrupting the blood supply of the remaining parts of the patient's duodenum was high and the option of restoration of the duodenal continuity with a primary end-to-end anastomosis was ruled out.
In order to restore the continuity of the patient's duodenum, we decided to interpose a pedicled loop of ileum (middle part of ileum) to bridge the gap. The two end-to-end anastomoses were performed at two layers (the bottom one in continuous suture) following catheterisation of Vater's papilla through a choledochotomy so that the papilla could be located and immobilised, in order to avoid including it in the suture line (Figures and ). Finally, a T-tube was placed through the choledochotomy and an intraoperative cholangiography confirmed that the patient's bile duct was unobstructed and the contrast agent was passing freely into the duodenum. There was no loss of blood during the operation. For better recovery, the patient was transferred to the intensive care unit, where he stayed for five days without presenting any particular problems.
Postoperatively, the patient was given octreotide subcutaneously at a dosage of 0.1 mg three times a day for a total of 15 days to treat his pancreatic injury. His haematocrit remained stable at about 38%, and his white blood cell count stayed at a steady level of around 10,000 K/μl. His serum amylase level was on average 100 IU/L. On the 10th postoperative day, the patient had mild leukocytosis (17,000 × 103/μl), a serum amylase level of 166 IU/L and a body temperature of up to 38.8°C. An abdominal CT scan showed fluid collection in the region of the head of the patient's pancreas, which was clearly demarcated and not compatible with a pseudocyst. The consensus was that these were manifestations of pancreatitis. The antibiotic treatment was changed from intravenous ampicillin/sulbactam 3 grams once a day to intravenous ciprofloxacin 400 mg two times a day and in the next few days the patient's body temperature dropped and there was a gradual decrease in his white blood cell count and serum amylase levels. The patient continued to be given fluids parenterally. Abdominal CT scans performed on postoperative days 12 and 19 showed a reduction of the fluid in the region of the head of the patient's pancreas and significant improvement of the original imaging findings. The patient was orally fed from the 14th postoperative day and tolerated this very well. An upper gastrointestinal series with water-soluble contrast medium (Gastrografin) was performed on the 20th postoperative day. The contrast material passed easily from the patient's stomach to the duodenum and no stenosis in the region of the anastomoses or leaks or fistulae appeared (Figure ). A cholangiography was also performed through the T-tube. This showed a satisfactory flow through the patient's bile duct and an unobstructed passage of the contrast agent to his duodenum (Figure ). The T-tube was removed the following day (21st postoperative day). The patient was discharged on the 22nd postoperative day in excellent general condition and has remained so to present date, five years later.


A 45-year-old non-smoker, non-alcoholic Hindu male patient presented to our out-patient department with recurrent scanty hemoptysis over a period of one month and a single bout of massive hemoptysis on the day of admission. He was little short of breath while walking even on level ground when compared to persons of his age and sex. He had no associated history of cough, expectoration, fever, chest pain, chest trauma or surgery in chest. His past history was suggestive of repeated antibiotic treatment for recurrent cough and cold, occasional scanty hemoptysis and an abnormal chest radiological finding since childhood including a course of empirical anti-tuberculosis treatment for one year in his late twenties. The chest radiographic finding persisted even after completion of ATD and was explained as a tuberculoma []. He was apparently healthy for the next fifteen years. None of his family members had similar illness, or any cardiac, hepatic, neurological or dermatological problem. Clinically, patient was afebrile, alert, conscious, tachycardic (120/min regular), tachypnic (28/min) with blood pressure 100/60 and reduced oxygen saturation by pulse oximetry (80 - 85%). On general examination, he had clubbing of both fingers and toes with no cyanosis. Examination of the respiratory system revealed no abnormality. Heart sounds were normal, with no precordial or extraprecordial murmur or bruit. Review of other systems was normal. Routine blood examination showed normal total leukocyte count. His chest X-ray showed homogenous opacity with ill-defined margin in left lower zone surrounded by patchy areas of infiltrations. Arterial blood gas analysis in room air revealed hypoxemia (PaO258 mm Hg, SaO284%). He was treated conservatively with blood transfusion and intravenous fluid. Despite minimal chest-X-ray finding and stable hemodynamic status, his arterial saturation did not improve even with 50% oxygen inhalation for 30 min by venture mask (PaO260 mm Hg, SaO285%), which initiated further investigations. Doppler echocardiography was done to rule out intracardiac right-to-left shunt. Contrast enhanced CT scan of thorax showed a few aberrant vessels in left lower zone []. CT- pulmonary angiogram was done and it showed left lower lobe pulmonary arteriovenous malformation with a saccular aneurysm 35 ×30 mm size, mainly involving lateral and anterior basal segments with left lower pulmonary artery as feeding artery and left lower lobar pulmonary vein as the draining vein []. CECT scan of brain and spinal cord and CT scan of abdomen showed no abnormality. He was then referred to cardiothoracic surgeon who later successfully resected the aneurysm.


A 30-yr-old female, diagnosed case of AIDS, was admitted for evaluation of weight loss and intractable diarrhea of 4 months duration. The patient complained of chronic, painless, nonbloody, profuse watery diarrhea with a weight loss of 10 kg (decrease to 30 kg from 40 kg prior to illness). She had no complaints of fever, cough or expectoration.
Previously, during evaluation of her complaints in the outpatient department, she was discovered to be HIV (human immunodeficiency virus) infected with a CD4 count of 38 cells/μl. She also had anemia with hemoglobin value of 8 g/dl, normal kidney function, normal AST/ALT (aspartate aminotransferase/alanine aminotransferase) and elevated serum alkaline phosphatase. Stool examination showed no red blood cells or leukocytes, and no ova or cysts were observed. A contrast enhanced CT scan of the abdomen (figure ) showed diffuse small bowel wall thickening, a fatty liver and no significant lymphadenopathy or ascites. Her chest radiograph was normal. Based on these details, a diagnosis of abdominal tuberculosis was made 2 months back, and she was started on standard 4-drug regimen for treatment of tuberculosis. Besides this, she was also given co-trimoxazole and once a week azithromycin prophylaxis for Pneumocystis jiroveci and mycobacterium avium-intracellulare infection respectively. Two weeks later she was started on non-zidovudine based HAART (highly active antiretroviral therapy), after she had tolerated antituberculosis drugs. However diarrhea failed to improve, and she continued to lose weight.
During this admission her stool sample was sent to a specialized microbiology laboratory, where acid fast oocysts of Cryptosporidium parvum were observed. Her antituberculosis drugs were stopped and she was started on treatment with tablet Nitazoxanide 500 mg twice a day. Her peripheral smear showed a megaloblatic anemia (mean corpuscular volume - 120 fl), for which folate and vitamin B12 were supplemented. Her kidney functions, AST/ALT were again normal, but she had raised serum alkaline phosphatase and a low serum albumin of 2.8 g/dl. In hospital she was also given supportive care with oral rehydration solution, antidiarrhoeals, and a nutritious diet low in lactose. After 2 weeks of nitazoxanide treatment the patient's stool remained positive for cryptosporidium. Her hemoglobin level had improved with folate and vitamin B12 supplementation. At this moment it was decided to discharge her on extended nitazoxanide treatment while continuing HAART, antibiotic prophylaxis and folate and vitamin B12, with monthly follow up.
Patient was again observed 2 months after discharge. Her diarrhea had settled for last 1 week. Her stool this time was negative for Cryptosporidium parvum, which was confirmed twice. Repeat CT scan of the abdomen (figure ) showed resolution of the small bowel thickening, persistent fatty liver, no lymphadenopathy or ascites. A repeat CD4 count was done which was 36 cells/μl only.
Following parasitological clearance, the patient showed improvement in appetite and gained 5 kg weight over next one month. HAART and vitamin supplementation was continued. In view of lack of definite guidelines on secondary prophylaxis, the authors decided to continue nitazoxanide until the patient would achieve a CD4 count of 100 cells/μl.


A 56-year-old male attended the ENT outpatient Clinic complaining of foreign body sensation in the neck and intermittent painful swallow. Symptoms had appeared 3 months ago without history of neck trauma or other incident. On examination, the patient appeared malnourished and reported increased alcohol consumption. He was a heavy smoker and reported a history of hypertension and angina.
Routine ENT examination was unremarkable, as was the flexible endoscopy of the larynx. A barium swallow test also did not show any pathology, and the patient was scheduled for examination under anaesthesia (EUA) which included direct hypopharyngoscopy, microlaryngoscopy, and esophagoscopy. The EUA was normal for esophagus and larynx, but revealed a bulge of the left posterior hypopharyngeal wall protruding into the left piriform sinus. On palpation, it was of bony or cartilage consistency, it had no characters of malignancy and was lined by smooth, macroscopically healthy mucosa (). It was suggested that thyroid cornu could be the underlying cause of the lesion, and a CT scan of the neck was ordered as the imaging study of choice. Biopsy was not an option as the underlying tissue was unknown.
CT scan confirmed the diagnosis of rotated thyroid cartilage and dislocation of the left superior thyroid cornu with medial anterior projection into the ipsilateral piriform sinus ().
The patient was reassured about the benignity of the disease and declined any further surgical treatment. However, he was advised to attend a yearly followup, due to the rest of his history.


A 30-year-old woman presented to hospital in Dhaka, Bangladesh, with 10 hours of sudden onset of voluminous diarrhea and vomiting. Since onset, the patient had experienced seven episodes of diarrhea and three of vomiting, and ingested approximately 2 liters of oral rehydration solution at home. She lived in an informal settlement area of Dhaka with two young children and a husband who was a day-laborer. The family would often drink unboiled tap water stored in open large containers, and shared a toilet with approximately 20 other families. The patient's past medical history was unremarkable. On admission, no family member was suffering from severe diarrhea. On examination, the patient was lethargic and thirsty, and had sunken eyes, dry buccal mucosa, reduced skin turgor, deep and rapid breathing, and a feeble pulse (). She had not urinated since onset of illness. Other systemic examination findings were normal. The patient's stool () had a fishy odor.


A 62-year-old Caucasian woman presented with a six year history of a growing mass in the right side of her neck. Our patient reported that she had had a euthyroid nodular goiter with a compensated autonomous adenoma and suppression of the residual thyroid 21 years previously. At that time, a subtotal thyroid resection of both lobes was performed. The postoperative period was unremarkable.
Clinical examination revealed a right-sided nodular goiter, which moved with swallowing. There was no dyspnea. Laboratory tests showed euthyroid metabolism. Scintigraphy results revealed a non-homogeneous right-sided recurrent goiter with some central cold areas. An ultrasound scan showed a right central richly echogenic nodule surrounded by otherwise poorly echogenic nodular tissue. The volume of the right thyroid lobe was 82 mL, and that of the left thyroid lobe was 3 mL.
Our patient's medical history included metabolic syndrome with second-degree obesity as indicated by a body mass index of 39 kg/m2, orally treated diabetes mellitus type 2b, stage II arterial hypertension according to World Health Organization (WHO) criteria, compensated renal insufficiency following a left nephrectomy for a hypernephroid clear-cell carcinoma (p-T2N0M0G1) in 1985 and an uncertain penicillin allergy, although piperacillin was tolerated with no problems during the reported treatment. Cardiac and rhythmogenic problems as well as epilepsy were excluded one year previously because of drop attacks with an undetermined cause. An episode of pyelonephritis was also treated one year previously with antibiotics. In addition, there was no history of any of the following pre-existing diseases and risk factors: sore throat, alcohol abuse, dermatitis or ulcers, Varicella zoster infection, or recent invasive treatments, injections or operations. There was no history of muscle or skin injuries, thrombotic tendency or infections contracted from a family member or from personal surroundings. Regular follow-up investigations of the cause of the renal carcinoma showed neither relapse nor metastasis, nor a second cancer.
Surgery was recommended because of the increasing size of the right-sided recurrent nodular goiter with cold areas. A right near-total or complete resection was proposed, depending on the intra-operative findings. After extensive discussion with our patient about the proposed surgery, its possible complications and alternative therapies, she decided to undergo the surgical treatment.
A right hemithyroidectomy with neuromonitoring of the laryngeal recurrent nerve was performed. Our standard pre-operative antiseptic procedure was performed, including triple alcohol disinfection of the operation area over five minutes and a single-use sterile covering of the operation site. Our patient did not receive pre-operative antibiotic prophylaxis because her medical history had revealed no increased infection risk.
The exploration of the left thyroid lobe showed a very small, homogeneous and unremarkable thyroid remnant, which was left in place. A drain was placed in the area of the right thyroid lobe and the surgical procedure was completed without complications after 85 minutes.
Our patient was observed for one night in our intensive care unit, which is standard procedure in our department. A temporary increase in our patient's body temperature to 38.6°C was noted in the late afternoon, but this returned to normal by the evening without further intervention. Our patient was able to return to the visceral surgical ward after an unremarkable night and normal laboratory values on testing.
Our patient presented with personality changes, dizziness and arterial hypotension, with systolic values between 80 and 100 mmHg on the evening of the first postoperative day, 29 hours after surgery. Her infusion therapy was continued. A short-term increase in our patient's body temperature to 38.5°C was again noted. Her wound appeared normal. There was no pain. She was returned to our intensive care unit on the evening of the first postoperative day due to increasing deterioration of her general condition and the need for careful observation. Arterial and central venous catheters were applied. Radiological diagnostic tests were performed (Figure ). Radiology (Figure ), microbiology and laboratory investigations were performed on the morning of the second postoperative day. The wound was still unremarkable. No increase in body temperature was observed. Immediate revision surgery was indicated under suspicion of mediastinitis with an unknown bacterium or NSTI. Intravenous antibiotic therapy, including piperacillin 3 × 4 g/day, gentamicin 160 mg/day and vancomycin 2 × 500 mg/day, was given.
Revision surgery took place on the second postoperative day, 20 hours after the start of symptoms and 49 hours after the primary surgery. Serous turbid liquid was revealed, with no bleeding and no evidence of esophageal injury. The wound was swabbed, rinsed and drained. Asystole occurred immediately after surgery and was resolved by mechanical and pharmacological resuscitation without further consequences. Our patient's condition was stabilized by volume substitution. A second revision surgery was performed on the third postoperative day. Infection had increased with grey muddy necrosis of the fascia which was excised and sent to our laboratory for histology. After rinsing the wound, a vacuum dressing was applied. Additionally, pleura drainage was performed on both sides (Figure ). Our patient was stabilized on catecholamine therapy (epinephrine: 0.16 μg/kg body weight/minute; noradrenaline: 0.112 μg/kg body weight/minute). She was ventilated, intubated and analgosedated, and was transferred to the department of pneumology, thoracic and vascular surgery on the third postoperative evening. The presumptive diagnosis of NSTI of the mediastinum with group A β-hemolytic streptococcus (GAS), with sepsis and empyema of the pleura was verified by the microbiological and histological results over subsequent days. A minithoracotomy with opening of the dorsal and anterior mediastinum and opening of all compartments, necrectomy of the upper paratracheal mediastinum and opening of the pericardiostomy was performed on the fourth post-operative day. A suction lavage drainage catheter was placed in each lung (Figure ). In addition, a percutaneous endoscopic gastrostomy (PEG) tube was inserted. The antibiotics used were changed to Zienam (imipenem, cilastatin-natrium) and metronidazol. Our patient's condition stabilized remarkably following these interventions (Figure ).
A further surgical revision, including a change of the vacuum dressing, was performed two weeks later. A circumscribed necrosis of the whole anterior wall of the middle third of the trachea was noted one week later during the dressing change. For that reason, a tracheotomy with a myoplasty of the right sternocleidomastoid muscle was required. The reason for the anisocoria, which had first been observed on the second postoperative day, was glaucoma in our patient's left eye. This was treated without complications in an ophthalmology clinic. After weaning from the respirator, incomplete proximal accentuated tetraparesis in combination with weakness due to inactivity, critical illness myopathy and central apraxia were observed. Our patient was transferred to an early neurological rehabilitation center three months after her initial surgery. At this time, she was tracheotomized but was able to eat and drink independently while the PEG tube remained in place.
Our patient remained immobile and developed a sacral decubitus ulcer, which was treated conservatively. Partial fecal and urinary incontinence were noted. During the three-month rehabilitation period, complete weaning from the respirator, the removal of the tracheal cannula, PEG tube and urinary catheter and mobilization were achieved. Our patient was discharged from hospital six months after her initial surgery. She was continent of feces and urine, was able to attend to her own personal hygiene, could walk 100 m with a walker and was able to climb a flight of stairs (approximately 20 stairs). A further 80 logopedic and 70 ergotherapeutic sessions were necessary to address speaking deficits and loss of motion of her right arm. Our patient had pneumonia of the left upper lobe with cardiac decompensation four months later (16 months after the initial surgery). She was again hospitalized for two weeks and treated with antibiotics for pneumonia. Finally, radiology of the thorax only showed minor residual pathology when compared to the pre-operative X-rays (Figures and ).
At present, four years after the initial surgery, our patient stated during a telephone evaluation that she has scars which are sensitive to weather changes with the feeling of a ring around her thorax. In addition, she has speaking difficulties under strenuous physical and psychological conditions as well as a loss of strength in her right arm. She lives in her own home, but requires assistance with daily activities and is not employed.
The pre-operative values and their controls until the evening of the first postoperative day were unremarkable. The postoperative laboratory values are reported in Table up to her transfer to the department of pneumology, thoracic and vascular surgery (Table ). Blood glucose levels were unremarkable. Discrete fluctuations were treated with insulin. The thyroid hormones were normal under daily prophylaxis with 100 μg of thyroxine.
A nodular colloid goiter with regressive changes was diagnosed in the 9 × 6 × 5 cm right-sided lobulated, resected specimen. There was no evidence of malignancy in the submitted material. The tissue obtained during the second revision surgery showed necrosis and suggested the presence of NSTI. The mediastinal tissue sample taken during the minithoracotomy showed extensive ischemic necrosis with massive bacterial colonization and phlegmonous purulent inflammation. The pericardial biopsy, which was taken during the pericardiostomy in the same operation, showed fibrinous and low phlegmonous granulocytic inflammation.
A lumbar puncture performed on the second postoperative day was sterile. The pleurocentesis revealed serous fluid, which contained leukocytes at a concentration of 20,000 × 103 cells/μL. No infectious agents were detected in either the immediate swabs or subsequent smears. Microbiological analysis of the intra-operative smear taken during the first revision operation revealed the presence of GAS, which was sensitive to the antibiotics administered. The samples of the pleurocentesis and later samples from the chest tube were sterile. Analysis of the bronchial secretions during the bronchoscopy on the third postoperative day revealed the presence of Klebsiella oxytoca and Candida albicans. The mediastinal swabs taken during the three revision operations in the thoracic center first showed the previously diagnosed GAS, later Staphylococcus epidermidis and Candida glabrata and, at the last surgery, Viridans streptococci.
The radiological diagnostic tests are shown in figure , figure , figure , figure and figure . A cranial computed tomography (CT) scan was performed because of our patient's personality changes. The results of this CT scan were normal. A radiological gastrografin swallow was also performed, which did not show an iatrogenic esophageal lesion. In addition, results of a gastroscopy performed on the third postoperative day were normal. A second cranial CT scan was performed on the fourth postoperative day after the successful resuscitation. No bleeding or infarcts were seen and normal internal and external cerebral fluid spaces were seen. Suspicion of a postischemic lesion in the basal ganglia was raised, but no evidence for this was seen in the following cranial CT.
Negative troponin test results and an electrocardiogram ruled out an acute myocardial infarction on the first postoperative day. Echocardiography after resuscitation did not provide evidence for acute cardiac damage on the second postoperative day. Only a slight impairment of left ventricular systolic function was observed.
Bronchoscopy showed a large volume of turbid purulent secretions on the third postoperative day. Pulmonary function tests showed a forced expiratory volume (FEV1) of 1.1 L, which was 50% of the predicted value, and a vital capacity of 1.7 L (61% of the normal value) 16 months after the recurrent goiter surgery. Blood gas analysis indicated partial oxygen saturation (pO2) of 74 mmHg and partial carbon dioxide saturation (pCO2) of 41 mmHg.


A 4-year-old boy presented with 3 days history suggestive of duodenal obstruction. On clinical examination, the patient appeared irritable with no evidence of fever or hemodynamic instability. The abdominal examination was unremarkable except mild discomfort in epigastrium on palpation. Plain abdominal radiograph was suggestive of high small bowel obstruction. Upper gastrointestinal contrast study showed obstruction in the second and third part of the duodenum. The contrast did not pass beyond third part of the duodenum. He was managed conservatively with nasogastric (NG) aspiration, intravenous fluids, and H2 blockers. He had large amount of greenish aspirate from the NG tube every day. His routine hematologic investigations and biochemistry were normal except high serum amylase level (307 U/L). An abdominal ultrasound showed a cystic mass (8 × 9 cm) in the epigastrium in relation to the head of pancreas. Computed tomography scan of abdomen showed similar finding and a diagnosis of pseudocyst at the head region of pancreas was made. Upper gastrointestinal endoscopy showed narrowing of duodenal lumen beyond the second part due to extraluminal compression of C-loop of duodenum []. There was an area of friable mucosa with fistula on the medial wall of the second part of duodenum in the vicinity of ampulla of Vater. A diagnosis of spontaneous internal drainage of pseudocyst of head of pancreas was thought of and no further endoscopic intervention was attempted. Conservative management was continued till the next 72 h when sudden improvement in the clinical condition was observed. His NG aspirates came down and repeat endoscopy showed complete disappearance of mass effect in duodenum with an opening in the medial wall of the second part of the duodenum suggesting spontaneous duodenal fistulization of pseudocyst of pancreas []. The patient had prompt clinical recovery with resolution of symptoms. The NG tube was removed and oral feeds were resumed. He was discharged home and repeat endoscopy done after 1 month was normal. The patient is on regular follow-up for the last 2 years and is doing well.


A 56-year-old female patient was admitted into the Department of Endocrinology of the Emergency County Hospital Timisoara, in August 2020, complaining of dysphonia, fatigue, inspiratory dyspnea and a painless left latero-cervical swelling, which was described as rapidly growing over the previous 4 weeks. The personal history of the patient pointed to a diagnosis of left nodular goiter, detected in 2007, with an indication for surgery since then. The patient declined the recommended treatment and didn’t show up for follow-up a long period of time. At the beginning of 2020, a diagnosis of chronic autoimmune thyroiditis was established.
At admission, the clinical examination of the anterior cervical region revealed a palpable painless nodule of approximately 4 cm, hard in consistency, adherent to the skin. Next to it, we noticed a left latero-cervical adenopathy of approximately 5 cm, fixed to underlying tissues, hard in consistency and painless, that appeared for the first time, affirmatively, in June 2020. The patient noticed a rapid growth of this lesion in the last 4 weeks. The thyroid ultrasound detected a small solid nodule in the right lobe, markedly hypoechoic, measuring 6/7.5/7mm, with a thin hypoechoic halo, showing an ultrasound (US) aspect "taller than wide" and increased internal vascularization. The thyroid nodule was classified according to ACR-TIRADS classification [], based on the nodule’s ultrasound features, as TIRADS 5 ( and ). In the left lobe, the thyroid ultrasound revealed a large solid, marked hypoechoic nodule, occupying almost the entire lobe; this nodule measured 27.7/42.6/26.6 mm, had ill-defined margins, microcalcifications and no halo. The nodule had mild peripheral and no internal blood flow; it was classified as ACR-TIRADS 5 (). On ultrasound, the left latero-cervical lymphadenopathy appeared round, hypoechoic, inhomogeneous, with mild internal vascularity and loss of hilar architecture. It measured 51/45.7/40 mm ().
A computed tomography (CT) scan of the cervical area and thorax was performed, which showed a right thyroid lobe of normal size, with an infra-centimetric nodule and a left thyroid lobe with increased dimensions, having a length of 43/50 mm, and displacing anteriorly the sternocleidomastoid muscle, without a clear separation plan. The latero-cervical left adenopathy measured 54/52/50 mm and was in close contact with the left thyroid lobe, displacing anteriorly the left jugular vein. The CT scan of the thorax showed a solitary infra-centimetric pulmonary nodule in the apex of the right lung that was not clearly described as a metastasis.
The laboratory examination revealed euthyroid status, with increased levels of anti-thyroid peroxidase (509 U/L, normal values < 60 U/L) and anti-thyroglobulin antibodies (481 U/L, normal values<60 U/L), confirming the diagnosis of chronic autoimmune thyroiditis.
The blood analysis also showed a slightly high white blood cell count (10,400/µL, normal values: 4,000-9,500/µL) with moderately elevated erythrocyte sedimentation rate (60 mm/h, normal values: 1-10 mm/h). The calcitonin levels were normal.
Taking into account the characteristics of the nodular goiter, i.e. increased dimensions, hard consistency, fixation to the surrounding tissues, presence of an ipsilateral left latero-cervical adenopathy with similar features like thyroid nodule, with accelerated growth in a short period of time (4 weeks) and compressive symptoms (dysphonia, dyspnea, cough), associated with a personal history of left nodular goiter (with recommendation for surgery more than 10 years before), we suspected the presence of anaplastic thyroid cancer, possibly an anaplastic transformation of a pre-existing differentiated thyroid cancer. The patient was referred immediately for surgery. A negative PCR-test for COVID-19 was required before surgery. Due to COVID-19 pandemic situation, to establish a definite diagnosis, a partial excision of the left latero-cervical adenopathy was performed on August 2020. The pathological examination revealed high grade tumor proliferation, with tumor cells showing diffuse and intense positivity for pan-cytokeratin (pan-CK), negativity for S-100, CD45, TTF-1, PAX8 and positivity for CK7, CK8/18 and EMA, concluding that it was a massive lymph node metastasis from an anaplastic carcinoma, most probably located within the thyroid gland.
A total thyroidectomy was performed on September 2020, after another mandatory negative PCR-test for COVID-19. The postoperative pathological exam identified in the right thyroid lobe a papillary microcarcinoma with irregular, infiltrating margins and follicular architecture, having a diameter of 9 mm. In the left thyroid lobe, a high-grade tumor proliferation was identified, accompanied by large areas of tumor necrosis; the tumor infiltrated the thyroid capsule, with large extension into perithyroidal connective tissue and tumor cell emboli in the lymph and blood vessels from the thyroid and perithyroidal connective tissue ( and ).
The conclusion of the postoperative pathological result was: 1. Undifferentiated thyroid cancer (anaplastic thyroid cancer), pleomorphic subtype, developed in the left thyroid lobe with large extrathyroidal tumor extension (pT4aN1L1V1R0); 2. Papillary microcarcinoma with follicular architecture and irregular, infiltrating margins, developed in the right thyroid lobe; 3. Coexisting chronic autoimmune thyroiditis. From a pathological point of view, the concurrence of two different tumors, split by normal tissue architecture and appearing in the same organ, is the definition for collision tumor, in our case, of the thyroid. Postoperatively, levothyroxine replacement therapy was immediately started, in order to avoid transient hypothyroidism during this period of COVID-19 pandemic. The patient was on a stable euthyroid status with 75 micrograms Levothyroxine, daily. After the oncologic evaluation, the patient was referred to radiotherapy.
At follow-up, in November 2020, the CT scan of the brain, abdomen and pelvis did not show any pathological findings. The CT scan of the cervical area revealed multiple left lymphadenopathies, in group IV, with a diameter of up to 22 mm and a necrotic center, interposed between the internal jugular vein medially, the sternocleidomastoid muscle anteriorly, the external jugular vein laterally, without a clear cleavage plane. Also, the CT scan identified internal jugular venous thrombosis. The CT scan of the thorax confirmed the persistence of the solid pulmonary nodule, with lobulated margins, measuring 8/4 mm, localized in the apex of the right lung.
After 1 year (August 2021), the patient is in a better clinical condition, but she developed a left axillary lymph node that was surgically removed, the pathological examination revealed a metastasis of anaplastic thyroid carcinoma.


A 45-year-old Hispanic female with PsA, nonalcoholic steatohepatitis (NASH), and history of gastric sleeve presents with worsening fatigue, hip pain, and lower extremity weakness. She reports progressive difficulty combing her hair, rising from a chair, and squatting. Physical examination revealed tenderness and swelling in the bilateral wrists, proximal interphalangeal joints, distal interphalangeal joints, and ankles (). Neuromuscular strength of upper extremity was 3/5 and lower extremity was 3/5.
Her medications included diclofenac-sodium 75 mg twice a day and etanercept 50 mg subcutaneous injection once weekly for PsA. Patient was previously on secukinumab, apremilast, adalimumab and prednisone, all of which failed to provide adequate long-term management.
Basic metabolic panel, complete blood count, and erythrocyte sedimentation rate were normal. Rheumatoid factor and anticyclic citrullinated peptide antibodies were negative. Autoimmune panel demonstrated elevated antimitochondrial antibodies of 26.5 and elevated antismooth muscle antibodies of 36. Elevated creatine kinase (CK) level of 1081 and positive anti-Jo antibodies (>8.0) made newly diagnosed inflammatory myositis likely (). Magnetic resonance imaging of the thigh muscles with contrast showed symmetric edema and myofascial enhancement of the anterior and posterior compartment of the thigh.
After detailed discussion with the patient, who was very reluctant to start corticosteroid treatment due to fear of weight gain, she finally agreed to start on prednisone 30 mg daily and azathioprine 50 mg twice a day for inflammatory myositis. This regimen resulted in significant reduction in CK and joint pain. Prednisone was tapered by 10 mg each week. Patient had finished steroid taper after a month. Azathioprine was then switched to mycophenolic acid 500 mg twice a day due to lack of response. Methotrexate was avoided due to history of NASH. Patient was informed that it was likely that prednisone was significantly helping to control her disease. Despite completing steroid treatment and being solely on mycophenolate, she continued endorsing minimal relief of joint pain after 6 months. Because she declined to restart prednisone or any intravenous disease-modifying antirheumatic drugs (DMARDs), mycophenolic acid dosage was increased to 500 mg 3 times daily.
Patient was later referred to a higher level tertiary care center in Los Angeles, California, for confirmatory muscle biopsy. At this facility, DM became a more likely diagnosis due to mechanic’s hands finding appreciated by the outside rheumatologist (). Although the diagnosis of DM is confirmed by muscle biopsy, this facility deemed it unnecessary to perform a biopsy and decided to proceed with treatment. She was started on methotrexate 20 mg once weekly for DM, achieving adequate response.


This case is reported in accordance with the CARE checklist.
 A 58-year-old man with no significant pathological history presented with a 15-day history of intermittent hematochezia associated with asthenia, adynamia, palpitations, and dizziness with positional change. In addition, deterioration of New York Heart Association functional class III/IV heart failure was detected. He had a family history of two brothers with Osler–Weber–Rendu syndrome, diagnosed after 50 years of age, and a brother with cavernous sinus venous thrombosis with a positive prothrombin gene mutation.
Physical examination showed a hemodynamically stable patient, mucocutaneous paleness with conjunctival hypochromia, wet oral mucosa with evidence of telangiectatic-type lesions on the tongue, no thoracic or abdominal abnormalities, and normal findings of a digital rectal examination without bleeding or dilation. A hemogram revealed a leukocyte count of 5 × 103/µL, neutrophil count of 2.5 × 103/µL, lymphocyte count of 1.9 × 103/µL, monocyte count of 0.5 × 103/µL, hemoglobin concentration of 11.3 g/dL, hematocrit of 36.6%, mean corpuscular volume of 88.3 fL, mean corpuscular hemoglobin concentration of 31 g/dL, red blood cell distribution width of 12.9%, and platelet count of 185 × 103/µL. The patient was hospitalized with a diagnosis of lower digestive tract bleeding and hypochromic microcytic anemia. Colonoscopy and endoscopy findings were normal, and the patient was discharged.
Because of persistent symptoms with rectal bleeding episodes, he was readmitted to the hospital and scheduled for capsule endoscopy (). The video capsule showed findings of angiodysplasia lesions in the proximal midgut. We therefore decided to perform antegrade double-balloon enteroscopy, during which angiectasis was found in the distal duodenum (). The areas of angiectasis were sclerosed with argon plasma () without complications and with excellent results, after which the patient was discharged without evidence of new bleeding or anemia. Outpatient follow-up with the internal medicine and gastroenterology departments was performed with clear recommendations and education regarding warning signs. At the time of this writing, the patient was in good health condition without new bleeding episodes or the need for new interventions.


The patient was a 15-year-old girl. Her family and medical histories were unremarkable. On Day –290 (290 days before treatment initiation), at age 14 years, she developed difficulty falling asleep and difficulty waking for no known reason. She developed a sleep-wake rhythm of going to bed at 5 am and waking at 1 pm, and thus, she was late for school. On Day –20, at age 15 years, she visited our department for the first time with the chief complaint of difficulty falling asleep and difficulty waking up on time; subsequently, her condition was diagnosed as DSWPD according to the International Classification of Sleep Disorders, third edition. After she and her parents agreed to off-label use of ramelteon for DSWPD with written consent, she was administered ramelteon 8 mg at 8 pm and zolpidem 5 mg at 11 pm. Her condition showed no improvement after administration. Therefore, she was admitted to our department (Day 0). At admission, her score on the Epworth Sleepiness Scale was 7 and her Morningness-Eveningness Questionnaire score was 21. The hospital follows a policy of lights out at 9 pm and lights on at 6 am, and the patient was instructed to comply with the activity rhythm of the hospital. During hospitalization, we monitored the sleep-wake rhythm of the patient using a sleep log and an actigraph (Octagonal Basic Motionlogger Actigraph; Ambulatory Monitoring Inc., Ardsley, NY, USA), and her biological rhythm was monitored by measuring the rectal temperature (Skin Temp & Humidity Logger LT8; Gram Corporation, Saitama, Japan). The sleep-wake rhythm of the patient using a sleep log before and after treatment is shown in . Ramelteon and zolpidem were discontinued at admission and her progress was monitored. On Days 0 to 2, she fell asleep at 4 am and woke up at 9 am and napped during the day. The mean nadir rectal temperature was recorded at 7 am. Accordingly, from Day 3, ramelteon 8 mg was administered at 7 pm. Subsequently, the mean nadir rectal temperature shifted to 6 am on Days 3 to 5, which indicated a shift in the biological rhythm of the patient by 1 hour; however, no significant difference was observed in her sleep-wake rhythm. In a previous study investigating the phase advance effect of ramelteon on healthy adults, ramelteon 1, 2, and 4 mg ingested 30 minutes before going to sleep moved the biological clock phase forward compared to a placebo; further, no significant difference was observed between the group that received ramelteon 8 mg and the placebo group []. Therefore, we reduced the dose of ramelteon on Day 6 to 4 mg at 7 pm. The delayed sleep phase shifted forward after reducing the ramelteon dose, and on Day 8, she had a sleep-wake rhythm of falling asleep at 10:30 pm and waking up at 6:30 am. In addition, the nadir rectal temperature shifted forward to 4 am on Days 6 to 8. On Day 10, the patient was subjected to irradiation of 10,000 lux of high-intensity white light from 6 am to 8 am. On Day 13, the nadir rectal temperature further shifted forward to 3 am. The patient was discharged on Day 19. She did not use the bright light therapy at home but continued administration of ramelteon 4 mg at 7 pm. The patient was examined as an outpatient on Day 34 and was found to have remained in remission.


A 57-year-old woman two years after last menstrual bleeding with no significant obstetric hystory. She had three normal births and four miscarriage. Her last menstrual bleeding was two years earlyer of day of admission to hospital wich was made because of prolonged moderate postmenopausal bleeding and sonographically suspicious heavy endometrial hyperplasia. On bimanual examination she had enlarged, softened uterus. Dicission was made to perform explorative curettage on department of one-day surgery. During intervention wich was made by general intravenous shorttime anaesthesia. During intervention, heavy bleeding was developed, resulting with spontaneous expulsion of tumorous mass sized 15x7 centimeters, wich macroscopically appeared as molar tissue ().
Immediately after intervention β HCG and complete blood count (CBC) was asked for. β HCG level was 193,057 mlU/mL. CBC was in reference interval except plateles-96x109/L. RTG of lungs was without significance. Due to very high level of β HCG and suspicion of choriocarcinoma, next day patient was taken to laparotomy and during the surgery dicision was made to perform total abdominal hysterectomy with bilateral adnexetomy (). Intraoperative finding was softened, enlarged uterus and no local spreeding of disease was identified during surgery. Postoperative recovery were with no significance. Serum β HCG level on fifth day after surgery was 1,996 mlU/mL. She was discharged on eight day after surgery
Hystopathology report was complete mollar pregnancy on both, the tumorous mass and the uterus.


A 47-year-old female (body mass index, 30.5 kg/m2 (160 cm, 78 kg)) presented in a corresponding hospital with acute pain in the upper abdomen after gastric bypass and cholecystectomy 9 years earlier and loosing 40 kg weight afterward. At the first consultation in the emergency department, she complained of massive abdominal pain since the night before admission, which did not respond to analgesic drugs. Because of the patient’s history of bariatric surgery and the suspicion of SBO, a computed tomography (CT) scan was performed, which was inconclusive at the first look with multiple differential diagnoses. It showed a thickening of the wall of the ascending colon and a diverticulum of the duodenum with semisolid contents. The patient was then referred to our hospital for further treatment.
In our emergency department, the patient’s general condition was reduced because of pain and signs of diffuse peritonitis. The vital signs showed a blood pressure of 120/70 mmHg and an accelerated pulse (120 bpm), a respiratory rate of 25/min and a normal body temperature. The blood results showed a leukocytosis with only slightly elevated C-reactive protein (14 mg/l). The CT scan was reviewed and revealed the presence of retroperitoneal and parapancreatic fluid with some air bubbles, which could also be seen in an additional abdominal sonography. Further a thickening of the colon ascendens was found (). A perforated duodenal diverticulum was likely and suspected. The thickening of the ascending colon was interpreted as an accompanying colitis.
Attributable to the reduced condition of the patient with little response to opioids, signs of diffuse peritonitis and our interpretation of the imaging, we decided to perform an explorative transverse laparotomy in the upper abdomen. Although the right colic flexure was mobilized, the exposure of the duodenum was difficult and very limited. However, a hard resistance could be palpated. After a Kocher maneuver and exposing the duodenum and the pancreas dorsally, we were then able to dissect the duodenal diverticulum. The diverticular wall was incised and a biliary stone of the size of ~7 × 4cm was exposed and removed (). Sutures then reattached the duodenal wall. A T-drain was placed intraduodenally, an Easy-Flow drain paraduodenally ( and ). Postoperatively, the patient was admitted to the ICU for initial surveillance. An empiric intravenous antibiotic therapy with Piperacillin/Tazobactam was initiated. After one night, the patient could be transferred to the normal ward in stable condition.
The postoperative course was uneventful. Pain was controlled with basis analgesia and slowly she returned to a normal diet. Inflammatory markers were declining and antibiotics could soon be stopped. Ten days postoperatively, a fistulography showed a persistent retroperitoneal collection of 3 × 3 cm so the drains were left in situ. Two days later, the patient was discharged from the hospital in proper general condition but with extraduodenal drains still in place.
One week after dismissal, the patient felt well with normal appetite and a regular intestinal passage. The fistulography showed a significant reduction of the collection so the T-drain was removed. Two weeks later, she still felt irritated by the last remaining Easy-Flow drainage, which continued showing some turbid liquid and was therefore left in situ. Intestinal passage was unchanged and there were no signs of inflammation. Another 2 weeks later, the drain fell out by accident. Seven weeks postoperatively, still no signs of inflammation, we were able to finish our treatment.


Our patient is a 39-year-old male diagnosed with plaque psoriasis at the age of 19,
who has trialled multiple topical, oral, and injectable therapies. Phototherapy was
not accessible. In his early 20s, he trialled cyclosporine and methotrexate which
were moderately effective (around 50%–60% improvement in his own words), but both
were discontinued due to uncontrolled hypertension from cyclosporine and severe
gastrointestinal upset from methotrexate.
At the age of 32, he presented to our clinic with a baseline body surface area (BSA)
of 46% and a Psoriasis Area and Severity Index (PASI) score of 26.3. He was treated
with ustekinumab 90 mg at weeks 0, 4, and 16, but had no improvement. A switch to
adalimumab at the recommended dosing regimen for 3 months resulted in some
improvement (BSA 31%, PASI 19.5).
At the age of 34, infliximab was started at a dosing regimen of 5 mg/kg at weeks 0,
2, and 6. After three loading doses at week 12, his psoriasis had not significantly
improved (BSA 27%, PASI 14.5). Infliximab was then increased to 7.5 mg/kg every
8 weeks, and after three additional higher doses his psoriasis improved (BSA 5%,
PASI 4.2).
The following year, his psoriasis worsened (BSA 13%, PASI 10.2). Apremilast 30 mg
orally twice daily was added, but was discontinued after 3 months due to lack of
efficacy and poor tolerance. Infliximab was further increased to 7.5 mg/kg every
6 weeks, but was stopped after 6 months when his psoriasis flared (BSA 38%, PASI
14.8).
Secukinumab was then started at the recommended dosing regimen, and after 3 months
his psoriasis improved (BSA 10%, PASI 4.0). This effect was short lived, as 3 months
later his psoriasis had worsened (BSA 20%, PASI 13.5). He then switched to
ixekizumab at the recommended dosing regimen. After 3 months, his psoriasis
moderately improved (BSA 11%, PASI 12.4). His psoriasis continued to improve by his
6-month follow-up (BSA 6%, PASI 6.2).
At the age of 37, his psoriasis flared (BSA 14%, PASI 13.0). He was switched to
guselkumab at the standard dosing regimen. There was minimal improvement with
guselkumab, and his residual psoriasis after 20 weeks of guselkumab is shown in
 (BSA 10%, PASI
11.2). A skin biopsy was performed at this time which was consistent with
psoriasis.
At the age of 38, brodalumab was initiated at the recommended dosing regimen of
210 mg at weeks 0, 1, 2, and 4, and every 2 weeks thereafter. A week after his
week-4 dose, almost all of his active psoriasis was clear, as shown in (BSA 2%, PASI 2.4).
He reported that his psoriasis was completely clear after the three weekly loading
doses and started to return during the maintenance phase of treatment. He requested
to receive brodalumab 210 mg every week. The dosing frequency was increased to
weekly as the drug was well tolerated. After two weekly doses of 210 mg, his
psoriasis cleared and only post-inflammatory hyperpigmentation remained. His
psoriasis has since remained clear 9 months later.


A 95-year-old woman with hypertension and dyslipidemia was admitted to our hospital because of dysarthria. She had a history of hospitalization because of cerebral infarction 30 years previously. She was prescribed aspirin (100 mg), nifedipine (40 mg), telmisartan (20 mg), and atorvastatin (10 mg). On presentation, her consciousness was clear and she had no paralysis or paresthesia. However, she could not speak well. Her blood pressure was 193/103 mmHg, and the pulse rate was 85 beats/min. Electrocardiogram revealed a normal sinus rhythm, but laboratory data showed that the D-dimer level was increased (2.2 μg/ml). Emergency magnetic resonance imaging showed cerebral infarction of the left temporal lobe, and magnetic resonance angiography showed no significant stenosis of the major cerebral artery []. After hospitalization in the neurosurgery department, she was treated by heparin and edaravone. There was no significant stenosis with plaque of the carotid artery by the carotid duplex. In addition, there was no evidence of an episode of arrhythmia during hospitalization. On the transthoracic echocardiogram, the ejection fraction was normal without abnormalities of wall motion, and there was no significant valvular disease. Consequently, she was tentatively diagnosed as having embolic strokes of undetermined source (ESUS). Transesophageal echocardiography (TEE) showed no sources of cardiac embolism, such as an atrial appendage thrombus, appendage stasis with reduced flow velocities, or significant aortic arch atherosclerotic plaque. However, PFO with spontaneous bidirectional shunt and the prevalence of PFO separation were detected, whereas the patient was at rest [Figure and ]. Furthermore, the Eustachian valve was found []. Ultrasonography of the leg vein revealed a thrombus in the deep vein. Finally, we diagnosed her as having cerebral infarction that occurred due to paradoxical embolism-related PFO.
Anticoagulant therapy (DOAC) was initiated 6 days after the acute ischemic event, as decided by the neurologist and cardiologist.


A 40-year-old Japanese man with a positive fecal occult blood test underwent a colonoscopy for colon cancer screening. He had no significant personal or family medical history nor any abdominal symptoms. His vital signs were normal, and physical examination revealed normal bowel sounds, with no tenderness or palpable masses in the abdomen. Laboratory tests of peripheral blood revealed hemoglobin level of 12.5 g/dL, hematocrit level of 38.0%, MCV of 89.2 fL, a platelet count of 278,000/μL, and white blood cell count of 4,200/μL.
We used a PCF-H290Zl endoscope (Olympus Medical System, Tokyo, Japan) to perform a diagnostic colonoscopy. The diagnostic colonoscopy by conventional white light observation (enhancement mode-A7) revealed a solitary flat elevated polyp in the ascending colon. The polyp was approximately 15 mm in diameter with an irregular shape and with a mixed reddish colored mucosa. Most of its surface was smooth, but a portion contained a cloud-like lesion (Fig. ). Using non-magnified narrow-band image (NBI) observation (enhancement mode B8), we observed that the vessels and surface pattern were consistent with Narrow-band imaging International Colorectal Endoscopic (NICE) classification Type 1 [] (Fig. ). We used magnified NBI and the Japan NBI Expert Team classification to determine that the polyp was consistent with Type 1 (Fig. ) []. Because this finding was consistent with a sessile serrated adenoma/polyp or hyperplastic polyp, we performed a diagnostic endoscopic mucosal resection, with no complications.
Hematoxylin and eosin staining revealed spindle cells and ganglion cells in thick nerve bundles (Fig. ). Follow-up staining for S-100 proteins and (Fig. ) synaptophysin (Fig. ) yielded positive results. Negative controls were obtained by omitting the antibodies to S-100 proteins (Fig. ). These findings were consistent with GNs. After the histological diagnosis, the patient underwent thyroid ultrasonography, enhanced abdominal computed tomography, and upper gastrointestinal endoscopy to rule out the possibility of systemic disease, including neurofibromatosis 1 and multiple endocrine 2B syndrome. The results were all negative; hence, the final diagnosis was colonic solitary GN.


A 25-year-old man presented in 1988 with a 6-month history of progressive numbness, tingling, generalized fatigue, and weakness in the upper and lower limbs. Examination showed grade 4 weakness of elbow, wrist, hand, hip flexor, hamstring, and quadriceps muscles and grade 3 power of more distal muscles in the legs. He had a coarse postural tremor, areflexia, and flexor plantar responses. Sensory testing showed a glove-and-stocking hypesthesia to pinprick and temperature extending to the mid-forearms and knees. Joint position was impaired at the toes and fingertips, and vibration sense was impaired distally in the toes. He had mild bilateral foot-drop gait and walked on a broadened base. He could not perform a tandem gait and the Romberg test was positive. He could not walk on heels or toes.
NCS showed demyelinating polyneuropathy with secondary axonal loss (Table ). Electromyographic examination showed fibrillation potentials, monophasic positive sharp waves, and reduced recruitment indicating axonal loss. The patient was diagnosed with CIDP and treated with prednisone and azathioprine. He improved clinically over the next 6 months with mild residual weakness, sensory loss, and areflexia, but NCS were unchanged. By 1990, he had more clinical improvement, with improved NCS as shown in Table with increased compound muscle action potential amplitudes and motor nerve conduction velocities as well as decreased distal motor and F wave latencies.
By mid-1992, he was asymptomatic with a normal examination apart from persistent areflexia. By 1993, he was able to play hockey, and prednisone was stopped. As azathioprine was slowly tapered to 25 mg daily by 1995, he remained well clinically, but F wave latencies increased (Table ). This increase in F wave latencies heralded a clinical relapse in 1996 that responded completely to a higher dose of azathioprine, but the NCS improved more slowly by 1998, although not fully, and he relapsed twice more as azathioprine was tapered.
By 2005 he felt 95–100% of normal, ran 5 miles daily, and worked full time. His upper limb reflexes were normal and he had sluggish knee reflexes. Strength was intact and he had mild distal sensory loss of pinprick. Azathioprine was slowly tapered and stopped in 2011, and by 2012 his NCS were normal (Table ). He relapsed in 2016 following a respiratory tract infection and responded to IVIG and azathioprine after 10 months when the IVIG was discontinued, although the NCS were unchanged. By late 2018, the patient was 100% of normal with normal strength, hypoactive reflexes in the upper limbs and absent reflexes in the lower limbs, as well as normal sensation and gait. NCS were normal and azathioprine was discontinued in 2019.


One 67-year-old man with a past medical history significant for diabetes mellitus, gastroesophageal reflux disease, and hypertension presented to our hospital for progressive dysphagia to solids and liquids for 4 - 5 month, and 40-lb weight loss. He denied any tobacco or alcohol use. His body mass index (BMI) was 23.2 kg/m2. Esophagogastroduodenoscopy (EGD) revealed a large villous, nodular, partially obstructive and ulcerated mass in the distal esophagus and gastroesophageal junction (GEJ) (). Endoscopic ultrasound (EUS) revealed a large hypoechoic circumferential mass in the distal esophagus with invasion beyond the muscularis propria (layer 4) and the presence of five malignant appearing peri-tumoral lymph nodes (EUS staging of T3N2Mx) (). Computed tomography (CT) of the chest revealed marked esophageal wall thickening in the mid to lower esophagus. Positron emission tomography/computed tomography (PET/CT) confirmed the presence of a hypermetabolic 4 cm × 6 cm mass in the distal esophagus with a standardized uptake value (SUV) of 8.0 ().
Two sets of mucosal biopsies obtained from the distal esophageal/GEJ mass on two separate endoscopic procedures were evaluated for hyperkeratosis (either parakeratosis and/or orthokeratosis), acanthosis (overall thickening or hyperplasia of squamous epithelium), dyskeratosis (defined as the presence of individual apoptotic keratinocytes), abnormal/deep keratinization (paradoxical keratinization), keratin-filled furrows/cysts, koilocyte-like cells, intraepithelial neutrophils (defined as the presence of neutrophils in the squamous epithelium), intraepithelial neutrophilic microabscesses (defined as the presence of six or more neutrophils with associated epithelial injury), and atypia. Histologic review of these two sets of mucosal biopsies revealed similar histologic features (). The biopsies consisted of multiple fragments of squamous epithelium demonstrating hyperkeratosis, acanthosis, neutrophilic inflammation, neutrophilic microabscess, dyskeratosis, focal atypia, koilocyte-like cells, and furrows. Luminal keratinous debris with neutrophilic inflammation and Candida organisms was present (pictures not shown). A score of 9 was tallied for all these features present using the previously proposed histologic scoring system by Chen et al []. Based on the clinical, endoscopic, radiographic and histological presentation, a diagnosis of carcinoma cuniculatum of the esophagus was reached at the multidisciplinary tumor board meeting. The patient underwent neoadjuvant chemotherapy (five cycles of paclitaxel/carboplatin) and radiation (50.4 Gy) followed by esophagectomy.
The esophagectomy specimen consisted of an esophagus with attached stomach. The portion of the esophagus measured 13.5 cm in length and 3.5 cm in open circumference. The portion of stomach measured 7.5 × 7.5 × 3.0 cm. A 4.3 cm × 1.0 cm, indurated tan-white near circumferential lesion was identified at the GEJ. The 1.3 cm distal esophagus was fibrotic and appeared to extend through the esophageal adventitia. Multiple lymph nodes measuring from 0.6 to 3.0 cm were retrieved from the periesophagogastric tissue. The lesion at the GEJ and the fibrotic area in the distal esophagus were entirely submitted for histology. Microscopically, the sections from the GEJ lesion and the distal esophagus showed ulceration, residual bland squamous epithelium-lined cysts, marked mural fibrosis, inflammation and multifocal giant cell and histiocytic response to keratinous material, dyskeratotic and residual squamous carcinoma cells (). Fifteen lymph nodes were negative for metastases. All margins were negative. The final histopathological diagnosis was residual carcinoma cuniculatum infiltrating through the muscularis propria into the adventitia and with marked treatment effect. The final pathology stage was ypT3N0Mx.
The patient had an uneventful recovery and was discharged on postoperative day 8. The patient was well 1 month after the esophagectomy.


A 62-year-old man presented with chest pain and dysphagia of 5-month duration and a weight loss of 30 lbs. The patient has a smoking history of 40 pack-years. He denied alcohol use. Chest CT revealed distal esophageal thickening. PET/CT revealed a hypermetabolically active lesion in the distal esophagus. EGD revealed a large 5 cm, partially obstructive and ulcerated friable mass in the distal esophagus extending 1 cm into the gastric cardia. The lesion could not be traversed with the echoendoscope. Limited EUS revealed extension of the mass beyond the muscularis propria (layer 4) with a 6 mm hypoechoic peritumoral lymph node (EUS staging of T3N1Mx).
Three sets of mucosal biopsies were obtained from the mass on three separate endoscopic procedures during a 1-month period. All biopsies revealed similar histologic features (). The biopsies consisted of multiple fragments of squamous epithelium demonstrating hyperkeratosis, acanthosis, neutrophilic inflammation, neutrophilic microabscess, dyskeratosis, focal atypia, koilocyte-like cells, and furrows/cysts with a tallied score of 9 using the previously proposed histologic schema []. Luminal keratinous debris with neutrophilic inflammation and Candida organisms was present as well (pictures not shown). Similar to case 1, a diagnosis of carcinoma cuniculatum was reached based on the aggregate clinical, endoscopic, radiographic and histologic features. The patient underwent neoadjuvant chemotherapy (5-fluorouracil and cisplatin) and radiation. EGD at the completion of chemoradiation revealed a 1 cm friable, nodular, ulcerated, flat mass at GEJ and the tumor was downstaged to T2NxMx by EUS. The patient underwent successful esophagectomy 2 months following completion of neoadjuvant therapy.
The esophagectomy specimen consisted of an esophagus with attached stomach. The portion of the esophagus measured 13 cm in length. The portion of stomach measured 6.5 × 3.5 × 0.3 cm. A 2.1 × 1.2 cm, ulcerated lesion was identified at the GEJ. Multiple lymph nodes (ranging from 0.1 to 0.8 cm) were retrieved from the periesophageal tissue. The lesion at the GEJ was entirely submitted for histology. Microscopically, the sections from the lesion and the distal esophagus showed marked surface ulceration, mural fibrosis, and multifocal giant cell and histiocytic response to keratinous material and terminally differentiated squamous cell carcinoma cells (). Twenty-eight lymph nodes were negative for metastases. All margins were negative. The final histopathological diagnosis of the esophagectomy specimen was residual carcinoma cuniculatum infiltrating through the muscularis propria into the adventitia and with marked treatment effect. The pathology stage was ypT3N0Mx.
The patient had an uneventful recovery from his esophagectomy. Twelve months after the esophagectomy, the patient developed primary squamous cell carcinoma of the right lung and underwent lobectomy. No recurrence or metastases of his esophageal or pulmonary squamous cell carcinoma were detected during his follow-up. EGD performed at 32 months after the esophagectomy revealed benign-appearing esophageal and gastric mucosa. Biopsy confirmed the absence of dysplasia or carcinoma. He was admitted to hospice care due to mixed obstructive-restrictive lung disease, and expired 36 months after the esophagectomy.
The clinical, endoscopic, radiographic, histopathologic findings in mucosal biopsy and esophagectomy specimens and clinical follow-up in these two cases are summarized in and .


A 72-year-old man was referred to our department with a suspected tumor in the right rib. An abnormal shadow in the right chest was found during screening at 50 years of age. The patient was later followed up intermittently by a general physician ( and ). At 72 years of age, he was referred to our department because of a suspected malignant tumor. There were neither subjective symptoms nor abnormal physical findings. A blood test revealed an elevated level for alkaline phosphatase alone at 706 U/L. A pulmonary function test showed a percent vital capacity (%VC) of 78.8%, indicating a mild restrictive impairment. Plain radiography showed a radiopaque tumor measuring 12 × 9 × 18 cm that was connected to the seventh rib in the right thoracic cavity (). When compared to previous images, the tumor had gradually grown over the preceding 22 years. Computed tomography (CT) showed an extra-osseous tumor-like lesion with calcification, cortical destruction of the right seventh rib and a similar small lesion in the right ninth rib (). Moreover, lesions were also detected in the ninth thoracic vertebral body. Magnetic resonance imaging (MRI) revealed a lower signal intensity inside the lesion compared to the muscle on T1-weighted images and a mixture of low and high intensity on T2-weighted images, while enhancement was observed in the lower intensity area on T2-weighted images ( and ). Bone scintigraphy and positron emission tomography/computed tomography (PET/CT) revealed an increased uptake in the right seventh and ninth ribs and ninth vertebral body, and the right seventh rib showed a high standard uptake value at 7.67 on PET/CT ( and ).
The lesion of the right seventh rib was surgically resected due to enlargement and restrictive lung disease. The right ninth rib was also resected. Because we found that the lesion in the seventh rib had adhered to the lung, which was partially resected. The ninth thoracic vertebral body was not resected. The resected sample was a white solid tumor-like lesion measuring 21 × 8 cm (). No malignant findings were observed despite a complete cleaving and thorough evaluation of the sample. The final diagnosis was locally aggressive fibrous dysplasia. The %VC was increased from 78.8% preoperatively to 95.1% postoperatively and restrictive impairment was improved. The patient had no recurrence for 29 months postoperatively and died of gastric cancer.
Because differential diagnoses included malignant transformation from fibrous dysplasia based on the clinical course and imaging, a CT-guided biopsy was performed. Tissue was obtained from various areas with differing contrast effect on MRI. Despite no histological evidence of malignancy, signs of fibrous dysplasia such as irregular osseous trabeculae of immature bone with no osteoblastic rimming were observed. Accounting for possibly insufficient samples, incisional biopsies of the right seventh and ninth ribs were performed. The results showed fibrous dysplasia signs similar to those that were shown by the CT-guided biopsy, and the patient was preoperatively diagnosed as fibrous dysplasia ().


A 19-year-old female (50 kg; 160 cm) was admitted in the palliative care unit of our department with complaints of severe burning and stretching pain in the right flank region. Her pain scores were 10/10 on the Numeric Rating Scale (NRS), where 0 means no pain and 10 means worst possible pain. The patient was a postoperative case of desmoid tumor for which resection was done 2 years back []. Skin on the right side flank region develops pain, thickness, and tenderness from the past 6 months. The patient received medical treatment (morphine, nonsteroidal anti-inflammatory drugs [ibuprofen and paracetamol], and gabapentin), but the pain did not improve. Hence, we decided to perform lumbar ESP block.
Under all aseptic precautions, a linear ultrasound probe was placed longitudinally at the level of transverse process of L2. The skin was infiltrated with 2 ml of 1% lignocaine. The 10-cm Stimuplex needle (Stimuplex® A, B. Braun Melsungen AG, Germany) was inserted by the in-plane approach to touch the surface of transverse process of L2 []. A total of 20 ml of 0.375% ropivacaine and 40 mg triamcinolone was injected into the target plane between the erector spinae muscles and the transverse process. The patient had adequate pain relief (3/10 on NRS) 10 min after the block and had extensive sensory blockade from dermatome T10 to L5. NRS was noted for 24 h after the procedure []. The patient was discharged with oral medicines tapered. The patient was still pain-free without consumption of any oral analgesics at follow-up after 8 weeks.


A 42-year-old male (45 kg; 155 cm) with right Pancoast tumor severe pain (7/10 on NRS) from 5 months in dermatome distribution from C5 to T3, incompletely relieved on medical treatment. Right ESP block was given at T2 level in the sitting position. Following administration of 20 ml of 0.375% ropivacaine and 40 mg triamcinolone, pain was relieved in few minutes (1/10 on NRS) with sensory blockade from C3 to T5 on the right side. NRS score was noted for 24 h []. The patient was discharged with oral medications tapered. The patient was still pain-free without consumption of any other oral analgesics at the follow-up after 2 months.


A 64-year-old male (46 kg, 152 cm) presented with postthoracotomy pain syndrome 1 year after undergoing right bilobectomy. He had severe pain (9/10 on NRS) over the anterior and posterior right chest area and described it as burning, tingling, and current-like sensation around the thoracotomy scar at the T8-T9 level. Despite the high dosage of oral analgesics, he experienced significant pain. A right ESP block with 20 mL of 0.375% ropivacaine and 40 mg of triamcinolone was performed at the T8 level. Following the injection, pain was relieved in few minutes (0 on 10 on NRS) with sensory blockade from T5 to T12 on the right side. NRS score was noted for 24 h []. The patient was discharged with oral medications tapered. The patient remained pain-free for 1.5 months without consumption of any other oral analgesic. A second ESP block was performed with 20 mL of 0.25% ropivacaine and 40 mg triamcinolone which again produced significant analgesia lasting 2 weeks.


A 9-year-old a female patient from Adigudem was admitted to Mekelle hospital's pediatric ward complaining of right upper quadrant abdominal pain for the previous two weeks, with associated decrease in appetite and vomiting. She also had significant weight loss, malaise, and low-grade intermittent fever. For this, she visited a local health center where she was given unspecified oral medication for 7 days, but saw no improvement. There was no history of diarrhea, yellowish discoloration of the eyes or contact with yellowish discoloration of the eye, bleeding from any site. No history of stool or urine color change, use of herbal medication or tattooing, blood transfusion, river water contact, or trauma or surgery, There was no history of cough, shortness of breath or chest pain, contact with patients having chronic cough or a TB-diagnosed person. On physical examination the patient was conscious. The vital sign was stable and in the normal range with a maximum temperature of 37.8 c. Anthropometry findings were; Weight – 25 kg, Height – 136 cm, MUAC – 14.5 cm (moderate wasting), BMI – 13.5 kg/M2 (underweight). The other indexes were normal. The pertinent finding was in an abdominal examination: The patient had palpable liver 3 cm below the right costal margin with a total liver span of ~12 cm which was a non-tender and sharp edge. No splenomegaly or fluid collection. On Initial investigation, leukocytosis with severe Eosinophilia (WBC − 15,500 with Eos – 50%, Neut – 25%, Lym – 20%, Hematocrit − 39.13%, Platelet – 501,700. An organ function test (both liver and kidney), chest x-ray and stool exam were normal. HIV test, HBsAg and HCV results were negative, Abdominal U/S hepatomegally with abnormal echo pattern with abnormal cystic changes (). With the diagnosis of pyogenic hepatic abscesses to R/O hydatid cyst; she started on Albendazole (15mg/kg/day) and IV antibiotics (Ceftriaxone 100 mg/kg/day and metronidazole 30 mg/kg/day). Computed Tomography (CT) and it shows; multiple cystic and small daughter cysts like a communicating hypoechoic mass-like lesion (). After a CT scan, the Hydatid cyst was considered and the patient continued with Albendazole and IV antibiotics were discontinued. After the patient taken to the operation theater (OR), the intra-operative finding was 3×3cm, 2×2cm, small 1×1cm (about 5 sites) on the anterolateral aspect of the liver. Upon entering the cysts, there was greenish pus with some calcifications. The surgeon opened the two large cavities and drained them and the smaller ones on the edge of the liver were excised for histopathology. Because of the intraoperative findings, post-op Dx of pyogenic liver abscess reconsider and she restarted the IV antibiotics (Metronidazole, Ceftriaxone, Gentamyecine) with Albendazole. After the biopsy result, which shows partly capsulated lobules of hepatocytes with numerous epithelioid granulomas, giant cells, necrosis, and microabscesses and with chronic inflammatory cells, mainly lymphocytes and eosinophils with a pathologic diagnosis of Liver TB (). After the biopsy result, all antibiotics and Albendazole were discontinued. She started the anti-TB medication (2ERHZ/4RH) daily. The effectiveness of the treatment was assessed by clinical resolution of symptoms, serial (abdominal ultrasound, WBC with differentials, and ESR). After 1 week of anti-TB treatment, she regained her appetite and the abdominal pain decreased and she was discharged with an appointment two weeks later. After three weeks of anti-TB, all symptoms resolved (vomiting, abdominal pain, and appetite loss) with significant weight gain () and decrement in peripheral eosinophilia. During follow up after anti-TB medication, the serial WBC and eosinophilia decrease significantly and normalized (). The patient was followed up with serial abdominal U/S and it showed improvement and the final U/S only showed a healed scar. The patient took anti-TB for six months and at the end of treatment, our patient was symptom-free, with significant weight gain (she gained a total of 5 kg) and all laboratory results were normal (). The patient was also followed for adherence and any adverse drug reaction clinically (vomiting, bleeding, jaundice, rash) and serial laboratory measurements (). She took anti-TB for the first two months of direct observational therapy (DOT) in the hospital and the nearby health center. For a further 4 months, she continued visiting nearby health centers to assess for adherence and any adverse effects. She was an adherent and no adverse effects were reported or found during the investigations. Currently, the patient is on followed up with normal laboratory findings and free from clinical signs and symptoms (with normal anthropometry) for the last two years.


A 31-year-old male presented with chief complaints of gradual decrease in vision in his right eye since 2 weeks. His best corrected visual acuity was 20/160, N36 in the right eye and 20/20, N6 in the left eye. Anterior segment examination and intraocular pressure were normal in both eyes.
Left eye fundus was unremarkable, but his right eye showed an active large plaque-like choroiditis lesion of 3 disc diameter size, located temporal to fovea with a central grayish pigmentation, a prominent orange ring and outer fuzzy active margins []. Fundus autofluorescence (FAF) showed two hyperautofluorecent rings around the margins of the lesion separated by a zone of hypoautofluorescence []. Optical coherence tomography (OCT) through the lesion showed loss of photoreceptors at the center with a folding of the retinal pigment epithelium (RPE) corresponding to the prominent orange line seen clinically or the inner bright hyperautofluorescent margin seen on FAF []. FAF being an easy, noninvasive and more sensitive tool was repeated at regular intervals rather than performing a fundus fluorescein angiography in our case.
Laboratory investigations revealed normal hemogram, a positive Mantoux test (>10 mm induration at 48 h) and negative serological tests for syphilis and human immunodeficiency virus. He was started on anti-TB therapy (ATT, 4-drug regimen) along with oral corticosteroids (1 mg/kg body weight). At 1 week follow-up, increased size of the choroiditis lesion with centrifugal movement of the orange ring suggestive of progression of the lesion was noted and confirmed on FAF [Fig. and ]. A transseptal injection of 40 mg triamcinolone was added to the treatment regimen.
After 2 weeks, the lesion showed further increase in size [Fig. and ], while he also developed corticosteroid-induced central serous chorioretinopathy in the left (fellow) eye. Hence, the oral steroids were rapidly tapered and he received an intravitreal dexamethasone implant (Ozurdex) in the right eye. On follow-up persistent activity was noted. He was started on mycophenolate mofetil 500 mg twice daily along with ATT. On the last follow-up, 6 weeks later, the lesion showed hypoautofluorescence suggestive of resolution of the lesion [Fig. and ]. Visual acuity improved minimally and stabilized at 20/80 as the lesion involved the macula and had extended toward the fovea before resolution.


An otherwise healthy, 47-year-old woman visited for surgical consultation after a 2.8 cm solid mass was found during a routine screening mammogram. The mass was located in the left, lower, inner quadrant and was radiologically categorized as BI-RADS 4 (suspicious for malignancy). The biopsy diagnosis was consistent with an adenomyoepithelioma. One month later, a partial mastectomy was performed. Pathological examination revealed a neoplasm growing with pushing borders, composed of benign and malignant components (). The benign component consisted of tubular structures lined by epithelial cells with scant eosinophilic cytoplasm, small hyperchromatic nuclei, and surrounding myoepithelial cells with clear cytoplasm (). The malignant component consisted of solid nests and islands of carcinoma cells with enlarged nuclei, multiple small nucleoli, a high nuclear-cytoplasmic ratio, and numerous mitotic figures, which were also seen invading non-neoplastic breast tissue ().
These observations are consistent with a carcinoma arising from an adenomyoepithelioma. The biphasic nature of the adenomyoepithelioma, demonstrated morphologically by epithelial and myoepithelial cells arranged in tubules, was lost in the malignant component. Although the malignant cellular proliferation presented as a conglomeration of highly atypical cells with no morphological clues of differentiation, the carcinoma still exhibited epithelial and myoepithelial differentiation by immunohistochemistry (). The epithelial cells were strongly positive for CAM5.2 cytokeratin (Dickinson, Becton Lakes, USA) and androgen receptor (AR; Cell Marque, Rocklin, USA), but negative for myoepithelial markers including smooth muscle myosin heavy chain (SMMHC; Ventana, Tucson, USA), α-smooth muscle actin (sm-actin-1A4; Ventana), p63 (Cell Marque), and CK5/6 (Cell Marque). In contrast, the myoepithelial cells were strongly positive for SMMHC, α-smooth muscle actin, high molecular weight cytokeratin including CK5/6 and CK34βE12 (Dickinson), SOX-10 (Biocare, Pacheco, USA), S100 (Cell Marque), and p63, but very weak for CAM5.2 and negative for AR.
Notably, the benign epithelial cells showed strong immunoreactivity for carcinoembryonic antigen (Dickinson) and epithelial membrane antigen (Dickinson) in a membranous apical pattern, both of which were lost in the carcinoma cells (). GATA-3 (Ventana) was observed to be strongly positive in foci within the benign tubules but weak within the carcinoma. The ki-67 proliferation index was high in the malignant component but low in the benign component (). Estrogen and progesterone receptors (ER, PR) and HER-2/neu were negative, and cyclin-D1 () was positive in both the benign and malignant components. The tumor was also screened for p16INK4a, p53, and c-MYC abnormalities. p53 showed immunoreactivity to wild type levels in both components, ruling out mutations in TP53. We observed variable expression of p16INK4a in both components, suggestive of cellular senescence and therefore ruling out homozygous deletion of CDKN2A. Overexpression of c-MYC was detected only in the carcinoma cells, with immunoreactivity covering both areas showing epithelial and myoepithelial differentiation ().
Break-apart fluorescence in situ hybridization was performed on formalin-fixed paraffin-embedded sections of the tumor with a mixture of MYC spectrum orange and green probes (Abbott Laboratories, Des Plaines, USA). The normal pattern of observations is 2 fusion events per cell (2 F/cell). However, in the tumor, we observed abnormal signal patterns (3–4 F/cell in 37%, > 4 F/cell in 40%, and 0 F/cell in 7%) indicating amplification of the MYC gene region on chromosome 8q24 and no evidence of rearrangement (). After discussion with our Multidisciplinary Breast Tumor Board, the patient underwent re-excision of the surgical site due to the presence of positive margins. Subsequently, the surgical margins were cleared of tumor and no chemoradiotherapy was administered. After one year of follow up, the patient has remained free of disease with no evidence of local or distant recurrence.


A 44-year-old right-handed man presented to the Neurology Department at the Second
Affiliated Hospital, Zhejiang University School of Medicine with a 5-year history of
involuntary movement in the upper extremities and head. Over the prior 3 years,
abnormal movement, slurred speech, and gait disturbance had developed in a
progressive manner, along with occasional dysphagia when drinking. In particular,
the patient experienced occasional involuntary movement in the bilateral upper
extremities, especially when he experienced anxiety and fatigue. Because this
movement initially did not influence his daily activities, he did not consult a
physician. Subsequently, the involuntary movement progressively worsened, and spread
to his head. Therefore, he presented to our hospital for diagnosis and treatment. At
that time, he did not receive a definite diagnosis, and symptomatic treatment,
including haloperidol and clonazepam, did not significantly alleviate his
complaints.
After 3 years of disease progression, the patient’s dysarthria began to cause
difficulties in routine communication, and his clinical symptoms became increasingly
complex. His unsteady gait and dysphagia occurred when he engaged in fast movement
and drinking, respectively, frequently leading to falls and coughing. He denied use
of a dopamine-blocking agent, but reported a prominent family history of these
manifestations in his elder sister, mother, aunt, and grandfather (. Neurological
examinations revealed dysarthria and dysphagia. Relatively slow saccadic eye
movement was detected in the patient and his elder sister. Moreover, an increased
tendon reflex was observed in the patient. The finger to nose test, heel to shin
test, and rapid alternating movements revealed marked abnormal findings, indicating
probable cerebellar malfunction. Muscle force, tension, and sensory examinations
demonstrated normal findings. His median score was 18 on the Scale for the
Assessment and Rating of Ataxia, while his total motor score was 26 on the Unified
Huntington’s Disease Rating Scale. Brain magnetic resonance imaging of the patient
revealed obvious cerebellar atrophy (. During 12 years of follow-up, the
patient’s ataxia and choreiform movements gradually worsened and he died of probable
respiratory disease and nutritional deficiency at 56 years of age.


A 44-year-old man presented with a 6-month history of gingival bleeding with no
obvious cause. The bleeding became obvious after eating and brushing, and it
could not be stopped easily. The bleeding improved after a platelet transfusion
at a local hospital, and the hospital recommended continuing treatment at a
higher-level hospital. Because the patient was on a high-protein diet after two
hepatic comas, he went to Beijing People’s Liberation Army 302 Hospital for a
computed tomography (CT) scan and was diagnosed with decompensated cirrhosis. He
was then transferred to the Affiliated Hospital of Tsinghua University for liver
transplantation. After completion of a preoperative examination, the patient
underwent a liver transplantation. Tacrolimus (2 mg every 12 hours) was given as
anti-rejection therapy for 3 days postoperatively. The patient’s blood
concentration of tacrolimus was 3.94 ng/mL, which was maintained within the
reference range for postoperative treatment. One week later, the patient
suddenly developed convulsions accompanied by eye twitching, restlessness, and
sudden weakening of the muscles on the left side of the body, including positive
facial and Babinski reactions. He had no history of epilepsy.
Electroencephalography (EEG) examination revealed the following three
abnormalities (): (1) synchronous or asynchronous bilateral frontal, temporal, and
frontal midline irregular slow-wave bursts of 3 Hz (bilateral symmetry); (2)
occasional localized single spike bursts in the right occiput; and (3)
occasional single spike bursts in the right frontal posterior and frontal
midline. An intramuscular injection of diazepam (0.5 mg) was immediately
administered, indicating mild demyelination of the white matter on cranial
magnetic resonance imaging (MRI) (). The patient’s symptoms were
relieved after beginning oral treatment with levomethylacetanilide tablets
(0.5 mg). Two days later, no abnormalities were observed on brain MRI (). Oral
administration of tacrolimus at 1.5 mg every 12 hours was continued for about 2
weeks, and the plasma concentration of tacrolimus was 7.55 ng/mL on
reexamination. The adverse events were believed to be related to the tacrolimus
and were relieved after symptomatic treatment. Finally, his left muscle strength
returned to normal and he had no seizures for several months.