Our patient was a 13-year-old female who had sustained an open right forearm fracture during gymnastics and required emergent orthopedic repair. She was otherwise healthy by history, on no medication, weighed 43 kg, and had no known allergies. There was no family history of anesthesia or of any medical problems that might have been relevant to her anesthetic care. She received intravenous (iv) midazolam for anxiolysis. Anesthesia was induced with propofol and fentanyl. Rocuronium was administered for muscle relaxation and she was easily intubated. Anesthesia was maintained with sevoflurane in 50% oxygen and air. Intravenous cefazolin was administered and she was also given iv morphine. Over the first 20 minutes after induction her blood pressure, heart rate, and temperature decreased. Increased end-tidal CO2 (EtCO2) was noted [] and ventilation was increased. EtCO2 continued to rise over the next hour in spite of doubled minute ventilation. The heart rate increased to 100/minute and there was mild hypotension, which was treated with additional iv crystalloid infusion; the patient's temperature also increased to 38.2°C. There was no other obvious explanation for the changes and so with MH in mind but without concerns regarding vital signs, sevoflurane was discontinued, fresh gas flows were increased to 10 L/minute, ventilation was changed from pressure-controlled to volume-controlled ventilation, and anesthesia was changed to iv propofol and opioids. Bispectral index monitoring was added. Active cooling was instituted with a forced-air warmer set on ambient temperature. Within 30 minutes, EtCO2 and required minute ventilation decreased and all vital signs returned to normal, reassuring us. An arterial blood gas (ABG) was drawn at that time to rule out mixed acidosis. We were expecting normal results but it revealed slightly elevated lactate and hyperkalemia of 7.2 mmol/L [], which persisted at 6.6 mmol/L 1 hour later at the time of completion of the surgery. The T-waves remained normal throughout. No muscle rigidity was noted by the anesthesiologists or surgeon at any time. In view of the rapidly resolving clinical picture, surgery was completed and no other specific treatment was instituted. However, we took samples for estimation of urine myoglobin and plasma creatinine kinase (CK). The patient was extubated and transferred to the intensive care unit (ICU) for monitoring. At this time, the patient and family were informed of the events, of the clinical diagnosis of MH, and that the patient and family members would have to be considered MH susceptible. The patient remained hemodynamically stable and potassium, lactate, myoglobin, troponin, and renal function tests all remained normal postoperatively. CK was increased to 764 U/l at the time of the first blood gas analysis, peaked at 1189 U/L postoperatively, and declined thereafter []. In view of the low CK, myoglobin was not retested. The patient was transferred from the ICU to the ward on the first postoperative day and was discharged home on the second postoperative day.
Consultation with the Malignant Hyperthermia Association of the United States (MHAUS)[] immediately after the surgery resulted in the recommendation to consider the patient MH susceptible and to send blood for ryanodine receptor gene sequencing to the Department of Pathology, Division of Molecular Diagnostics, at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA. The report identified a ‘heterozygous nucleotide substitution of G to C at nucleotide 742 of exon 9 of the type-1 ryanodine receptor (RYR1)’ gene located on chromosome 19q13.1, a change resulting in a ‘missense amino acid variant known to cause disease’ as per the European Malignant Hyperthermia Group (EMHG).[] The patient and her family were informed of the genetic test results and the implications to her and her relatives. Over several follow-up calls we recommended that the family members undergo genetic counseling and genetic testing, either through the local department of medical genetics or at an MHAUS center, both of which were informed. MH susceptibility, as well as succinylcholine and all inhalational agents, were added to the patient's electronic medical record in the section on allergies, which will identify her as MH susceptible at any future hospital encounter. To protect her from receiving triggering agents outside this institution and keeping in mind situations where the patient may be unable to provide a history, we also recommended that she wear a medical ID bracelet. The findings, recommendations, and information regarding available resources for MH patients were shared in writing with the patient and her family as well as with the patient's primary care pediatrician.
The patient subsequently underwent a second orthopedic procedure under intravenous anesthesia without problems.


A 55-year-old man without any history of radiotherapy or anabolic steroid intake presented with history of left testicular swelling associated with pain and fever of one and half month duration. He was treated elsewhere with antibiotics for two weeks with a diagnosis of left epididymo-orchitis. Physical examination revealed an 8 × 5 cm hard mass in the left testis. The spermatic cord was normal. Ultrasound of the scrotum showed a 6 × 5 cm hypoechoic mass lesion in left testis without any calcifications, suggestive of a tumor. The contralateral testis was normal. Computed tomography (CT) scans of abdomen and chest were unremarkable. Tumor markers, alpha-fetoprotein and beta-human chorionic gonadotropin, were within normal limits. The patient underwent left high inguinal orchidectomy. The cut section of the testis showed an intraparenchymal, grey-white, poorly encapsulated lesion measuring about 7 × 5 cm, pushing the normal parenchyma to one pole. Epididymis was normal. Microscopy [] showed a tumor composed of interlacing fascicles and whorls of elongated spindle cells with eosinophilic cytoplasm and hyperchromatic nucleus with mitosis (8/10 hpf). Epididymis was uninvolved. Immunohistochemistry was positive for desmin. These findings were consistent with the diagnosis of a primary high-grade intratesticular leiomyosarcoma.
Postoperatively, the patient did not receive any adjuvant therapy, as there was no evidence of nodal or distant metastasis. He presented eight months later with diffuse soft tissue and bone metastasis and was referred for chemotherapy []. He received Adriamycin single-agent chemotherapy—the standard regimen for advanced or metastatic soft tissue sarcomas from other sites—but succumbed after two cycles, within three months of diagnosis of metastasis.


A 37-year-old man presented with low back pain and bilateral sciatica without neurologic deficits. MRI showed a contract enhancing intradural mass at L3–L4 with a diameter of 1.5 cm. Total resection of this vascular tumor was performed after which the patient made a full recovery. Histologic diagnosis confirmed the tumor to be a paraganglioma and there is no recurrence after 11 years.


A 41-year-old man presented with low back and right-sided leg pain. Neurologic examination only revealed sensory loss in the right leg without motor deficits. MRI showed an intradural mass at L2–L3, roughly circular, with a diameter of 2 cm and with strong but inhomogeneous gadolinium enhancement []. At surgery, the highly vascular tumor was attached to the filum terminale and only minimal arachnoid adhesions with the nerve roots was seen. After total resection the patient made a full recovery. Histologic diagnosis was paraganglioma. Staging with MRI of the whole spinal cord, the brain and abdominal computed tomography (CT) scan was negative. There is no recurrence after 13 years.


A 51-year-old man presented with low back pain with bilateral irradiation to the gluteal region. No neurologic deficits were present. MRI showed an intradural mass at L4, with a diameter of 1.5 cm, circular with somewhat irregular margins, moderate enhancement, and clearly located centrally in the dural sac []. A total resection of the tumor was performed [Figures and ]. Staging (MRI of the whole spinal cord, the brain, and abdominal CT scan) was negative. The patient fully recovered and there is no recurrence after 5 years.


This 38-year-old gentleman, known case of end-stage renal disease (ESRD) with acute hepatitis E in resolving phase, presented to our emergency OPD with complaints of multiple episodes of malena for 1 day. Patient had been on maintenance hemodialysis (HD) twice per week elsewhere and had received last HD 2 days prior to onset of peptic ulcer bleed. At presentation, he was severely anemic and hemodynamically unstable with blood pressure of 80/50 mmHg and pulse rate of 120/minute. His relevant laboratory investigation were as follows: hemoglobin 4.1 g/dl; platelet count 328×10
3/mm3; white blood cell count 8,500/mm3; INR 1.1; serum bilirubin 4.0 mg/dl (direct: 2.2 mg/dl), alanin transaminase: 41 IU/L, aspartate transaminase 47 IU/L, alkaline phosphatase 328 IU/l (normal: 32-92) IU/L), serum albumin 2.0 g/dl, blood urea 156 mg% and serum creatinin 6.5 mg/dl.
After resuscitation, an emergency esophagogastroduo -denoscopy (EGD) was done which revealed a large oozing ulcer in the anterior wall of the duodenal bulb []. Endoscopic treatment consisted of injection of 2 ml 0.2% adrenaline at four sites around the ulcer followed by application of tip of the heater probe directly to the bleeding site to apply tamponade and coagulation with long pulses at 15 W power setting. Hemostasis was achieved from bleeding vessel; however, minimal ooze was noted at the margin of ulcer which was controlled with APC. Patient was given intravenous infusion of a proton pump inhibitor and a transfusion of five units of packed red blood cells.
A day following endoscopic treatment, patient developed epigastric discomfort, recurrent bouts of vomiting along with fall in hemoglobin level from initial rise of 7.7 to 6.3 g/dl. EGD was repeated on the third day which revealed a large sub-mucosal bulge in the first part of duodenum near ulcer site causing duodenal obstruction [Figures and ]. The lesion was consistent with a large IDH on CT scan of abdomen []. The bulk of hematoma was located at the postero-inferior wall of the duodenal bulb and its distal extension was seen up to third part of duodenum. This was not the site of injection or application of the heater probe. He was treated with bowel rest, parental nutrition and nasogastric decompression. For ESRD, patient was given twice weekly heparin-free HD with intermittent saline flushes. He became symptomatically improved over the next 7 days. On follow-up at 8 weeks, a repeat EDG revealed healed duodenal ulcer with no evidence of hematoma [].


A 60-year-old male hailing from Akola, Maharashtra, was admitted on 15th April 2009 in our hospital with complaints of jaundice and itching for 2 months, along with loss of appetite and weight loss. He had undergone open cholecystectomy in a private hospital in February 2009.
On examination, he was afebrile with pallor and icterus. His pulse was 86/minute and blood pressure was 110/70 mmHg. No abnormality was detected in cardiovascular, central nervous system, and respiratory system. Abdomen was soft. Total leukocyte count on admission was 15,000/cu mm, with neutrophils 85%, lymphocytes 13%, eosinophil 1%, and monocyte 1%. Hemoglobin was 10 gm/dl. His total bilirubin was 10.6 mg/dl (direct 5.9 and indirect 4.7 mg/dl). Fasting blood sugar level was 101 mg/dl. HIV antibody and HBsAg were negative.
Endoscopic retrograde cholangiopancreatography (ERCP) revealed total tear of the bile duct at supraduodenal level. A percutaneous transhepatic drainage was done under local anesthesia and a bile sample was sent for culture. The specimen was directly plated on MacConkey agar (MA) and blood agar (BA), incubated at 37΀C overnight. Simultaneously enrichment was also done in 0.5% bile broth. Next day 2-3 mm circular, smooth, convex, non-lactose fermenting colonies appeared on MA, which were catalase positive and oxidase negative. On BA, colonial morphology was same with a dull yellow pigment. Hanging-drop preparation revealed that the organism was motile. It was identified as C. luteola by standard biochemical tests.[] It utilized glucose, mannitol, and maltose oxidatively, hydrolyzed esculin, reduced nitrates to nitrites, did not decarboxylate lysine, did not hydrolyze urea and did not produce indole. It was sensitive to Polymyxin B, but resistant to Penicillin G.
Subculture from bile broth onto MA also grew the same bacteria. Antibiotic susceptibility was tested by the Kirby-Bauer disk diffusion method onto Mueller-Hinton agar according to CLSI guidelines.[] It was susceptible to amikacin, ciprofloxacin and imipenem, but resistant to ampicillin, amoxycillin-clavulanic acid, cefotaxime, ceftriaxone, ceftazidime, piperacillin, and piperacillin-tazobactam. Daily fluid output from the drain was 500-600 ml. He was given ciprofloxacin 500 mg twice daily and omeprazole once a day on an empty stomach. Fluid output gradually reduced and total bilirubin became 3.94 mg/dl. But total leukocyte count was 11,100/cu mm, with N 80%, L 17%, E 1%, M 2%.
Therefore, hepaticojejunostomy was done after 1 month of admission. Postoperatively he received cefotaxime, gentamycin, and metronidazole intravenously for 2 weeks. He recovered gradually and was discharged after removing the T-tube. His condition was stable on discharge.


A 56-year-old man presented with a 6-month history of pain in his non-dominant left wrist. Although the range of motion of the wrist was normal, the distal end of the ulna was enlarged and tender. Radiographs revealed a multilobular and radiolucent area with a clear margin in the distal ulna (Fig. ). A CT scan showed a lesion measuring 8 cm in length and 4 cm in width, expanding and partly destroying the thin cortex. On T1-weighted MRI images, the lesion showed a low-intensity signal and on T2-weighted images with fat suppression, a heterogeneous high-intensity signal (Fig. ). Plain chest radiographs and a CT scan of the thorax and abdomen were normal without evidence of metastasis.
The work-up diagnosis was primary GCT, which was confirmed by trucut biopsy. The patient underwent a wide en-bloc resection of a GCT of the distal ulna, including the triangular fibrocartilage complex, the ulnar border of the pronator quadratus and part of the distal radioulnar joint capsule, with immediate reconstruction of the distal radioulnar joint (DRUJ) using a radioulnar joint prosthesis (APTIS MEDICAL, Louisville, Kentucky, USA) []. This semi-constrained prosthesis was used to substitute the deficiency created by the absence of soft tissue support of the DRUJ and to address the gross instability of the remaining ulna caused by a large segmental resection. In our case, 2 cm of radiographically normal-appearing proximal ulnar bone was resected in order to achieve a wide safety margin. The total amount of bone removed from the distal end of the ulna was 10 cm long. As a consequence of this, we placed one short diaphyseal fibular intercalary allograft between the ulnar stump and the ulnar stem prosthesis in order to cover the total surface of the plasma coating implant within the ulna (Fig. ).
After the chirurgical intervention, we applied a well-padded short-arm splint. The splint remains in position for 2 weeks at which time sutures are removed and range of motion exercises are started. The tumor was sent for routine gross, histological and pathological examinations. Histologically, the lesion was a typical CGT composed of a large number of uniformly distributed osteoclast-like giant cells in a bland stroma of spindle-shaped mononuclear cells. Mitotic figures were absent, and surgical margins were free of tumor.
The functional results were evaluated using two scoring system: the Ferracini et al. score [], based on range of motion, pain level, muscle strength and the presence or absence of ulnar impingement and ulnar or carpal instability and Mayo wrist score [], based on pain intensity, functional status, range of motion and grip strength. With the Ferracini et al. [] score, the patient achieved excellent results, scoring 18 out of 18 points at 6 and 12 months post-operatively, and with respect to the Mayo wrist score [], the patient achieved a score of 82 (good) and 92 (excellent) at 6 and 12 months, respectively.
The oncologic results showed a good evolution with no evidence of local recurrence at 2-year follow-up. The patient’s wrist was free from pain, and measurements of active range of motion, hand grip and key pinch strength at 2 years post-operatively are shown in Tables and , respectively.


A 34-year-old male presented with 3 months history of pain in the left flank and weight loss of around 20 kg over 3 months. His medical history was non-contributory. Clinical examination revealed blood pressure of 120/80 mmHg without any postural drop. There was no lymphadenopathy, and abdominal examination revealed mild splenomegaly. Investigations revealed a normal complete blood count with normal liver and kidney function tests. Serum electrolytes were within normal limits. Lactate dehydrogenase was 487 U/L (normal range 320–460 U/L). X-ray chest was within normal limits. Ultrasonography(USG) of the abdomen demonstrated a retroperitoneal mass in the left side of the abdomen with hepatosplenomegaly without lymphadenopathy. Contrast-enhanced computed tomography (CT) scan abdomen showed a large 13 × 8.8 × 9.7 cm, heterogeneously enhancing mass in left suprarenal area involving superior pole of left kidney, displacing spleen and pancreas with a normal sized adrenal gland on the right side without any retroperitoneal lymphadenopathy []. Fine needle aspiration cytology of the lesion revealed malignant round cell tumor favoring high-grade lymphoma. Subsequently a CT-guided trucut biopsy of the mass lesion was performed. Microscopic examination of the material revealed adipose tissue infiltrated by sheets of large monomorphic, transformed lymphoid cells with basophilic cytoplasm, and nuclei having vacuolar chromatin with two to three prominent nucleoli suggestive of non-Hodgkin's diffuse large B-cell lymphoma (DLBCL). Immunohistochemistry demonstrated CD20 positivity and did not stain for CD3 suggestive of B-cell lymphoma. Examination of bone marrow and CT imaging of chest was normal. Thus, based on the radiological and pathological assessment, a final diagnosis of primary adrenal non-Hodgkin's DLBCL was made. Although the patient had a normal sized right adrenal gland, the patient was subjected to adrenocorticotrophic hormone (ACTH) test. Serum sample for cortisol was taken in the morning in the basal state and 1 hour after giving 250 μg of synthetic ACTH. Basal cortisol was 11 μg/dL, and peak 1 hour cortisol was 23.2 μg/dL (normal value of >18 μg/dL). An informed consent was obtained from the patient. Meanwhile the patient was started on combination chemotherapy Rituximab, Cyclophosphamide, Adriamycin, Vincristine and Prednisolone(R-CHOP). Presently, the patient is asymptomatic for his disease and a follow-up contrast enhanced computed tomography (CECT) abdomen showed a marked regression in the adrenal size measuring 7.5 × 2.5 cm [].


A 55-year-old male smoker, with diabetes mellitus for 4 years, controlled on metformin 500 mg/day, was admitted with 2 months history of marked weight loss, abdominal pain, vomiting, and passage of loose stools. His medical history was insignificant. On admission, physical examination revealed a normal blood pressure without any postural drop, decreased skin turgor, and hyperpigmentation over the buccal mucosa and lips. Investigations revealed anemia (Hb of 11 g/dL) with normal blood counts. His kidney and liver function tests were normal. Serum electrolytes were within normal limits. Lactate dehydrogenase was 813 U/L (normal range 320–460 U/L). Clinical suspicion of primary adrenal insufficiency was confirmed by a low morning serum cortisol of 7.2 μg/dL (normal value of 12–25 μg/dL) and peak cortisol response of 5.2 μg/dL to ACTH stimulation test (normal value of >18 μg/dL). Contrast-enhanced CT abdomen revealed bilateral solid adrenal masses encasing renal hilar vessels and inferior venacava with gastric antral wall thickening and splenomegaly []. Subsequent CT-guided biopsy of the adrenal mass disclosed non-Hodgkin's DLBCL [], and immunohistochemistry showed diffuse CD20 positivity of lymphomatous cells []. Bone marrow, CT chest, and upper GI endoscopy revealed no abnormality. With this background of primary bilateral NHL and adrenal insufficiency, patient was started on steroids (prednisolone 5 mg and fludrocortisone 100 μg in the morning) and diabetes was controlled with two doses of premixed (30/70) insulin. He stabilized and was planned for combination chemotherapy Cyclophosphamide, Adriamycin, Vincristine and Prednisolone (CHOP). An informed consent was obtained from the patient. Patient received two cycles of chemotherapy but died at home after few days; cause of death could not be ascertained.


A 29-year-old married woman was referred for surgical opinion for pain and swelling of left leg since 2 days. On examination, her left limb was swollen and tender. Color Doppler sonography confirmed early DVT. She also complained of nasal blockage and was diagnosed to have severe persistent asthma concomitantly. Except high erythrocyte sedimentation rate (ESR), complete blood count (CBC) and biochemical parameters were normal. She had history of taking OCCP (ethinylestradiol 30 μg, levonorgestrel 0.15 mg) since last 3.5 months for which she had consulted a gynecologist and also prednisolone on and off for allergic rhinitis. Wells Predictive pretest probability score was applied. Score for this patient was 1; thus, she had moderate pre-test probability for DVT (17% prevalence). She was treated with parenteral anticoagulant and simultaneously oral anticoagulant was started. She also received treatment for asthma (nebulized bronchodilators and inhaled steroid) concurrently. On discharge (5th day), she was advised to continue oral anticoagulant and local hirudoid cream for 2 weeks and continue medication for asthma. She was instructed for follow-up after 3 days for prothrombin time (PT)/International Normalized Ratio (INR) test. She was advised to discontinue OCCP.


A 19-year-old male patient presented with fever and weakness for 18 days. On examination, he was febrile, pale and had enlargement of bilateral cervical, left axillary and left inguinal lymph nodes. There was mild splenomegaly. All the lymph nodes were discrete, soft to firm and mobile, measuring 1–2 cm in size. The left axillary lymph node was 2 × 1 cm and tender on palpation. FNAC was performed using 23 G needle from the left cervical and left axillary lymph node by non-aspiration technique. Two smears were air dried for May-Grünwald-Giemsa (MGG) stain and one was wet fixed in alcohol for hematoxylin and eosin staining. Peripheral blood film (PBF) was also prepared.
FNA smears from the left axillary lymph node showed predominantly immature lymphoid cells, two to three times the size of small lymphocytes with scanty cytoplasm conforming to morphology of lymphoblasts. Many hand mirror cells and teat cells were also present []. Also seen were occasional giant cells with multilobated nuclei and abundant cytoplasm, nucleated red blood cells (RBCs) and occasional metamyelocytes []. Background showed few mature lymphocytes and numerous lymphoglandular bodies. The left cervical lymph node aspirate smears showed mixed population of lymphoid cells in varying stages of maturation comprising follicle centre cells and mature lymphocytes. The PBF was examined keenly and showed decreased cell counts with 12% lymphoblasts and reduced platelets with normocytic normochromic red cells.
In corroboration with the PBF findings, a diagnosis of partial infiltration by lymphoblastic leukemia and evidence of EMH with megakaryocytes in the left axillary lymph node was made. The cervical lymph node was diagnosed as reactive lymphoid hyperplasia. A complete hemogram with a bone marrow examination was advised.
The hemogram showed hemoglobin of 7.6 g/dL; total leucocyte count of 8900/μL; differential leucocyte count (DLC) neutrophils-17%, lymphocytes-64%, monocytes-02%, blasts 12%; platelet count -14,000/μL and nRBCs 2/100 white blood cells. Bone marrow smears were hypercellular and showed 96% blasts, which were small sized with high nucleus to cytoplasmic (N:C) ratio and 0–1 small nucleoli. Cytochemistry was performed and the blasts were negative for myeloperoxidase, Sudan Black B and Periodic acid Schiff stain. Total Binets score was two plus and a diagnosis of acute lymphoblastic leukemia (ALL)-L1 was given. The erythroid, myeloid and megakaryocytic series were markedly depressed. Bone marrow trephine biopsy showed diffuse replacement of marrow spaces by the lymphoblasts, with marked paucity of myeloid, megakaryocytic and erythroid precursors.


A 23-year-old female presented with a complaint of a sudden central right-sided visual field defect. She was otherwise healthy, with no past history of thrombophillic disorders. The only medication prescribed to her was progesterone, only a contraceptive pill. She had no past ocular history and did not smoke. On direct questioning the patient admitted to intranasal cocaine use 72 hours previously, although she was not a chronic abuser.
On examination, the unaided visual acuities were 20/40 in the right eye and 20/20 in the left eye. Anterior segment examination was normal, intraocular pressures were 15 mmHg in both eyes, and there was no pupillary abnormality. Fundus examination showed an area of retinal edema along the course of the right cilioretinal artery, which spared the fovea along with few dot hemorrhages in the posterior pole []. The retinal vasculature was otherwise normal. A fundus fluorescein angiogram was performed [], which demonstrated that there was a flow within the right cilioretinal artery. The automated visual field analysis demonstrated a central visual field defect and decreased foveal threshold sensitivity in the right eye []. Extensive blood tests to rule out either a thrombophillic, vasculitic or embolic source for the occlusion were unhelpful; these included an echocardiogram, full blood count, erythrocyte sedimentation rate, electrolytes, and urea levels, as also a thrombophillia screening.
The patient was managed with vigorous manual massage of the eyeball, fast intravenous mannitol (250 ml in half an hour), followed by oral acetazolamide (500 mg) four times a day. Also, anterior chamber paracentesis was tried immediately. One day later, the patient felt a slight improvement in vision and was discharged against medical advice. She was lost to follow-up and presented after six months maintaining a visual acuity of 20/40 in the right eye and a normal appearing fundus.


A 45-year-old male presented with sudden onset headache and altered sensorium. On arrival, his Glasgow coma score was E4M5V4. His pulse was 65/minute. Blood pressure (BP) was 126/76 mmHg. Plain computed tomography of the head revealed blood in left Sylvain cisterns suggestive of subarachnoid hemorrhage. Four-vessel angiogram revealed 6-mm aneurysm in left middle cerebral artery bifurcation.
Patient was taken up for endovascular coiling on first available operation theatre, i.e., 3 days after admission under general anesthesia. His groin was cleaned and draped. The entire body was covered with sterile gown. His BP at induction was 120/76 mmHg and pulse 76/minute. General anesthesia was maintained as per standard protocols. The femoral artery was punctured with 6-French (F) check flow. The angiogram was performed with standard techniques using 6-F angiocatheter. Pressure cuff was applied on the infusion vac and a pressure of 250 mmHg was maintained on the pressure bag to allow easy flow of heparinised saline. A microcatheter (prowler 14) was put for selective catheterization of middle cerebral artery. While negotiating microcatheter, the BP shot up to 200/110 mmHg and pulse was 100/minute. Patient was, however, in deep anesthesia. At this stage of the procedure, the flow of saline solution stopped despite a pressure of 250 mmHg in infusion chamber. There was reflux of blood via the 6-F catheter back into the irrigating arterial tubing despite a constant pressure of 250 mmHg on the fluid bags. There was no evidence of intraoperative rupture of aneurysm during procedure. For about 20 minutes the attempts to control the BP with Diltizam (5 mg) and propofol failed and BP remained on higher side (200/110 mmHg). His arterial blood gases were within normal limits.
The reflux of blood back from femoral artery into the intra-arterial lines resulted in halting of the procedure.
At this stage surgeon noticed grossly distended abdomen and suspected a full bladder. The urine bag was empty. The tubing of Foleys catheter was found to be kinked. The tubing was repositioned, which resulted in bladder empting and settling of BP and pulse.
The reflux of blood also settled and coiling of the aneurysm was successfully completed. Patient was discharged on fourth postop day in satisfactory condition.


A 43-year-old man with a previous history of hypertension complained of sudden severe epigastric pain that began 6 hours before admission and rapidly progressed to more severe diffuse abdominal pain. Physical examination was consistent with suspected surgical abdomen. The laboratory data showed no significant abnormalities. Abdominal computed tomography (CT) showed a focal dissecting flap in the proximal SMA (white arrow) with a severely narrowed true lumen (). The SMA angiogram showed a focal dissection flap 2 cm distally from the origin (arrow) with a combined dissecting aneurysm (arrowheads) (). Immediately after contrast injection during SMA angiography, the dissecting flap propagated acutely and rapidly (arrows), and a large amount of thrombus migrated to the entire distal trunk of the SMA, the iliocolic, and jejunal branches (arrowheads), leaving the SMA main trunk nearly occluded ().
After cannulation of the SMA main trunk with a 2.4F microcatheter, a total of 500,000 I.U urokinase were continuously infused through angiographic catheter and microcatheter separately during 15 minutes, and aspiration embolectomy was performed with a 7F aspiration catheter. After removal of most of the thrombus within the SMA main trunk, a 7 mm×6 cm self expandable stent (Protégé; Micro Therapeutics, ev3, Irvine, CA, USA) was deployed over the dissection flap at the proximal SMA (white arrows), while jejunal branches remained occluded due to distally migrated thrombus (white arrowheads) (). Completion angiography showed a completely excluded dissecting flap in the proximal SMA and complete recanalization of the SMA and its branches (). The patient experienced complete improvement symptom of the immediately after the procedure and remained asymptomatic during 25 months of follow-up.


A 44-year-old man presented to our hospital in 2005 with complaints of generalized edema and frothy urine of two months duration. Evaluation showed nephrotic range proteinuria, hypoalbuminemia, and hypercholesterolemia. Kidney biopsy showed minimal change disease. There was no clinical or laboratory evidence of a secondary cause for nephrotic syndrome. Patient responded to oral prednisolone 1 mg/kg/day and attained complete remission in 4 weeks, when prednisolone was tapered over 8 weeks and stopped; on subsequent follow-up over 4 years, he was an infrequent relapser. He was readmitted in June 2009 with anasarca of three weeks duration and sudden onset of weakness involving left upper and lower limbs, and severe pain with bluish discoloration of right hand for 1 day. He was not a smoker. There was no history of trauma or intake of any medications. Right hand and forearm showed clinical features of ischemia with absence of pulsations in brachial, radial, and ulnar arteries. Central nervous system examination revealed left supranuclear facial palsy and dense left hemiplegia. Evaluation confirmed relapse of nephrotic syndrome: Nephrotic range proteinuria (24 hours urinary protein: 8 gm), hypoalbuminemia (serum albumin: 1.4 gm/dl), and hypercholesterolemia (serum cholesterol: 433 mg/dl). Renal functions (serum creatinine: 0.8 mg/dl) and liver functions were normal. Doppler study showed absence of blood flow in all arteries of right upper limb; carotid arteries did not show any evidence of plaques. Doppler study did not reveal any evidence of thrombosis in renal veins, IVC, or lower limb veins. Chest roentgenogram and ECG were normal. Echocardiography showed normal heart valves and chambers with no evidence of thrombus in the cardiac chambers. Computed tomography (CT) angiogram showed thrombus involving right brachiocephalic trunk [Figures and ] with embolic occlusion of right axillary artery and right middle cerebral artery (MCA). CT scan of head showed features of acute right MCA territory infarction []. Patient was worked up for hypercoagulable state: protein C 27% (normal, 70 – 140%), protein S 61% (normal, 60 – 110%), antithrombin III 73% (normal, 75 – 125%), absent factor V Leiden mutation (negative), APTT 32 seconds (control, 32 seconds), PT 13.2 seconds (INR, 1.0), homocysteine 13 micromol/l (normal, 5 – 15 micromol/l). Blood fibrinogen was 736 mg/dl (normal, 200 – 400 mg/dl). Cryoglobulins, anticardiolipin antibodies, and beta-1-glycoprotein antibodies were negative.
He underwent emergency open right axillary artery embolectomy followed by anticoagulation. Initially he was started on heparin, which was followed by oral Warfarin. Subsequently, ischemic changes in the right upper limb improved clinically, power of left upper and lower limbs improved gradually. Patient was continued on oral anticoagulation therapy. Oral prednisolone 1 mg/kg/day was started. After 8 weeks, patient attained remission; steroids were tapered and stopped at the end of 16 weeks. Patient was lost to follow-up; hence, repeat imaging studies could not be done.


A 28-year-old man presented at our clinic with a rapid growing mass located on his left flank. The patient had first recognized tensile force on the area and then found a soft, painful mass two months prior to presentation. There was no episode such as trauma or physical injury before development of the mass. Upon physical examination, we noticed a subcutanous mass that was tender, mobile and soft with a diameter of about 3 cm (). The differential diagnosis included lipoma, angiolipoma, leiomyoma and neurilemmoma. No abnormalities were detected upon laboratory work up. Computed tomography (CT) revealed a well-defined, approximately 2.5×2.3 cm sized soft tissue density mass in the subcutaneous area on the left flank without significant lymphadenopathy (). Histopathologic examination showed a relatively well circumscribed, nonencapsulated tumor immediately under the dermis with an infiltration of the lateral margin (). The tumor consisted of dispersed atypical lipoblasts and plentiful, plexiform "chicken-wire" capillary vasculatures in a prominent myxoid stroma (). Some areas showed collection of the uniform round to oval shaped primitive nonlipogenic mesenchymal cells. Atypical proliferating lipoblasts showed varying degrees of differentiation and small signet-ring lipoblasts were occasionally seen (). On immunohistochemistry, alcian blue stain demonstrated mucin deposits in the surrounding stroma with mucopolysaccharide lakes (), but CD34 and S100 were negative. The tumor was eventually diagnosed as a myxoid and round cell liposarcoma. The patient was then transferred to the department of plastic surgery and the lesion was widely excised with a flap. There was no recurrence within seven months of the excision; however, long-term follow-up was recommended.


A 28-year-old female soft contact lens wearer with a 10-day history of pain, redness, and blurred vision in her left eye presented to the emergency clinic. Prior to the presentation, she had started treatment with antiviral and antibacterial topical medications elsewhere (at a dispensary clinic) without any improvement. Three days before presentation, she had started treatment with 1% topical prednisolone acetate.
At presentation, there was marked photophobia, irritation, and substantial discomfort, but the patient reported symptomatic improvement after the initiation of the topical steroid. The best corrected visual acuity (BCVA) in the right eye was 20/20 and in the left eye, 20/160; the intraocular pressure was 16 mmHg in both eyes. Slit lamp biomicroscopy of the left eye showed intense bulbar conjunctival congestion and multiple radial, linear, and branching anterior stromal infiltrates starting in the paracentral cornea with edematous intervening stroma []. The overlying epithelium was intact. There was +1 anterior chamber reaction without keratic precipitates. Clinical examination of the right eye was unremarkable. Fundus examination showed a healthy posterior pole in both eyes. The clinical picture was consistent with herpes simplex or Acanthamoeba stromal keratitis. Corneal scraping was performed, and samples underwent Gram, Giemsa, and potassium hydroxide with calcofluor white (KOH + CFW) staining. Culture experiments were conducted using blood agar, chocolate agar, brain heart infusion broth, thioglycollate broth, Sabouraud dextrose agar, and nonnutrient agar with Escherichia coli overlay, allowing for the growth of Acanthamoeba. Both contact lenses and the solution underwent culturing. During the interim of laboratory testing, the patient continued empirical treatment, which included topical prednisolone acetate four times daily, acyclovir ointment five times daily, 1% cyclopentolate drops three times daily, and topical ofloxacin four times daily. The patient was requested to return for follow-up after 1 day.
Laboratory results from the contact lens solution indicated Acanthamoeba cysts. The corticosteroid drops were discontinued, and full anti-Acanthamoeba treatment was initiated, which included 0.02% polyhexamethylene biguanide (Baquacil, ICI America, USA) hourly around the clock, chlorhexidine eye drops hourly around the clock, neomycin/polymyxin B/bacitracin (Neosporin) drops every 2 h around the clock, and oral dose (200 mg) fluconazole two times daily, as well as cycloplegic drops. The patient was requested to return for follow-up after 3 days. A slight improvement was initially observed, followed by extensive spread of stromal infiltrates and increased corneal edema on the seventh day after the initiation of the treatment [].
When the corneal smears were performed again, they were positive for both Acanthamoeba and P. aeruginosa. The patient was admitted to the hospital, and fortified ceftazidime (50 mg/ml eye drops administered hourly around the clock) was added to the regimen; ofloxacin was discontinued. The patient stabilized first followed by slow improvement. After 2 weeks of intensive treatment, fortified ceftazidime was tapered and was then replaced with ofloxacin (four times daily) as prophylaxis. After 1 month of anti-Acanthamoeba treatment, topical drops were reduced to every 2 h for 2 weeks. The patient was then discharged from the hospital and was kept on the same medications (topical drops every 4 hours) with the exception of neomycin/polymyxin B/bacitracin (Neosporin) eye drops, which were discontinued.
One week after discharge, the hypopyon recurred, and the right eye showed an epithelial defect, approximately 2 × 3 mm, with a prominent ring infiltrate surrounding the epithelial defect. A corneal biopsy showed Acanthamoeba. Full anti-Acanthamoeba treatment – hourly polyhexamethylene biguanide and chlorhexidine eye drops, neomycin/polymyxin B/bacitracin (Neosporin) drops every hour round the clock, and oral dose (200 mg) fluconazole two times daily – was restarted. Within 48 h, the hypopyon had completely resolved, and during the next 3 weeks, the stromal infiltrate showed slight improvement. The intensive treatment was continued for 2 months, followed by a taper over 6 months. At 6 months’ follow-up, patient's BCVA was 20/30. The eye showed no signs of inflammation but did have faint corneal scarring and a mild superficial corneal neovascularization superonasally []. At the most recent follow-up (14 months after initial presentation), the neovascularization had resolved.


A 24-year-old female, complaining of redness, pain, and photophobia in the left eye for 1-week duration, presented to the emergency room. She had a history of periodic contact lens wear for cosmesis 2 weeks before presenting to the emergency room. She had no other ocular or systemic complaints. Her visual acuity was 20/20 in the right eye and 20/40 in the left eye; the intraocular pressure was normal in both eyes. Slit lamp examination of the right eye was normal. The left eye had lid swelling, conjunctival injection, redness, with radial, linear, and branching corneal stromal infiltrates, starting in the paracentral cornea and extending toward the limbus []. No corneal epithelial defects or any anterior chamber reactions were detected in the left eye. The rest of the eye examination, including the dilated fundus examination, was normal.
Corneal scraping was carried out, and samples underwent Gram and Giemsa staining and culturing. Culture experiments were performed with various types of media, including blood agar, chocolate agar, brain heart infusion broth, thioglycollate broth, Sabouraud dextrose agar, and nonnutrient agar with E. coli overlay. Results obtained from both staining and culturing were suggestive of Acanthamoeba keratitis. Confocal microscopy showed enlarged corneal nerves, but no cysts were observed. Anti-Acanthamoeba treatment was initiated, which included 0.02% polyhexamethylene biguanide and chlorhexidine eye drops hourly around the clock, neomycin/polymyxin B/bacitracin (Neosporin) drops every 2 h around the clock, and oral dose (200 mg) fluconazole two times daily, as well as cycloplegic drops. The patient was admitted to the hospital and was kept on this regimen for 3 weeks. The patient was then discharged with instructions to instill topical chlorhexidine every 6 h for 3 months, topical neomycin/polymyxin B/bacitracin (Neosporin) every 6 h for 3 months, and oral (200 mg) fluconazole two times daily for 1 month only. The patient was regularly followed up in the clinic. A complete resolution of the infiltrate was achieved within 3 months, and no recurrence was detected in the first year of follow-up []. The patient achieved a final visual acuity of 20/20. At the most recent follow-up visit (18 months after initial presentation), corneal vascularization and recurrence of infiltrate were not detected [].


A 39-year-old female patient of American Society of Anesthesiologists (ASA) grade 2 was presented for total abdominal hysterectomy. She was a known diabetic and hypertensive, well controlled with insulin and Angiotensin Converting Enzyme (ACE) inhibitors. Systemic examination was clinically normal. Blood counts, urea, creatinine, electrocardiograph, and chest X-ray were all normal, except for mild anemia (hemoglobin 9.8%).
Following overnight fasting, she received oral antihypertensive, i.v. antibiotic, and i.m. pethidine and promethazine.
Surgery was performed under general anesthesia. Airway maneuvers were smooth and recovery uneventful; 1000 ml crystalloid was infused intraoperatively.
For the next 24 h, patient was hemodynamically stable with good urine output.
Because hemoglobin was 8.4 g% and PCV (Packed Cell Volume) 27%, whole blood transfusion was advised on the second postoperative day. After approximately 250ml of blood had been transfused, patient developed chills, fever, and tachycardia. Blood pressure was 150/90 mmHg.
Patient became tachypneic, dyspneic, and SpO2 was 89% on room air. Diffuse bilateral crepitations were present.
Transfusion was discontinued and remaining blood was found to be compatible when re-crossmatched. The donor was the patient's brother and the whole blood did not undergo leukodepletion. Patient received O2 by face mask, along with bronchodilators, steroids, and diuretics. There was no oliguria or hemoglobinuria. Overnight patient maintained 95% saturation with 10 l/min O2 by face mask.
Patient showed persistent tachycardia and tachypnea on the third postoperative day. Blood counts, urea, creatinine, and electrocardiograph were normal.
Chest X-ray showed bilateral nonhomogenous opacities but no cardiomegaly []. Echocardiogram showed mild RA/RV dilatation possibly due to acute lung injury (ALI).
ABG (Arterial Blood Gas) revealed pH 7.45, pO2 81 mmHg, SpO2 96%, pCO2 32 mmHg, and BE –3.0 at 10 l/min flow of oxygen via face mask.
After sedation and paralysis, she was intubated and ventilated on controlled mode using FiO2 1, PEEP 10 cm H2O resulting in a saturation of 100%. Bronchodilator, steroid, and antibiotic therapy were continued.
A clinical diagnosis of ALI, probably transfusion related, was made after excluding other causes (vide infra, see DISCUSSION).
On the fourth postoperative day, significant improvement occurred clinically, radiologically, and on ABG, hence weaning was initiated.
Patient was successfully extubated on the sixth postoperative day and O2 was continued via face mask [].
She was maintaining saturation on room air and was shifted to the ward on the seventh postoperative day.


A 58-year-old woman was admitted with Wallenberg syndrome due to occlusion of the right posterior inferior cerebellar artery []. Her angiogram showed a basilar bifurcation aneurysm [Figure, ]. Two months after the infarction, a craniotomy was performed. Neck clipping of the aneurysm was through a right anterior temporal route. Her TCMEP with 300 V stimulation of the left APB and bilateral abductor halluces (AH) muscles disappeared with temporary occlusion of the basilar artery for 10 min [], arrow] and partially recovered by recirculation after neck clipping [, arrow head]. An 81% reduction in amplitude was observed in the left AH muscle by CMAP after peripheral nerve stimulation compensation. Postoperatively, monoparesis appeared in her left lower limb and persisted for a month. Angiography after the operation showed complete neck occlusion [Figure , ]. This was a true-positive case.


A 47-year-old man had been struck by a motor vehicle while on his bicycle and suffered from motor weakness of his hands. The magnetic resonance image of his cervical spine showed marked spinal canal stenosis at C3-6 by spondylotic change [Figure –]. Right C3-6 unilateral open-door laminoplasty with titanium miniscrews and miniplates through hydroxyapatite ceramic spacers was performed a month after the trauma [Figure ]. Although full decompression was achieved [] and bilateral grasping force was recovered postoperatively, the amplitudes of TCMEP on the bilateral APB muscles decreased after decompression. The final amplitude reduction rates were 96% (left APB) and 89% (right APB) with CMAP compensation. This was a false-positive case.


A 35 year-old male presented with a right-sided, scrotal swelling of three days’ duration associated with acute scrotal pain of increasing severity. His past medical history was not significant and there was no history of trauma. Clinical examination revealed an enlarged, firm, tender nodule, three cm in diameter, while the contralateral testis was normal. A clinical diagnosis of torsion testis/testicular neoplasm was made. All routine investigations gave normal results. An emergency scrotal ultrasonography (USG) revealed a 2.5 cm, single, ovoid, well-defined, hypoechoic, solitary mass in the right testis. Guided aspiration was done under local anesthesia using a 10 mL syringe and a 24 gauge needle to obtain a scanty, grey-white aspirate. The smears were stained with hematoxylin-eosin (H and E), Papanicolaou, and May-Grünwald-Giemsa (MGG) stains. The smears were moderately cellular, consisting of tumor cells arranged in sheets and clusters. The cells were round to oval, having eccentric, vesicular nuclei with a fine granular chromatin along with a pale/vacuolated cytoplasm []. A cytological diagnosis of adenomatoid tumor was made. The patient underwent orchidectomy as the mass was firmly adherent to the tunica albugenia making conservative surgery unfeasible. The specimen showed the testis with a well circumscribed, encapsulated mass measuring 2.5 × 2 cm [] and its cut section was gray white. Histopathological examination (HPE) showed cuboidal to flat epithelial cells in solid cords, some lining the cystic spaces. Some of these epithelial cells showed prominent cytoplasmic vacuolation. Intervening stroma showed fibrocollagenous tissue with sparse lymphocytic infiltrates []. These features were consistent with those of an adenomatoid tumor.


A 30 year-old male presented with a right-sided, tender scrotal swelling of four days’ duration. He had no significant past medical history or history of trauma. On local examination, a firm, mobile, and tender mass measuring 2 × 2 cm was found; the contralateral testis was normal. A clinical diagnosis of tuberculous epididymitis or testicular neoplasm was made. Routine hematological and biochemical investigations, urine analysis, and a chest radiograph revealed no abnormalities. USG of the scrotum showed a well defined, hypoechoic mass measuring 2.5 × 2 cm in the region of the globus major of the right epididymis. Aspiration was done using a 10 mL syringe and a 24 gauge needle to yield a scanty, grey-white aspirate. The smears were stained with H and E, Papanicolaou, and MGG stains. The cytological features were similar as those of case 1 and a diagnosis of an adenomatoid tumor was made. The patient underwent a conservative testis-sparing surgery with the excision of the epididymal nodule. The nodule measured 2 × 2 cm and the cut section was grey-white with microcysts. The results of the histopathological investigation were consistent with features of an AT.


Our case, a 33 year-old male patient presented with the complaints of swelling on the right side of the neck that had been gradually growing for one month, as well as shortness of breath and cough. His thoracic computed tomography (CT) showed a 1.5 cm lymph node on the anterior mediastinum and a mass of about 11 × 10 × 8 cm, extending from the right lung apex to the right hilus, with regular contours and without contrast enhancement. His abdominal CT revealed a hypodense, heterogeneous, and cystic necrotic mass of about 10 × 7 × 5 cm that was para-aortic at the infrarenal level. The patient was given a preliminary diagnosis of a central bronchus tumor and the lymphoma was then subjected to transthoracic FNAC. Cytopathological examination demonstrated pleomorphic epithelial cells, either individually or in groups, having cytoplasm with vacuoles. It was noted that these cells had eccentric located nuclei containing one or more nucleoli. In light of these findings, the patient was diagnosed with a nontypeable, malignant, epithelial tumor and was directed to undergo a genitourinary examination []. Upon finding a high alpha fetoprotein (AFP) value (5724 IU/mL), scrotal ultra sonography (USG) was performed and showed a mass filling the whole testis on the right side. The patient was diagnosed with a mixed germ cell tumor (60% mature teratoma and 40% yolk sac tumor) by histopathological examination of the orchiectomy material.


A 30-year-old, non-smoker and previously healthy male presented with gradually progressing breathlessness and left-sided chest pain for the past one month. Chest radiograph revealed left-sided pleural effusion. The hemorrhagic pleural fluid sent for cytological evaluation showed pleomorphic malignant cells. Computed tomography (CT) of thorax revealed a heterogeneously enhancing lesion in the left hemithorax, with a major portion in anterior mediastinum with left hilar involvement. Ultrasound-guided fine needle aspiration cytology (FNAC) was performed from the anterior mediastinal mass and smears were stained with hematoxylin and eosin (H and E) and May-Grünwald Giemsa stain (MGG).
Smears were highly cellular showing dimorphic pattern []. One cell type was predominantly ovoid-to-elongated with spindle-shaped nuclei, coarse chromatin and scant cytoplasm. The other cell type was round-to-polygonal with finely vacuolated cytoplasm. The nuclei were hyperchromatic with indistinct nucleoli []. The final cytological diagnosis was given as non-small cell carcinoma probably from lung. Subsequently the patient underwent CT-guided biopsy.
Histopathological examination showed a tumor composed of primitive glandular structures lined by columnar cells with clear and vacuolated cytoplasm surrounded by spindle cell component showing oval plump nuclei []. The nuclei of both components were hyperchromatic and pleomorphic. Foci of blastema components were also seen. Occasional mitotic figures were noted in the spindle cell component. A final diagnosis of classic biphasic pulmonary blastoma was given. Secondary deposits in the lumbar vertebrae with involvement of L2–L3 roots were seen on magnetic resonance imaging. He underwent three cycles of chemotherapy.


A 27-year-old female patient presented with non-healing painful ulcer in the left hand of 6 months’ duration. The lesion started as a pustule which evolved into an ulcer within 1 week. There was no history of trauma at the site. Fever and other constitutional symptoms were absent. On examination, an ulcer measuring 10 × 6 cm was present over the ulnar aspect of the dorsa of left hand which extended to the first three fingers and the palmar aspect of left hand []. The edges were sloping and the floor showed granulation tissue.
Investigation revealed anemia. Liver function, renal function, and chest X-ray were within normal limits. Mantoux, smear for AFB, KOH for fungus, and Tzanck smear were negative. Culture for tuberculosis and atypical mycobacteria were sterile. Fungal culture was negative. A biopsy of the ulcer showed neutrophilic vasculitis, necrosis, and ill-defined granulomas. The possibility of pyoderma gangrenosum was considered. P ANCA and C ANCA were also negative. HIV ELISA was not requested.
The patient was treated with sulfasalazine 500 mg twice daily. Oral steroids were added to the dose after 5 days as the lesions increased in size. She was discharged with T. prednisolone 20 mg daily. After 15 days, her ulcer did not show any improvement but pain was aggravated. Sulfasalazine was stopped. Cyclosporine 100 mg was advised and after 5 days she reported with vesicles and ulcers over perianal region.
On genital examination, multiple vesicles and ulcers with polycyclic border were seen in the perianal region and vesicles were present near the ulcer in the left hand. The blood picture showed pancytopenia. Tzanck smear from perianal vesicle showed multinucleated giant cells whereas from the vesicles on the hand showed only neutrophils. Pus culture showed staphylococcus and E. coli, and Linezolid 600 mg twice daily was started according to sensitivity pattern. A workup for STD revealed HIV 1 Elisa to be positive, and result was confirmed by Western blot. CD4 count was 65. She was treated with Famciclovir 500 mg thrice daily. She had dry cough for 3 days and chest X-ray showed patchy haziness on both sides. Early morning sputum for AFB was negative on three consecutive days. She was treated for Pneumocystis carini infection with co-trimaxozole. We planned to initiate antiretroviral drugs after her PCP treatment to prevent IRIS. Diagnosis of herpetic ulcer was made. After 5 days of famciclovir, her perianal lesions resolved and her hand ulcer showed some improvement with subsidence of pain. The ulcer over the hand healed in a span of 25 days [].


A 9-year-old male child was brought to the plastic surgery outpatient department by his parents with chief complaints of deformity in the neck region. On first inspection, it seemed to be a case of torticollis. But complete examination enabled us to diagnose it as a case of webbed neck with bilateral contracture more on the right side []. There was no family member with characteristics of NS. On elicitation of past history, it was revealed that the child had undergone some cardiac intervention at the age of 2 years. Examination of past medical record revealed that he had undergone ligation of patent ductus arteriosus (PDA) under general anesthesia. Thereafter, the child had normal growth with no significant medical history. Presently, the patient had no symptoms pointing toward any cardiac decompensation. His exercise tolerance was good. He was not receiving any medication and parents did not convey any untoward incident of drug allergy or any other systemic medical disease. The hemoglobin level was 12.8 g/dL and the serum electrolytes, creatinine, blood glucose, and rest of the investigations were within normal limits. Hematologic investigations revealed no coagulation or platelet defects.
On local examination, we found bilateral neck bands with short webbed neck and low posterior hairline. On clinical examination, pulse rate was 94/min and regular and blood pressure was recorded to be 104/68 mmHg. Mallampatti score was labeled as grade 3 with mouth opening of approximately 1.5 cm and the weight of the child was 24 kg. On auscultation, a pan systolic murmur was heard at pulmonary and aortic area. Chest X-ray showed normal bronchovascular markings with a radio-opaque ligature of PDA []. Lateral view of the cervical spine revealed a short base of skull with a steep angle, basilar invagination, atlanto-occipital fusion, as well as the fusion of 2nd, 3rd, 4th, and 5th cervical vertebrae [].
The electrocardiogram (ECG) showed T-wave inversion in L3, V1, V2, and V3 leads with no any other abnormality. Echocardiographic findings revealed normal left ventricular function, mild aortic stenosis with bicuspid aortic valves, pulmonary stenosis with thickened cusps, and small PDA of approximately 2.5 mm. The child was reviewed by a cardiologist and was advised infective endocarditis prophylaxis before the scheduled elective surgery for the release of bilateral neck bands.
On the day of surgery, the child received 75 mg of ranitidine and 12.5 mg of oral promethazine syrup 1 h before the scheduled surgical procedure. The child was very cooperative inside the operation theater and a peripheral venous access was secured using 20G cannula. Resuscitation and difficult airway management trolley was kept by the side and the equipment for tracheostomy was made available. An ENT surgeon had already scrubbed and was ready in case for any eventuality. The child was preoxygenated with 100% O2 for 5 min.
Induction of anesthesia was achieved with Fentanyl 50 μg, glycopyrrolate 0.1 mg, propofol 50 mg, and 2% sevoflurane. After establishing a successful bag mask ventilation, 2.5 mg vecuronium bromide was administered. After 3 min of ventilation, fiberoptic bronchoscopy was carried out. It was a little difficult negotiating the pharyngeal curves but within a minute we were able to view the glottis and a cuffed endotracheal tube number 5.5 mm internal diameter was safely placed into the trachea. Thereafter, surgery was performed in a prone position and throughout the procedure strict vigil monitoring was carried out, which included heart rate, ECG, end-tidal carbon dioxide, pulse oximetry, and noninvasive blood pressure. Maintenance of anesthesia was achieved with oxygen, nitrous oxide, sevoflurane, and vecuronium bromide. The entire procedure lasted for 2 h. At the end of surgical procedure, neuromuscular blockade was reversed with injection neostigmine and glycopyrrolate. Extubation was done after the onset of rhythmic breathing and return of protective airway reflexes. The child was given postoperative oxygenation for 5 min and after that kept in postanesthesia care unit for 2 h and strict monitoring was carried out. Diclofenac sodium was given as postoperative analgesic as infusion. The postoperative period was uneventful and the child was discharged on 8th postoperative day in a satisfactory condition.


An 80-year-old woman with a history of collapse at home was admitted to Emergency when she had a cardiac arrest and was successfully resuscitated and intubated. She also had diabetes mellitus, hypertension, and atrial fibrillation. She had a past history of total thyroidectomy.
While she was ventilated in the ICU she developed pneumonia, was treated and extubated. She had another episode of respiratory distress and needed re-intubation, was ventilated and shifted to our hospital.
On admission she had an episode of upper gastrointestinal bleeding which was treated endoscopically. She got infected with acinotobacter in the sputum, had bilateral pleural effusion and was unweanable from the ventilator. Considering the status of the patient a decision was taken to do the PDT electively. This was expected to facilitate the weaning from the ventilator or as a therapeutic measure considering the uncertainty of duration of the ventilator support.
Her past history of thyroidectomy was considered in expecting an altered anatomy and difficulty in identifying the landmarks during PDT. The patient was positioned for PDT and prepared and draped. On identification of landmarks with palpation, a pulse was felt which is unusual at the midline of the trachea at the level of the third and fourth tracheal rings. The pulse was rhythmic with the monitor which confirmed the presence of an artery. The artery was traced superiorly and inferiorly and it was seen that it became lateral to the trachea on the right side.
The confirmation of this distortion was done by ultrasound guidance (sonosite M turbo - USA) with a high-frequency linear probe. The sonoanotomy revealed that the right common carotid artery after emerging in the neck ascended in the neck very close to the trachea and formed a loop anterior to the trachea at the level of the third and fourth rings and ascended laterally further before dividing into the external and internal carotid arteries []. There were no other abnormalities seen in the vasculature either on the right side or left side. The procedure was abandoned citing the abnormal anatomy and expected difficulties in the PDT. The case was referred to thoracic surgery for surgical tracheostomy and the findings on ultrasound were confirmed during surgical tracheostomy []. There was presence of fibrous tissue lateral to the trachea on both sides, on the right the common carotid artery was found adherent to the tracheal wall and forming a loop anterior to the trachea. The surgical tracheostomy was done successfully.


A 59-year-old male patient was admitted to our hospital with complaints of right flank pain and hematuria. Increased neutrophil count with normal white blood cell level and high blood urea nitrogen (BUN) (82 mg/dL, normal range: 10-50 mg/dL) and creatinine (2.7 mg/dL, normal range: 0.6-1.2 mg/dL) levels were found on laboratory examination. A hypoechoic, heterogeneous, solid renal mass seen on US was attributed to renal malignancy []. T1 weighted MRI demonstrated a hypointense mass measuring 9 cm × 10 cm originating from the upper pole of the kidney. T2 weighted sequence revealed peripheral solid component to be hypointense and central cystic component to be bright. Other imaging features were invasion of the psoas muscle posteriorly and enhancement of the mass in the delayed phase after intravenous gadolinium injection []. On the basis of the clinical and radiological findings, a malignancy such as renal cell carcinoma (RCC) was suspected. The patient had exploratory surgery, since the mass was adhering to the psoas muscle, the surgeon did not resect the mass and the kidney. A large volume of tissue was obtained during the surgery for histopathology evaluation. Chronic inflammatory cells with vimentin positive myofibroblastic cells were seen in histopathologic examination with no evidence of malignancy.
The patient had palliative medical treatment and the CT done 3 months later revealed significant regression in the size of the mass lesion with the relief of symptoms []. MRI of the patient performed 6 months after the operation showed complete regression of the lesion in the right kidney. The patient is currently free of disease, 1 year after the initial diagnosis.


A 73-year-old male patient presented at the Department of Oral Medicine and Radiology with ulcerative lesion in his palate. The lesion was discovered by his dentist during a routine check-up. The patient himself was unaware of the lesion. He gave a history of pressing soft biscuits on his palate while eating, 2-3 weeks prior to the occurrence of the lesion. The ulcer was not associated with pain or paresthesia. About 10 years before he was treated for adenocarcinoma of rectum and tuberculosis of abdomen. He was a known asthmatic and was on salbutamol inhalation. On intraoral examination, two irregular shaped ulcers were noticed in the posterior part of the palate (junction of hard and soft palate), one measuring about 1.5×1 cm and the other measuring about 0.8×0.5 cm. The margins of the ulcers were slightly raised, erythematious with surrounding mucosa appearing blanched, pale and grayish white. The underlying bone was partially exposed, the floor was covered by yellowish grey slough, and the base was mildly indurated (). As the patient had a previous history of tuberculosis; a provisional diagnosis of tuberculous ulcer of palate was made. Differential diagnosis of necrotizing sialometaplasia of minor salivary gland of palate, chronic traumatic ulcer, malignant ulcer, both primary and secondary from adenocarcinoma of rectum, syphilitic ulcer, adenocarcinoma of minor salivary gland of palate were considered.
Occlusal radiograph () showed no bony involvement. Chest radiograph and blood investigations also demonstrated normal state, and rapid plasma regain for syphilis was negative. Incisional biopsy was performed and histopathologic features on hematoxylin-eosin stain were suggestive of NS ( and ). The patient was advised to apply gentian violet 2-3 times a day with cotton and maintain good oral hygiene with saline rinse 3-4 times a day. The lesion showed remission after 6 weeks of follow-up except for an area of erythema () which resolved completely after a week.


A 35-year-old male patient came to our department with a chief complaint of occasional chipping of teeth while eating and dislodged fixed partial denture. Patient had experienced abnormal dentition since childhood []. He had undergone extraction of some primary teeth due to caries. The color of primary dentition was yellowish. He had experienced continuous chipping of tooth structure while masticating especially lower dentition. Six-year back his lower left molars were extracted due to fracture and attrition. He had gone for extraction of 16, 27, 46 and 47 last year and nickel-chrome fixed partial denture was fabricated on 14, 15, 16, 17, 18, 33, 34, 35, 43, 44, 45, 46, 47, 48.
These fixed partial dentures frequently come out during eating. The patient was keeping cotton below these fixed partial dentures for retention while eating. He keeps them out of mouth for the rest of the time. No history of any major illness or hospitalization was there. His grandfather has got opalescent brown, worn-out dentition.
OPG full mouth and IOPA X-rays revealed total obliteration of pulp chambers with 33,34,35,43,44,45,48. Partial obliteration of pulp chambers with rest of the teeth with abnormal pulpal morphology. No evidence of any periapical pathology with any tooth was revealed. Posterior to anterior (PA) chest and PA skull were normal [].
Maxillary badly destructed second molar was sent to lab for histological examination. It was revealed that there was normal enamel rods, irregular calcified dentinal tubules, and almost completely obliterated pulp chamber.
After correlating clinical pathological and radiographic findings, diagnosis of dentinogenesis imperfecta (Type-II) was made and osteogenesis imperfecta was ruled out from the differential diagnosis.
treatment plan for this patient should be placement of endosseous implants for missing teeth followed by full mouth rehabilitation.[] Due to economical factors under the circumstances, full crowns and fixed partial dentures were planned for maxillary teeth. Ideally, single complete denture is not indicated in mandible.[] As the denture base coverage area is very less so there are chances of midline fracture in mandibular single complete dentures due to flexural fatigue and impact force.[] To avoid this complication in this case denture base was reinforced the with glass fibers which is supposed to be one of the best choice for denture reinforcement.[]
Diagnostic impressions were made and diagnostic wax-up was done []. 17 was extracted and send to the oral pathology lab for investigations. Amalgam restorations were done with 18, 48. Scaling and polishing was done. Crown lengthening was carried out with 11, 12, 13, 14, 15, 16. 33, 34, 35, 43, 44, 45 were prepared to receive nickel-chrome overdenture copings [] and overdenture copings were cemented on 33, 34, 35, 43, 44, 45 []. Special tray was fabricated for lower overdenture. Border molding was carried out with low fusing impression compound (DPI Pinnacle Tracing Sticks, DPI, India). Wash impression was made in medium body PVS impression material (Aquasil, Dentsply Caulk, USA). Final cast was prepared, blocked out, and duplicated. On the working cast, temporary denture base was fabricated. Wax rim was prepared and height was adjusted posteriorly up to a level 2/3 of retromolar pad and anteriorly up to the level of lower lip. The vertical dimension was recorded according to esthetics and phonetics. Centric relation was recorded in bite registration wax (Alminax, UK) []. Teeth arrangement was done according to anatomical landmarks, phonetics, and esthetics.
Lower overdenture was flasked and dewaxed. After dewaxing, posterior teeth were removed from their indentations and they sectioned horizontally from occlusal one third. Wax loops were placed at the back of sectioned teeth for anchorage. These sectioned occlusal surfaces with loops were casted in nickel-chrome. These metal occlusal surfaces with the help of loops were kept into their remaining part of respective indentations and luted [Figures and ].
Glass fibers were impregnated with silane (Heliobond, Ivoclar) and pre-peg was prepared. This pre-peg was then sandwiched in dough of heat cure acrylic and packed (compression molding technique). Curing was done. Finished lower overdenture was evaluated intraorally [Figures and ].
Worn out tooth structure was build with core buildup composite [] (Lumiglass, Dentsply Caulk, USA) reinforced with titanium pins (Amalgam pins, DPI, India) for each cusp. Upper teeth were prepared according to the occlusal surface of lower overdenture teeth. Provisionals were fabricated and delivered along with lower over denture. The increased vertical dimension was evaluated up to 4 weeks. After the final adjustment of the provisionals, interocclusal records were made and articulator (Hanau H2, USA) was programmed accordingly. Final preparation of the upper teeth was done. Gingival retraction was done with retraction cord (Ultrapack, Dentsply, USA) impregnated with haemostatic agent (AlCl3 MP Sai, India). To prevent relapse of marginal gingiva before loading of impression material and to have uniform space for impression material, impression was made with the matrix impression technique using bite registration material (Exa Bite, GC, Japan) and Light body PVS and Putty PVS (Aquasil Dentsply Caulk, USA ) []. After the final setting the tray was removed in toto and poured in type IV die stone (Kalrock, Kalabhai, India). Thus master cast fabricated and transferred to the articulator according to the lower denture [Figures –].
Centric relation was recorded along with final overdenture and relation transferred to the articulator []. Upper nickel-chrome FPDS and full crowns with acrylic facing were fabricated. Upper FPD's full crowns were luted with temporary non-euzenol cement (Temposil, Coltene Whaledent, Switzerland) and lower overdenture delivered. Patient was recalled after 15 days for final luting. Final cementation (GC 1, Gold label, Japan) was done.


A 27-year-old female patient came to our clinic with five-year history of exertional dyspnea. The patient was a clerk for 8 years. She was smoker with history of 8 pack-year. Her medical history and family history were unremarkable, except 3-year history of PAM. In her physical examination, pulmonary and cardiac system examinations were unremarkable, except the presence of the chest wall deformity (pectus excavatum). The posteroanterior chest X-ray revealed bilateral innumerable, diffuse micronodular opacities predominantly in the middle and lower lung fields []. The pulmonary function test showed a restrictive pattern with results as follows: Forced Vital Capacity (FVC): 1.65 l (44% of predicted), Forced Expiratory Volume in 1st second (FEV1): 1.46 l (52% of predicted), FEV1/FVC: 88%, Diffusing capacity of the lung for carbon monoxide (DLCO): 47 mmol/kPa.min, and DLCO/Alveolar Volume (VA): 80 mmol/kPa.min/l. The laboratory tests, including complete blood count, erythrocyte sedimentation rate, C-reactive protein, and serum calcium level, were in normal limits. The thorax computed tomography (CT) revealed bilateral diffuse interstitial pattern (sandstorm appearance), ground-glass opacities, bilateral apical fibrotic changes, and surrounding pleural calcifications mimicing cardiac constriction []. The whole-body bone scintigraphy showed diffuse Tc-99m methylene diphosphonate (MDP) uptake in the both lungs []. The echocardiography revealed mitral and tricuspit valve calcifications. The pulmonary arterial pressure and the right and left heart functions were measured in normal ranges. The 18F-FDG-PET/CT imaging was performed to evaluate any evidence of inflamation in the lung before starting an anti-inflamatory therapy. The images of FDG-PET/CT revealed low metabolic activity in areas of micronodular opacities [Maximum tandardized uptake value(SUVmax): 2.7]. Other lung regions without calcifications revealed lower FDG uptakes [].
Only the palliative treatment consisting inhaler salbutamol (max. 800 mg/day, as needed) was prescribed. Patient was got under regular follow-up.


A 21-year-old woman with the presumptive diagnosis of Apert syndrome was referred to the department of periodontology, school of dentistry, Babol University of medical sciences for regular dental treatment. She was born of a nonconsanguineous marriage. Her parents were clinically normal and at birth her mother was 22 years old and her father was 29 years old. There were no complications during pregnancy, and no other family member showed a similar condition. At birth, she had craniosynostosis, brachycephaly and syndactyly of the hands and feet. The patient has mild mental retardation, but her social development and bonding skills are satisfactory. She has never experienced seizures.
Extraoral examination revealed a brachycephalic skull with midface hypoplasia, a flat forehead, depression of the temporal bones, proptosis, hypertelorism, short nose with a bulbous tip and septal deviation and trapezoidal shape of the mouth. In the lateral cephalogram, hypoplasia of the maxilla gave the appearance of a class III skeletal relationship (). Syndactylies of the right hand’s third, fourth and fifth digits and the left hand’s second, third and fourth digits were present (). Both feet showed a fusion of all toes (). Intraoral evaluation revealed poor oral hygiene with varying degrees of periodontal involvement, an arched swelling (pseudo cleft configuration), class III malocclusion, anterior open bite (), posterior cross-bite, supernumerary teeth, ectopic eruption and creamy white enamel opacities, the tongue appeared excessively large and the maxillary arch was v-shaped ().
The CT scan revealed palatal cleft and maxillary hypoplasia and nasal septum deviation. The patient’s medical history showed recurrent media otitis.
Initial dental treatment consisted of oral hygiene orientation for both patient and mother by means of disclosing tablets to be more familiar with plaque concepts and electrically powered toothbrushes (Oral-B®) and chlorhexidine mouth rinse 0.2% (Donyaye Behesht Co®) two times per day for two weeks, followed by plaque control via monthly professional prophylaxis. After an adaptation period, restorations and primary tooth extractions were performed. Orthodontic therapy is under consideration. The therapy consisted of super-numerary teeth extraction and orthodontic minor tooth movements to correct the crowding and achieving a stable occlusion. Preventive treatments included topical fluoride therapy. The patient was referred to a plastic and reconstructive surgeon for her extremities as she also complained of inability to brush her teeth because her fingers were malformed.


A 23-year-old woman was admitted to Medical Intensive Care Unit with organophosphorus poisoning. The patient required mechanical ventilation and ionotropic support. Left femoral artery catheter was inserted for blood pressure monitoring. On the seventh hospital day she developed fever (102°F) and thachycardia. Three days later the patient was noted to have erythematous papules on the left lower limb. The white blood cell count was 16,500/mm3 (neutrophils 84%, lymphocytes 12%, monocytes 3%, eosinophils 1%). Two sets of blood cultures were sent and the intra-arterial catheter was removed. The skin lesions were biopsied and sent for histopathology and culture. Over the next few days the skin lesions became blackish with necrotic areas (arrow) []. The blood, catheter tip, and skin lesion cultures yielded Pseudomonas aeruginosa sensitive to ceftazidime. Biopsy of the skin lesion revealed acute neutrophilic infiltration pronounced in the perivascular area with necrotic area. The patient was treated with ceftazidime for 2 weeks and lesions resolved completely. Subsequently the patient had full recovery from organophosphorus poisoning and was discharged home.


A 50-year-old woman presented with sudden-onset severe headache and vomiting associated with dull aching pain in the right eye, followed by diplopia, drooping of the right eyelid, and numbness over the right half of the face. These symptoms had evolved over a period of 2 days. On evaluation, she had complete ophthalmoplegia on the right, with subtle sensory loss in the right V1 and V2 trigeminal nerve distribution. Vision was preserved. She had no focal deficits. CT scan of brain [Figure , and ] and MRI of brain [Figures and and and ] revealed a well-defined, 2.6×2.7×2.7-cm lesion in the right paracavernous region, extending from the superior orbital fissure up to the petrous apex, suggestive of a cavernous carotid aneurysm. She underwent digital subtraction angiography (DSA) [], which revealed a flame-shaped right cervical ICA dissection, with occlusion of the entire carotid artery 1.5 cm distal to its origin and nonfilling of the aneurysm. The ipsilateral ophthalmic artery was seen filling through the middle meningeal artery, and good cross-circulation was seen on left ICA injection through the anterior communicating artery. In view of the thrombosed aneurysm and the arterial dissection, she was treated with an antiplatelet agent (aspirin). At the last follow-up, her eye pain had subsided but the cranial nerve and ocular deficits persisted.


A 15-year-old boy presented with persistent painful erection of 46 h duration. The patient had woken up in the early morning with pain. He had experienced a similar episode of painful erection 1 month back, which resolved spontaneously within 4 h. There was no history of perineal trauma or sickle cell anemia. He was not on any medications. There was a history of delayed developmental milestones.
Physical examination revealed a poorly nourished adolescent male with pallor, clubbing, and generalized lymphadenopathy (bilateral cervical, axillary, and inguinal). Liver was enlarged but spleen was not palpable. No xanthelesma observed. Genitourinary examination showed an erect viable penis, edema of proximal shaft of penis, and adjacent scrotum []. Blood sample aspirated from the penis was dark red and consistent with venous blood.
Laboratory evaluation revealed a white blood count of 13.9 × 109/L, hematocrit 43.6%, and platelet count 356 × 109/L, which were within normal limits. Sickle cell test was negative. Corporeal blood gas analysis showed a pH of 6.86, paCO2 88 mmHg, and paO2 26 mmHg. Ultrasonography revealed mild hepatosplenomegaly. Biopsy of the lymph node from the cervical area showed infiltration of paracortical and cortical areas by foam cells, which are large cells with abundant pale pink vacuolated cytoplasm with small pyknotic nucleolus placed centrally as well as eccentrically []. Bone marrow aspiration showed large histiocytes with abundant vacuolated cytoplasm (sea-blue histiocytes) characteristic of Neimann-Pick cells suggestive of metabolic storage disorder []. These cells were PAS negative.
He was managed with cavernous aspiration and irrigation with saline followed by 100 μg phenylephrine injected into corpus cavernosum for a total of 4 doses, 10-15 min apart. One unit of blood transfusion was given with supplemental oxygen and sedation. Complete detumescence was achieved with this treatment. At 6 months follow-up, the patient denied spontaneous erection.


A 40-year-old married male presented with a 2-year history of multiple asymptomatic skin eruptions. Lesions first appeared over lower limbs and then gradually spread over trunk and upper limbs. In addition, painful lesions were also noticed on leg for past one month. Dermatological examination showed multiple, well-defined, non-scaly, discrete, violaceous to hyperpigmented plaques of variable size over trunk and extremities [Figures and ]. Multiple, tender, skin colored to erythematous plaques present on left lower leg []. Oral cavity was normal. Looking to the morphology of the skin lesions we thought of KS's as our diagnosis. On further enquiry, there was no history of fever, diarrhea, or weight loss. Patient admitted having multiple unprotected heterosexual exposures in past but denied having any homosexual contact. There was no history of blood transfusion or intravenous drug abuse. There was no history of any drug intake prior to the onset of lesions. Patient otherwise was in good general health and systemic examination was normal.
Laboratory investigations including complete blood count, renal function, and liver function tests were normal. ELISA for HIV was positive. Sputum was negative for acid fast bacilli (AFB). Serology for hepatitis B and C was negative. Serum VDRL was non reactive. CD4 count was 173 cell /mm3. Chest X-Ray and ultrasound sonography of the abdomen were normal.
Skin biopsy showed innumerable jagged irregular thin walled vascular spaces infiltrating the collagen with foci of moderately dense plasmacytic infiltrate in upper and mid reticular dermis. At places promontory sign (proliferation of new vessels is seen surrounding preexisting vascular structures) was present []. A diagnosis of KS was made on the basis of clinical presentation and histopathological examination.


A 60-year-old man enters with his wife. Diagnosed with metastasising cancer a year ago, he has undergone an operation and seven subsequent chemotherapy sessions. The doctor looks forthcoming and attentive and presents the medical history while glancing at the patient for confirmation. From the computer he identifies the current issue as the growth of one of the metastases. The patient explains that he can feel the tumour growing and the doctor asks about symptoms like urination problems, pain and nutrition. The patient describes a gradual loss of appetite, which his wife confirms. Looking at the computer, the doctor nods. “Yes. Yes, I can see that… Yes, I can tell from your blood results that you… you are in what we call a catabolic state, which means that you break down a little more than you build up.” When the wife expresses concern about her husband's weariness, the doctor attempts to quantify his daily activities. Afterwards, he examines the patient's stomach and exclaims: “Yes! But this we can… We can manage to radiate this one, I'm sure.” Left alone for a moment, the patient and his wife express anxiety at the rapid progress of the disease. In a timid voice, the wife questions the treatment when the doctor re-enters the room, and he briefly explains why radiation is the preferred treatment, going into details about the radiation procedure while the patient listens and nods. He sums up the plan, but the patient makes no move to leave. The wife brings up the liver metastasis, but the doctor dismisses her. The patient nods: “Right, right. Yes, yes.”, but he does not move. After a moment of silence, the patient finally rises: “Well, well… But then… I guess it sounds okay then.” The doctor smiles, says “see you later” and shakes their hands.
Again, the doctor's strong medical concerns guided the conversation, overshadowing other important matters. Even though all the treatment is palliative, the patient's underlying existential agony is never addressed, and is even actively disregarded. The doctor focuses on the medical data and only allows the patient to comment on this. The computer, rather than the patient, is asked about the reason for the consultation, which is defined as ‘growth of one of the metastases’.
The doctor avoids obvious existential concerns; when the patient talks about the tumour, the doctor does not address the underlying fear but asks about symptoms. Likewise, when the patient's increasing tiredness is brought up, he is made to quantify his activity levels. Explicit worries are met with medical answers, and the patient's dying process is even described as ‘a catabolic condition’. The tacit existential dimension appears uncomfortably present at the end, when the fears that are unaddressed seem to prevent the patient from leaving.
But the doctor also shows courteousness, and is attentive to both the patient and his wife, maintaining a good atmosphere and often smiling. He is polite, listens patiently, takes time to answer questions and does not hurry the patient out. Still, the light tone and the almost cheerful doctor make a stark contrast to the patient's grave situation. These contrasts are highlighted at the end of the consultation when the doctor says he will see them later, when they are probably all aware that there might be no “later” for this patient.


We report a case of spindle cell sarcoma of the breast in a 76-year-old man. He presented to the Daegu Catholic University Hospital with a lump in his left breast that had been present for the previous two months. He had been taking medication for hypertension and benign prostate hypertrophy and had not suffered trauma to his chest wall. Further, he had no family history of malignancy, including breast cancer.
On physical examination, the patient had a poorly demarcated, mobile, firm mass in his left breast. The mass was nontender, approximately 1 cm in diameter, and was detected in the subareolar area of the left breast. There was no clinical evidence of regional lymphadenopathy, and there were no abnormal findings in the right breast. Mammography revealed a dense lesion occupying the subareolar region; this lesion was consistent with prominent fibroglandular tissue and suggested asymmetric left gynecomastia (). Ultrasonography revealed a poorly demarcated and highly suspicious malignant lesion in the periareolar area of his left breast, and the lesion was categorized according to Breast Imaging Report and Data System (BIRADS) as BIRADS 4C (). He underwent ultrasound-guided core needle biopsy, which indicated the presence of atypical cells in the fibrous, proliferative lesion (). Preoperative examination consisted of a complete blood count, serum kidney and liver function test, thyroid function test, and tests for the levels of several hormones related to the development of gynecomastia, including estrogen, testosterone, prolactin, and gonadotrophic hormones. All results were within the normal limits.
The patient underwent wide excision of the lesion, including removal of normal breast tissue to provide a safety margin and he did not require subsequent axillary lymph node dissection. Gross examination of the specimen revealed a whitish, fibrotic nodular lesion, measuring 1.5×1 cm in size including surrounding adipose tissue. The specimen was fixed in 10% formalin. Paraffin sections were prepared and stained with haematoxylin and eosin (H&E). Microscopic examination of the sections from the specimen showed nodular proliferation of fibrous tissue with focal infiltrating margins (). There were no ductal components and epithelial tissues. The nodules were composed of plump to spindle-shaped fibroblasts, many lymphoplasma cells, eosinophilic infiltrate, and many keloid-like collagen bundles (). A few atypical multinuclear giant cells and pleomorphic cells were noted; however, abnormal mitosis was not identified. Immunohistochemical staining for desmin, smooth muscle actin (SMA), and S-100 protein was negative (). These diverse histological and immunohistochemical findings established the diagnosis of atypical spindle cell lesion with uncertain malignant potential, exhibiting features of a reactive fibroblastic lesion.
The patient's progress was monitored after the operation, and no specific adjuvant treatment was administered. One year later, he returned with a recurrent mass at the previous surgical site. On physical examination, a firm mass of about 2 cm in diameter was palpated in the wound from the previous surgery. Radiological studies, including computed tomography (CT) and positron emission tomography-CT (PET-CT), were conducted, and PET-CT showed faint fluorodeoxyglucose uptake in the area of the left breast that corresponded to the lesion seen on the CT scan (). There was no evidence of either regional lymphadenopathy or distant metastasis. The lesion was surgically removed using wide excision.
A histological assay showed that the recurrent tumor was 3.8 cm sized in diameter and had an irregular margin. On sectioning, the cut surface showed fibrous bands and lobular adipose tissue with focal congestion without necrosis. The nodules were composed of plump to spindle-shaped fibroblasts, many lymphoplasma cells, eosinophilic infiltrate, and many keloid-like collagen bundles. Microscopic findings were similar to the previous histological findings (), but many atypical cells and abnormal mitotic activity ranging from 6 to 10 mitotic figures per 10 high power fields (hpf) were noted and the resected margins were involved with the tumor (). Based on the rapid recurrence of the mass, increase in tumor size, high degree of cellularity, presence of atypical cells, many abnormal mitotic figures, and infiltrating growth pattern, malignancy was indicated. The immunohistochemical staining for CD34 showed focal positivity; however, the cells were not reactive for other immunomarkers including cytokeratin (CK), epithelial membrane antigen (EMA), SMA, murine double-minute protein 2 (MDM2), desmin, S-100 protein, CD68 and anaplastic lymphoma kinase (ALK). These established histological features of malignant pleomorphic spindle cell tumor in addition to the immunohistochemical results demonstrated no line of differentiation and led to the diagnosis of undifferentiated pleomorphic sarcoma of the breast. Due to the involvement of the resected margin, the patient underwemt simple mastectomy.


A 31-year-old woman with a 2-year history of a painless subcutaneous nodule on the left upper chest wall presented with a progressively growing perianal mass that had developed 1 year before she consulted this department.
She had no significant medical history. Physical examination showed a light gray-colored, polypoid, well-defined, firm, movable perianal mass (size, 1.5 cm) adjacent to the anal verge and extending to the perianal skin. A benign fibrous tissue tumor was first considered and a quiescent perianal abscess should be considered in the differential diagnosis. The mass in the chest wall (size, 1.5 cm) was a firm and well-circumscribed subcutaneous nodule. For pathological diagnosis, a surgical excision was performed for both chest and perianal masses under the local anesthesia.
Histopathological examination of the perianal mass showed that the mass was characterized by polygonal cells with abundant eosinophilic granular cytoplasm, and an immunohistochemical study revealed that the cells were positive for the S-100 protein (). No nuclear mitosis and necrosis associated with malignant cells were observed, and these histopathological findings were consistent with a typical benign GCT. Histopathological and immunohistochemical findings of the chest wall mass were similar to those of the perianal mass ().
The postoperative course was uneventful. The patient was followed up for 1 year, and no evidence of recurrence was observed.


A 54-year-old woman presented with intermittent postprandial abdominal discomfort and radiating back pain that she had suffered during the past month. She had no trauma history, but several episodes of pancreatitis. On physical examination, a palpable mass without clear borders was detected on the left subchondral region. Laboratory findings, including serum carcinoembryonic antigen and carbohydrate antigen 19-9, were within normal limits. Abdominal computed tomography (CT) revealed the presence of a well-circumscribed homogenous mass (about 8 × 6.5 cm) arising from the tail of the pancreas without septa or enhancing solid portion (). The wall of the tumor was slightly enhanced after administering intravenous contrast medium. No regional lymphadenopathy, ascites or metastasis was demonstrated. From these radiologic findings, we diagnosed a pancreatic pseudocyst. At laparotomy, we identified a cystic mass of about 7 × 6.5 cm originating from the body of the pancreas, and a milky fluid was contained within the mass (). The patient underwent distal pancreatectomy with splenectomy. Microscopically, the specimen showed enlarged cyst-like space lined by endothelial cells contained within lymph-like fluid content (). The endothelial cells lining the surface of the cystic spaces were positive for D2-40 (). There was no staining of CD34, caletinin, or MOC-31. The final diagnosis was cystic lymphangioma of the pancreas. The patient had an uneventful recovery and she was discharged on the 18th postoperative day. There was no evidence of recurrence in the 6 months after surgery.


A 44-year-old woman sought evaluation from a gynecologist for a palpable right lower quadrant mass. The abdominal mass was found incidentally while bathing 2 months ago, and has persisted. The physical examination revealed a smooth, mobile mass in the right lower quadrant. She underwent a laparoscopic tubal ligation for contraceptive purposes 20 years ago. The blood chemistries and other laboratory findings were normal. A computed tomography (CT) scan and ultrasonography of the abdomen showed a 14 × 5 × 4.5 cm cystic mass arising from the cecum (). The patient was referred to the department of general surgery, where we discussed the surgical options and recommended a laparoscopic resection.


An 81-year-old man had a palpable right lower quadrant mass of 2 months duration and severe headaches. Brain and abdominal CT scans revealed a chronic subdural hematoma and a large, tubular, cystic appendiceal mucocele, 15 × 4.5 × 4 cm in size. A colonoscopy also demonstrated a large protruding mass from the cecum (). After evacuation of the subdural hematoma, a laparoscopic mucocelectomy was performed 1 month later.


A 68-year-old man presented to our outpatient department with discomfort from a palpable mass in his right testis that had persisted for 1 month. The mass was insidious in onset and had increased gradually in size. He had undergone robot-assisted laparoscopic radical prostatectomy (RALP) at another institution in December 2009. The preoperative metastatic evaluation at that time, including a bone scan and computerized tomography (CT) of the abdomen and pelvis, was negative. The pathological report of the surgical specimen revealed cribriform, poorly differentiated ductal adenocarcinoma with a positive surgical margin. The adenocarcinoma had a Gleason score of 9 (4+5) and the pathologic stage was T3. After the RALP, the patient had received adjuvant radiation therapy for 1 month and had been continuously treated with androgen deprivation therapy. The serum prostate-specific antigen (PSA) level of the patient was stable, ranging from 0.04 to 0.07 ng/ml. However, the patient's PSA level had increased to 0.347 ng/ml over the past 3 months.
The scrotum was normal except for a mildly enlarged right testis. The right testicular mass was hard and non-tender. The spermatic cord was also nonspecific. The laboratory examinations showed a normal complete blood count and normal renal and liver functions. Tumor markers for testis tumor were as follows: lactate dehydrogenase 345 U/l, alpha-fetoprotein 2.6 ng/ml, and beta-human chorionic gonadotropin 0.0 mIU/ml. The result of a chest X-ray was normal. Ultrasonographic examination of the scrotum showed a right intratesticular solid mass and an ovoid hyperechoic and slightly heterogeneous mass sized 2.4×1.7×2.0 cm (). The right testis was enlarged to 4.0×2.4×3.0 cm in size. CT of the abdomen and pelvis showed no evidence of local recurrence after radical prostatectomy and no abnormal lymphadenopathy suspicious of primary testicular cancer metastasis.
On May 12, 2011, the patient underwent right inguinal orchiectomy. The mass in the right testis measured 2.5×2.5×2.5 cm (). Histopathological examination revealed metastatic cribriform ductal adenocarcinoma of the testis from prostate cancer (). An immunohistochemical prostate acid phosphatase examination of the specimen was performed and revealed diffuse immunoreactions. This proved that there was metastasis from the prostate to the testis.
On May 26, 2011, the patient attended a follow-up examination. His serum PSA level was 0.03 ng/ml and a bone scan showed no metastatic involvement. We are going to continue the androgen deprivation therapy and regular follow-up of the serum PSA level.