A 17-year-old girl with chronic postprandial abdominal pain and weight loss was referred to our clinic. The other causes of chronic abdominal pain were investigated by several studies including gastrointestinal endoscopies and imaging; however, no definitive cause could be identified. Doppler ultrasonography was able to reveal a compression on the celiac artery. Peak systolic velocity (PSV) in the celiac trunk was measured as 250 cm/s, and dropped to 170 cm/s with deep inspiration (ΔPSV = 80 cm/s). Diagnosis was confirmed by three-dimensional (3D) CT angiography confirming the narrowing of celiac artery at the beginning of the celiac trunk arising from abdominal aorta [].
The procedure was carried out via four 5 mm trocars. After opening the lesser omentum, crural fibers of diaphragm was dissected to expose median arcuate ligament. Celiac ganglion was cauterized and incised with hook cautery. Then, arcuate ligament was dissected above celiac artery and released with a sealing device (Ligasure; Covidien®) []. After the releasing of the ligament, celiac trunk was free, and pulsation can be seen clearly at the distal branches of celiac artery. There were no intraoperative complications and the patient was discharged on the second postoperative day.
In the postoperative period, patient was admitted to our clinic with recurrent symptoms of mild abdominal pain. The patient underwent postoperative Doppler ultrasonography. PSV in the celiac trunk was measured as 202 cm/s, and dropped to 162 cm/s with deep inspiration (ΔPSV = 40cm/s). Also, 3D CT angiography was performed to demonstrate the improvement in narrowing of celiac artery. However, surgical clips did not allow for demonstration of celiac artery properly. Although the pain was described to be of lower intensity when compared with presurgical state, it continued to be disturbing and required frequent use of analgesics. Therefore, the patient was referred to the pain management service in the department of anesthesiology for paraspinal ganglion blockage. The patient is free of symptoms in the 9-month follow-up, gained weight and resumed normal daily activity.


A 43-year-old male patient presented to the emergency department with a fall from a height of 4 feet. He gave a history of charging his mobile, standing on a shelf of four feet height following which he suffered an electrocution injury. He fell down from the shelf, after which he was unable to stand up on his feet or move his legs due to pain. On examination, his bilateral lower limbs were externally rotated and both hip movements were extremely painful.
Radiographic studies confirmed the diagnosis of bilateral transcervical neck of femur (). Investigations revealed his vitamin D levels were low (11.1ng/ml). The patient was taken up for surgery, closed reduction and internal fixation by 6.5 mm cannulated cancellous screws. Surgical technique:
The patient was operated on the same day. The fracture was reduced by Leadbetter’s technique and reduction was maintained using traction table. Using the lateral approach, the tensor fascia lata was dissected and the area 2.5 cm distal to the vastus ridge was chosen for inserting three 6.5 mm cannulated cancellous screws with washers. After screws were inserted, reduction was checked again with the aid of C-arm. The traction was released before final tightening of the screws. The left hip was fixed by the inverted triangle pattern of screw fixation, whereas the right hip was fixed with upright triangle pattern of fixation () The post-operative period was uneventful. The patient was taught static quadriceps exercises and active knee and ankle range of movements 5 days after surgery. Active hip movements were initiated six weeks after surgery. Patient was ambulated using a four stand walker at the end of 12 weeks. At the end of 16 weeks, patient was independently ambulatory and had good range of movements ofboth the hips (, , )


This case involved a 73-year-old woman who was retired, right-handed, a smoker, with no medical history and was not taking any medication. The patient underwent a bilateral aponeurectomy for digitopalmar Dupuytren’s disease. Two years later, she presented an excellent result in the left hand, but a recurrence on the right hand involving the fourth radius on the central digital adhesion next to the proximal interphalangeal joint. A sewing machine-type rheumatological PNA was performed in the digital area. Three weeks later, the after effects were marked by a deficiency of flexion in the distal interphalangeal (DIP) joint, which occurred without making an effort; the patient did not undergo any rehabilitation and did not wear a splint. The MRI confirmed the rupture of the deep common flexor tendon at the first phalanx of the fourth radius with a proximal stump retracted into the palm () (). The surgical indication was retained. The operation was performed in outpatient surgery Under locoregional anesthesia. Under loupe magnification, a Z-shaped incision was made, according to Bruner. The exploration permitted detection of the proximal stump of the deep common flexor at the palm (). The latter was resected. In a subsequent surgery, tenodesis of the distal stump was performed at the digital canal and at the palmar plate of the DIP at 10° of flexion. A dorsal splint supporting the DIP was worn for a duration of five weeks.
Six months after surgery, the patient was satisfied and did not present any pain; her DIP was stable, she could curl up her fingers almost completely and functionally, with a pulp-to-palm distance at 1 cm. We observed a flexum of the proximal interphalangeal [PIP) joint of 20°.


A 68-year-old Caucasian female with type 2 diabetes mellitus had diffuse DME diagnosed in her left eye in October 2010. The treatment history is summarised in Table and was previously reported when only 6 months of follow-up were available. At diagnosis, VA was 46 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, converted from Snellen VA using the equation 85 + 50 x log (Snellen fraction), CFT was 712 microns, and intraocular pressure (IOP) was ≤22 mm Hg.
The patient had phacoemulsification plus intraocular lens insertion in the left eye in February 2012. Intravitreal triamcinolone acetonide was also administered to treat the persistent DME postoperatively. At the first postoperative visit, VA was 70 ETDRS letters, CFT was 278 microns, and IOP was 20 mm Hg. Over the next 5 months, VA (50 ETDRS letters) and CFT (805 microns) progressively worsened, and the patient was admitted into the Matisse trial in September 2012 to test the effects of ranibizumab plus a small-interfering RNA agent.
Between October 2012 and March 2014, the patient received 5 injections of ranibizumab plus the small-interfering RNA agent and then subsequently listed for 2 further courses of 3 intravitreal injections of ranibizumab. By the end of this stage of treatment, by 1 month after the final injection of ranibizumab, the DME had recurred, VA was 55 ETDRS letters, CFT was 774 microns, and IOP was 17 mm Hg.
The patient's DME was now chronic (over 18 months of duration), relapsing, and her CRT had fluctuated wildly through the different treatment phases, which is believed to have a deleterious effect on the function of the retina and, more specifically, on the visual function due to the presence of submacular fluid []. It was at this stage that the patient was treated with ILUVIEN according to NICE TA301 (please see ). Figure shows the response of VA and CFT after a single ILUVIEN implant without any further treatment to this eye over the next 2 years. Within 7 days, VA had increased to 61 ETDRS letters and CFT had decreased to 267 microns. Within 2 weeks, VA had improved further to 70 ETDRS letters, which is the legal requirement to hold a driving license in the UK. These early improvements were then largely maintained throughout the next 24 months without further intervention, as shown in Figure . Figure shows optical coherence tomography scans before and after ILUVIEN implantation, illustrating the structural improvement that occurred alongside the functional improvement in vision. Over the course of the 2-year period, IOP remained below 21 mm Hg, and no IOP-lowering medication was required.


A 70-year-old female ex-smoker was diagnosed with bilateral synchronous lung primaries during staging of a right-sided breast carcinoma. Computed tomography (CT) of the thorax revealed a 1.5 cm spiculated left upper lobe mass and a 1.2 cm right upper lobe nodule. Positron-emitted tomography (PET)-CT demonstrated no evidence of mediastinal or hilar lymphadenopathy [ and ]. Core biopsies of the lung confirmed a left upper lobe squamous cell carcinoma positive for cytokeratin (CK) 5/6 and P63. The right upper lobe nodule was an adenocarcinoma that was thyroid transcription factor 1 (TTF-1), napsin, and CK-7 positive and CK-20 negative. The core biopsy of the breast demonstrated an infiltrating Grade II ductal carcinoma that was estrogen receptor positive, progesterone receptor negative, and Her-2 positive. Immunohistochemistry was CK-7 positive and CK-20, TTF-1, and napsin negative.
The breast carcinoma was managed with herceptin (trastuzumab), and she proceeded to a successful left upper lobectomy and mediastinal lymph node dissection. Final histopathology demonstrated a completely resected 20 mm squamous cell carcinoma and staged pT1aN2 (positive lymph node station 6). She had an uneventful postoperative recovery.
Interval CT imaging 3-months following surgery in preparation for resection of the second lung primary demonstrated a significant reduction in the size of the right upper lobe nodule. There was only a 12 mm focus of residual scarring with no discrete mass identified. These findings were confirmed on PET imaging which demonstrated only faint FDG-avidity and residual linear scarring at the site of the previous right upper lobe nodule [ and ]. Retrospective analysis of the right upper lobe core biopsy confirmed an invasive adenocarcinoma that was CK-7, TTF-1, and napsin positive and CK-20 negative, verifying a lung primary. However, it was now also noted that there was focal weak membranous staining with Her-2 in more than 10% of tumor cells.


We report a 15 year old girl with tuberous sclerosis who was noted to have multiple AML’s of the liver and kidneys found on routine ultrasound screening. She was asymptomatic at this stage and in view of the small size of the AML’s a repeat ultrasound of the liver and kidneys was performed twelve months later ().
This showed a dramatic increase in the size of the AML’s. The patient was asymptomatic and had normal liver biochemistry and clotting. MRI of the liver (,) showed signal dropout on opposed phase imaging and also on spectral fat suppression, in keeping with fat content of the AML’s.
The lesions also enhanced avidly in the arterial phase with washout in the venous phases. These findings on MRI of the liver were typical of AML’s. In view of the rapid progression in the growth of the lesions an ultrasound guided biopsy of the suspected AML’s was performed despite the typical MR findings in order to exclude malignancy. Histological examination showed the blood vessel (angioid), smooth muscle (myoid) and mature fat (lipoid) components. No malignant components were identified.


A 12-year-old male child was referred for follow-up cardiac magnetic resonance (CMR) of complex congenital heart disease, characterized by aortic decoarctation, interventricular and interatrial septal defects (VSD and ASD) closure and bicuspid aortic valve.
CMR showed unicuspid unicommissural aortic valve with normal valve area and without significant regurgitation. A sub-aortic spur was detected, without outflow obstruction. There were no signs of recoarctation nor residual septal defects; both ventricles were of normal size and function (–).


A 55-year-old, right-handed man presented with sudden language impairment and right-side numbness. There was no history of trauma and other identified risk factors of a stroke except smoking. Neurological examinations revealed receptive aphasia and right-sided hypoalgesia. Emergent cranial computed tomography showed a hypodense lesion in the left temporal lobe. Two days after an onset, brain magnetic resonance imaging (MRI) revealed a 4.0 × 3.5 × 3.5 cm ruptured dermoid cyst (Fig. A and B) and watershed infarcts in the left hemisphere (Fig. C). Five days later, brain magnetic resonance angiography (MRA) demonstrated mild stenosis on the M1 segment of left middle cerebral artery (MCA), and further high-resolution MRI examination showed an unstable atherosclerosis plaque in the left MCA (Fig. D). Simultaneously, we monitored the blood flow velocity of bilateral MCA (M1 segment, 58 mm) with transcranial Doppler (TCD). The results showed a decreasing tendency of the peak systolic velocity (PSV) of left MCA at a different time points after the stroke (290, 250, 200, 150, and 120 cm/s at 2, 6, 8, 10, and 30 days after the stroke, respectively). By comparison, the PSV of the right MCA was kept stable at all time points (80–91 cm/s) (Fig. A). Although the pulsatility index of the left MCA at different time points were almost within normal range (0.65–1.10), it showed a decreasing tendency (0.9, 0.62, 0.65, 0.71, and 0.7 at 2, 6, 8, 10, and 30 days after the stroke, respectively). Dynamic cerebral autoregulation (dCA) examinations of the patient were also performed. The gains in the affected (left side) and unaffected hemispheres were 2.40 versus 0.93 (day 6), 2.52 versus 0.87 (day 8), 1.67 versus 0.973 (day 10), and 1.93 versus 0.94 (day 30), respectively (Fig. B). The phase difference in the affected hemisphere versus unaffected side was 34.47° versus 28.60° (day 6), 9.08° versus 21.38° (day 8), returned to 22.35° versus 30.18° (day 10) and then remained normal at 30.46° versus 30.89° at the 30-day follow-up (Fig. C). As a result, a dermoid cyst rupture-related cerebral infarction was diagnosed. The patient received aspirin (100 mg/d) and atorvastatin (20 mg/d), and the neurological deficit was significantly improved on 30 days follow-up. Seizure did not occur to this patient during treatment. A neurosurgical operation was strongly recommended to minimize the risk of further injury of the ruptured dermoid cyst; however, the patient had refused the recommended treatment.


Following a motor vehicle accident, a 25-year-old female complained of intense neck pain, but remained neurologically intact. The lateral cervical radiograph showed an oblique fracture of the axis; the fracture diagonally separated the vertebra in two parts and extended from the body of the axis to the posterior elements. In addition, the computed tomography (CT) scan revealed several craniovertebral junction (CVJ) anomalies, which included spontaneous KFS fusion of the C2-C3 disc space and the C2-C3 right articular facets/laminae. Furthermore, the anterior C1-arch was bifid and there was a partial agenesis of the posterior C1 arch [Figure –]. Following immobilization in a halo vest for 3 months, the fracture fused, maintaining adequate alignment []. When contacted by phone 2 years later, she was asymptomatic.


A 20-day-old male child admitted to the pediatric causalty of Guru Teg Bahadur Hospital (GTBH) on April 16, 2014 with the complaints of fever, decreased appetite, and rapid breathing since morning. The baby was apparently healthy 1 day back, but suddenly he developed fever which was mild grade 101°F since morning. There was no history of vomiting, loose motions, abnormal movements, bleeding etc. Baby had normal vaginal delivery in GTBH on March 27, 2014 to the second gravida mother at 34 weeks of pregnancy and cried immediately after birth. There was no history of perinatal asphyxia. Baby was breast feed till April 5, 2014 after which baby was given top feeds. On examination, weight of the baby was 1.8 kg. Bacillus Calmette–Guérin mark was seen. Child appeared sick with poor activity. Respiratory system examination revealed respiratory rate of 48 breaths/min with normal air entry bilaterally. Other systemic examinations revealed mild hepatosplenomegaly. On investigation, his complete blood count showed total leukocyte count 22,200/cumm with 68% neutrophils and platelet count 91,000/cumm, hemoglobin was 15.6 g/dL. Serological investigations for HIV, HBsAg, toxoplasmosis, cytomegalovirus, and herpes virus 1 and 2 were negative. Liver enzymes were slightly elevated. His cerebrospinal fluid (CSF) study and culture was suggestive of tubercular meningitis. Gastric aspirate was positive for acid-fast bacilli (AFB) on 3 consecutive days. Chest radiography showed miliary shadows in both sides of the lung. There was no growth in both aerobic and anaerobic blood culture. All other tests were negative. Antenatal history of mother revealed leaking per vagina for 15 days prior to delivery. Mother suffered from cough at the 8th month of pregnancy and was diagnosed as a case of pulmonary TB. Her sputum was positive for AFB on both spot and morning samples. Endometrial biopsy was not performed, and she was nonreactive for HIV. She was started on antituberculosis treatment (ATT) on April 8, 2014. Mother recalled the previous history of pleural effusion 1 year back, but sputum samples were not taken during that time and ATT was not initiated. On the basis of above findings and maternal history, the baby was diagnosed as a case of congenital disseminated TB and baby was given injection monocef on the 1st day then later on started with isoniazid, rifampicin, and pyrazinamide along with amikacin for 12 months and advised to come every month for monitoring treatment outcome. The baby's gastric aspirate was AFB-negative and chest X-ray showed few military shadows after 8 months of therapy. Treatment continued till 12 months and X-ray was done again at the end of treatment, which was normal.


A 20-year-old female presented with complaints of yellowish discoloration of skin over the face, forearms, palms, and soles due to yellow colored sweat since 1 month. She also complained of yellowish staining of the clothes. This discoloration was aggravated with exertion. There was no history of ingestion of any drugs, foods rich in carotene such as carrots, citrus fruits, and sweet potatoes. She denied contact with yellow colored products in the form of any chemicals, dyes, deodorants, and colored clothes. She also denied using any type of cosmetics over her body. There was no history of specific odour and she had no underlying psychiatric ailment. There were no similar complaints in the past or in the family. On dermatological examination, skin appeared yellowish over the palms and forearm, toe webs, and face [Figure +]. Axillae and groins were normal. Wood's lamp examination showed yellowish florescence over face and palms. [Figure +] Blotting sweat with a white cloth showed yellow stain. [] There was an odourless yellowish discoloration on her clothes. []. The color of her tears, saliva, and urine was unchanged. Routine laboratory investigations were normal. Microscopy and culture of skin scrapings were negative for fungus and bacteria. Skin biopsy was negative for lipofuscin granules, which excluded chromhidrosis. Therefore, this was labelled as a case of pseudochromhidrosis. Patient was started on empiric treatment with oral erythromycin and antiseptic soap for 15 days, to which patient responded well. [Figure +].


A 30-year-old woman was transferred to our hospital in a stuporous state with right hemiparesis. She had earlier been admitted to another hospital for two weeks after she was injured in a traffic accident. On admission to our hospital, she first complained of headache and dizziness only. She was alert and had no neurological deficits. Initial brain computed tomography (CT) and magnetic resonance (MR) images taken at the other hospital showed no abnormal lesions in the intracranial space (). She was diagnosed with hyperthyroidism 2 months ago, and has been taking 15 mg of methimazole and 40 mg of propranolol daily. She had no past history of other diseases. On admission, laboratory investigations showed low levels of thyroid stimulating hormone (TSH) (0.011 µIU/mL, reference range: 0.27-4.2 µIU/mL), low levels of free T4 (0.644 ng/dL, reference range: 0.93-1.7 ng/dL), elevated levels of triiodothyronine (T3) (2.58 ng/mL, reference range: 0.8-2.0 ng/mL) and elevated levels of thyrotropin-binding inhibitory immunoglobulin (TBII) (62.80 IU/L, reference range: 0-15 IU/L). MR angiography demonstrated cerebral infarction in the posterior cerebral artery (PCA) territories and multiple stenotic lesions in both middle cerebral arteries (MCAs), anterior cerebral arteries (ACAs), and PCAs (). Cerebral angiography also revealed severe vasospasms in all the MCA, ACA and PCA territories (). Therefore, intra-arterial chemical angioplasty with verapamil was performed for two consecutive days. A total of 25 mg of verapamil was injected slowly: 10 mg each for the left and right internal carotid artery and 5 mg for the left vertebral artery. Successful dilatation of the spastic arteries was demonstrated (). However, cerebral angiography performed the next day still showed some remnant vasospasm. Thus, chemical angioplasty was performed again using 15 mg of verapamil. After the procedures, the patient was given antithyroid medication and "triple-H" therapy (hypervolemia, hypertension, and hemodilution) to increase cerebral perfusion. Follow-up angiography performed at 6 weeks demonstrated complete recovery of the vasospasm (). At the 2-year clinical follow up, she was alert with mild weakness and cortical blindness (modified Rankin scale score, 4).


A 75-year-old male presented with the complaints of obstructive and irritative lower urinary tract symptoms for 6 months. Physical examination revealed Grade 3 enlargement of the prostate. On evaluation, he was found to have benign enlargement of the prostate with chronic retention. Ultrasound examination of the abdomen revealed bilateral hydroureteronephrosis up to the urinary bladder with a prostate size of 81 cc and residual urine volume of 268 cc. His serum creatinine was 3.8, and after catheterization, it reached a nadir of 1.5 after 4 weeks. His urine culture grew Klebsiella and he was treated with a course of culture-sensitive antibiotics.
He is a known case of coronary artery disease and chronic obstructive pulmonary disease on treatment. He had an episode of unstable angina in the meanwhile and was treated by the cardiologist. He was a very high-risk candidate for surgery due to his comorbidities. He was stabilized and taken up for TURP after 2 months.
He was operated under epidural anesthesia. Cystoscopy revealed Grade 3 trilobar enlargement of the prostate. Bladder had multiple diverticula largest being in the dome of bladder. Resection was done using 26 Fr continuous flow resectoscope. Valleylab cautery was used with a monopolar cutting current of 100 W and coagulation current of 60 W. 1.5% glycine was used as the irrigant. When the median lobe and most part of the left lobe were resected, he developed bradycardia and breathing difficulty and it was decided to terminate the procedure. The total resection time was 35 min. While hemostasis was being achieved near the bladder neck, there was a sudden loud pop sound. The irrigation fluid returns decreased, and bowel loops were visible through the bladder. Intraperitoneal bladder explosion was suspected, and lower midline laparotomy was performed. The large diverticulum had exploded, and there was a large rent in the dome of the bladder extending in a “V” fashion along the posterior wall up to the trigone []. The anterior wall muscular and mucosal layers had two large lacerations, but the serosa was intact. The margins were ragged and irregular. The ureteric orifices were not injured. There was no bowel or vascular injury. Bladder was repaired with two layers of continuous polyglactin sutures. Suturing was extremely difficult due to the multiple bladder diverticula. Suprapubic catheter and drain were placed along with 22 Fr perurethral catheter.
He had an uneventful postoperative recovery. Drain was removed on the 2nd day and was discharged on the 4th day. Suprapubic catheter was removed after 7 days. Retrograde cystogram [] was performed through the perurethral catheter after 2 weeks. There was no leak of contrast, and the perurethral catheter was removed. He voided with good flow after catheter removal. His postvoid residual urine was only 10 cc, and his serum creatinine was stable at 1.4. The biopsy report was benign. He remains asymptomatic at 6 months of follow-up.


A 71-year-old man was hospitalized for a clinical and biological presentation of acute pancreatitis. Pain occurred suddenly and was associated with an increased level of lipase above 2000 UI/L, a cholestatic icterus (bilirubin: 103 µmol/L) and a hepatic cytolysis (ALT: 154 UI/L; AST: 131 UI/L). An initial computerized tomography (CT) scan showed a significant but unspecific infiltration around the pancreas head, without dilatation of biliary ducts. A first endoscopic ultrasound (EUS) (Pentax, EG 3670 URK, France) showed similar data. The hypoechoic infiltration of the pancreas head was heterogeneous and extended to the hepatic hilum, in contact with portal vein. There was no biliary lithiasis, nor context of alcohol consumption during the last days before the admission. However, the patient was treated with Lenalidomide plus dexamethasone for a Immunoglobulin A (IgA) plasmacytoma diagnosed 3 years ago [t(4;14) positive, del(17p) negative; at baseline: LDH: 173 UI/L, monoclonal immunoglobulin peak: 40.5 g/L, Kappa and Lambda serum free light chain: 11.7 and 18.6 mg/L, respectively], without hypercalcemia nor kidney failure. He relapsed dramatically one year ago, with an extramedullar localization (L4 lumbar spine). Based on hematotoxicity (platelets: 41000 G/mm3) and lake of specific radiologic features, the initial diagnosis suspected was a dual hepatic and pancreatic toxicity of Lenalidomide. Indeed, acute pancreatitis and hepatitis had been occasionally reported as a side effect of Lenalidomide[,]. Common hepatitis viral serologies were tested before carrying out a transjugular hepatic biopsy which showed a histological aspect compatible with the diagnosis of drug hepatitis or hepatitis related to a biliary obstruction (centrilobular and portal infiltrate of polymorphs inflammatory cells including eosinophils). Although an empirical treatment with 500 mg intravenous methylprednisolone daily was started, bilirubin level increased at 345.8 μmol/L within the following ten days. Hence, a new CT-scan was performed and showed the occurrence of a mild to moderate dilatation of biliary ducts and a low abundance ascites. At the moment of admission, the infiltration of the pancreas head significantly resembled a tumor (Figure ) and the diagnosis of a pancreatic localization of the plasmacytoma was suspected. After platelets support, EUS (Pentax, EG 3670UTK, France) guided fine needle aspiration (FNA) was carried out with a 22-gauge needle. Tumor infiltration appeared to be growing due to portal vein invasion. Linear EUS passage through the pylorus was drastically limited, so that FNA was performed from the gastric antrum. Then, an endoscopic retrograde cholangiopancreatography was attempted to place a biliary stent for palliative treatment, but the cannulation of the bile duct had failed due to a major parietal oedema of the duodenum which was easily bleeding due to the contact of the sphincterotome. A percutaneous biliary drainage was considered, but an ultrasound-guided paracentesis was preferred, taking into account technical difficulties of the biliary drainage. Cytology of the FNA was not contributory (epithelial cells of pancreas without malignity signs) while the analysis of ascites showed plasmacytosis with severe atypia enabling the diagnosis of pancreatic plasmacytoma (Figure ). Bone marrow was exempted from dystrophic plasma cells, proving an extramedullar relapse. The increase of the monoclonal spike (from 2.3 g/L to 8.1 g/L within 4 mo) and LDH (259 UI/L) was compatible with this diagnosis. Kappa and Lambda free light chain, at this time of the disease, were 0.4 mg/L and 24.8 mg/L, respectively, without hypercalcemia, Bence Jones proteinuria, nor kidney failure. Hence, after contacting the referral hematologist of the patient, a cure of 40 mg dexamethasone daily was started inciting a drastic decrease of bilirubin level within the next three days (183.1 μmol/L). Then, a second line of chemotherapy (Bortezomib + Cyclophosphamide) was started with a good short-term safety. Although a biological response, especially for monoclonal peak (2.1 g/L), at one month, the patient died 4 mo after the diagnosis of pancreatic plasmacytoma.


A 45-year-old woman underwent debulking surgery including total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, pelvic node dissection, and appendectomy for a massive right ovarian mass (pathological staging Ia G3 clear cell type). Nine months later, computed tomography (CT) of the abdomen and pelvis revealed a slight increase in the size of the left para-aortic lymph node and newly developed peritoneal carcinomatosis. She had previously undergone 6 cycles of chemotherapy with paclitaxel and carboplatin after the index surgery on 2007. Hence, she was treated with modified chemotherapy with irinotecan on days 1, 8, and 15 along with cisplatin on day 1 for the recurrence of the disease. After 7 days of irinotecan and cisplatin administration, she was admitted to the hospital with complaints of general weakness; nausea; darkened face, palm, and nail; epigastric pain; chills; and dyspepsia. Hematological investigations revealed hyponatremia (119 mEq/L). She was treated with water restriction and drip infusion protocols until the electrolyte imbalance no longer persisted. The remaining two cycles of irinotecan were continued without cisplatin. A second cycle of irinotecan and cisplatin (day 1) was initiated after 4 weeks. A few days later, she was admitted to the hospital with signs of nausea, general weakness, and poor oral intake. Her plasma sodium concentration was 123 mEq/L, plasma osmolarity 267 mOsm/kg/H2O, and urine osmolarity 473 mOsm/kg/H2O, which were higher than the normal limit, thus confirming the diagnosis of SIADH induced by chemotherapy (); however, the patient remained alert. After intravenous drip infusion, her electrolyte balance was maintained. Magnetic resonance imaging of the head did not demonstrate any secondary metastases, edema, or cerebrovascular insults. Findings from the brain and chest CT performed after completion of the second cycle of chemotherapy were non-significant, but the recurrence of the cancer was evident around the abdominal area, as depicted on CT.
A new regimen of the chemotherapy including three cycles of docetaxel was started because of the elevation of tumor markers and metastases, and was continued subsequently. Irinotecan and cisplatin treatment was discontinued as the electrolyte disturbance that occurred during the chemotherapy sessions strongly suggested that they induced the SIADH.


We present a case of a 20-year-old boy with a history of kidney transplantation for medical renal disease 6 months ago, who presented with generalized weakness, weight loss, fever, and loose motions and was referred for an 18F-FDG PET-CT scan. His K + was 2.8 mEq/l (N: 3.3–4.8), Na + was 124 mEq/l (N: 135–147), Cl-was 114 mEq/l (N: 101–111), serum creatinine: 3.4 mg% (N: 0.7–1.31), Hb: 9.8 g/dl (N: 13–18), RBC:3.16 million cells/ulit (N: 4.5–6.5), and ultrasonography revealed increased echogenicity of transplanted kidney.
Because of frequent episodes of loose motions, he had developed hypokalemia for which he required potassium chloride (KCl) infusion (10 cc KCl in 0.9% NS at a rate of 100 ml/h) which was continued till the time of 18F-FDG injection. The whole-body PET-CT scan demonstrated altered physiological distribution of 18F-FDG with markedly increased uptake in almost all major muscle groups, including those of the neck, thorax, abdomen, pelvis, and the extremities [] and reduced uptake in organs that physiologically show much better uptake for example, liver. There were no obvious morphologic changes in these muscles on CT scan. Hence, the study was not interpretable. The patient's medication at the time of 18F-FDG PET-CT scan included KCl infusion and steroids (Deflazacort). There was no history of incomplete fasting, hyperglycemia, insulin administration, or excess muscle activity before imaging. The whole-body 18F-FDG PET-CT scan was repeated after stopping KCl infusion 12 h before 18F-FDG injection. It showed normal biological distribution of 18F-FDG [] with abnormal increased diffuse heterogonous uptake in enlarged pancreas with adjacent stranding [] raising possibility of pancreatitis, and there was a minimal uptake in muscles. Pancreatitis was subsequently confirmed by serum amylase and lipase levels which were raised (220 u/l and 513 u/l, respectively).


A 1-year-old, previously healthy, 10 kg male child, presented to Accident and Emergency (A and E) department following a domestic accident. On admission, he was irritable and drowsy (Glasgow Coma Score = 7) with a mild right-sided weakness and unequal pupils (right 5+ and left 3+). There were no external injuries. As venous access was difficult, an intra-osseous (IO) needle was placed in the right tibia. He was intubated using 4.0 cuffed endotracheal tube after induction with fentanyl 2 mcg/kg, propofol 2 mg/kg, and rocuronium 0.8 mg/kg through the IO needle and hand ventilated to maintain a normal end-tidal carbon dioxide. His immediate head computed tomography scan conducted under general anesthesia showed an acute right-sided subdural hematoma with a significant midline shift. Therefore, he was immediately transferred to the operating theater for a right frontal craniotomy and evacuation of the acute subdural hematoma.
On arrival in theater, his systolic blood pressure was 98 mmHg with good pulses. However, his peripheries were mottled, with a pale blue skin. Therefore, venous access was gained through a left femoral triple lumen central line. Arterial pressure monitoring was established through a right femoral 22G cannula. His tympanic membrane temperature was 36.0°C. At this time, it became evident that he had had received 30 ml/kg of (3%) HS instead of the 3 ml/kg dose prescribed in A and E department. Surgery commenced regardless and anesthesia was maintained with O2/N2O and sevoflurane and positive pressure ventilation.
He passed a large volume of urine on his bed at the induction of anesthesia. Based on clinical judgment, a total of 400 ml (40 ml/kg) of Hartmann's solution was infused during surgery in 5 ml/kg boluses to maintain blood pressure during anesthesia. Blood loss was moderate, but a transfusion was not required. An arterial blood gas during surgery recorded a mixed respiratory acidosis (pH – 7.08, PCO2-9.2 KPa, PO2-31.6 KPa, Na+ – 154 mmol/L, K+ – 3.0 mmol/L, Cl – 129 mmol/L, Ca++ – 1.36 mmol/L, glucose – 14.1 mmol/L, lactate – 0.8 mmol/L, hemoglobin [Hb] – 10.0 g/L, base excess – 9.8). The highest serum sodium recorded during the surgery was 158 mmol/L. Hb was 8.0 g/dl at the end of the surgery. His right fronto-occipital hematoma was evacuated. He was transported to the pediatric Intensive Care Unit (PICU), ventilated, and sedated with midazolam 3 mcg/kg/min and morphine 20 mcg/kg/h infusions.
He was extubated 2 h after surgery in the PICU. His postoperative fluid intake was maintained at 2/3rd of daily requirement orally. He demonstrated a good urine output of 1–2 ml/kg/h. SaO2 was 98%–100% self-ventilating room air, respiratory rate was 24–28 bpm, there was no respiratory distress, heart rate was 140/min, and blood pressure was 112/66 mmHg. Pupils were equal and reacted to light. He was awake and alert. His electrolytes showed a normal Na+ (139–141 mmol/L) but a lower and normalizing K+ (3.4, 3.6, 3.8 mmol/L) during the next 24 h. He developed a single temperature spike to 38.8°C that resolved with paracetamol. The drug error with regard to HS overdose was explained to parents in keeping with the duty of candor. He made an uneventful recovery with no detectable residual defects either due to subdural hematoma or due to salt overdose. There was no evidence of renal injury or residual brain damage during the immediate postoperative period or at subsequent follow-up after 1 month.


A 57-year-old female patient presented an erythematous swollen patch with bullae on both hands and feet for three days after using traditional herbal medicines ().
She applied fig leaves decoction for psoriatic lesion on both feet. She received the treatment for six or seven times during a week. Afterward, she walked outside on a sunny day. Five hours after the exposure to the sun (ultraviolet light), she felt a burning sensation in both hands and feet, and an erythema had developed on the feet dorsa; the lesions were hidden under the straps of the sandal (). There was no history of a similar rash in the past or any form of drug or medication use. She was otherwise systemically well and did not have any personal or family history of photosensitivity. Histopathologic examination revealed sub-epithelial blisters with intensive epidermal necrosis ().
On follow-up examination, after a 4-month period using systemic and topical steroids, improvements were observed.


A 69-year-old woman presented with erythematous patches with bullae on the photo-exposed area of both feet, 7 hours after exposure to fig leaves decoction and sunlight (, ). A detailed history revealed that she had applied a self-prepared fig leaf remedy to treat her onychomycosis. She had been soaking her feet in the decoction water three times daily for two days. Skin biopsy showed full epidermal necrolysis (). Treatment included the administration of systemic steroids, antihistamines, and the application of topical antibacterial creams. Her lesions resolved after two months.


A 66-year-old man developed a sharply defined erythematous swollen patch with bullae on both feet (). The previous day, he had soaked his feet in fig leaves decoction to treat his onychomycosis. Afterwards, he walked outside on sunny day. His lesions were treated with systemic and topical steroids, but he was not available for skin biopsy and follow-up.


An 87-year-old man presented with extensive skin lesions. On examination, erythema, edema, vesicles, and bullae were observed exclusively on both feet (). When questioned about the history, he remembered that the previous day he had soaked his feet in fig leaves decoction to treat his onychomycosis. He soaked his feet three times a day and spent time in the outside. The patient refused skin biopsy. He was treated with systemic and topical steroids with instructions to avoid exposure to sunlight. After his condition improved, he has experienced no relapse thus far.


In early autumn, a 70-year-old woman presented with erythema, edema, and large bullae on her feet dorsa (). Before the symptoms presented, she had soaked her feet in fig leaves decoction three times a day for three consecutive days. Afterward, she felt increasing pain rather than pruritus. She refused histological examination. Administration of systemic steroids and topical antibacterial ointment for over seven days led to the resolution of erythema and bullae.


The patient was a 55-year-old female with a history of smoking since the age of 16 years (20 cigarettes/day), with no other cardiovascular risk factors and presenting with a body mass index (BMI) of 25 kg/m2. She reached menopause at the age of 53 years. The patient had no other concomitant conditions, and her medical record indicated that she had not been previously treated with corticoids.
In 2010, following an intense lumbar effort, the patient experienced severe lumbar pain. Lumbar X-ray and computed tomography (CT) revealed D11 fracture and L1 partial collapse. Femoral and lumbar dual energy X-ray absorptiometry (DEXA) densitometry showed a total femur bone density of 0.770 g/cm2 (T-score −1.9; Z-score −1.6) and a bone mineral density on lumbar spine of 0.881 g/cm2 (T-score −2.5; Z-score −1.8), consistent with femoral osteopenia and lumbar osteoporosis, according to the World Health Organization (WHO) criteria. Accordingly, in September 2010, the patient was prescribed a combination of alendronate 70 mg and cholecalciferol 5600 IU once weekly, as well as nonsteroidal anti-inflammatory drugs. Improvement was noted and since then periodical routine densitometry tests have been carried out, which showed femoral and lumbar osteopenia (Table ). In October 2013, the patient continued to complain of chronic dorsolumbar pain.
In April 2014, the patient felt a sensation of stabbing pain in the sternal area while sitting up in bed, followed by pain while moving and breathing, but no dyspnoea. She had not suffered any external force (i.e. pushing) or trauma. Because of these alarming symptoms, she came to the hospital Emergency Department. Physical examination disclosed a swollen, painful area located on the sternal region of the body. Coronary involvement was ruled out. Sternal X-ray revealed sternal body fracture, which was seen to be transverse, noncomminuted and without displacement. Magnetic resonance imaging (MRI) was undertaken to rule out the presence of either a pathological fracture or a fracture resulting from osteoporotic fragility. MRI showed a triple sternal fracture involving the body, as well as the upper and lower manubrium of the sternum (Fig. ). Pathological fracture was ruled out; however, an old pathological fracture of the eleventh dorsal vertebra (D11) with several vertebral collapses at D4, D7 and D8 was noted.
Metabolic study to dismiss potential secondary osteoporosis-related causes and tests aimed at ruling out other bone diseases (i.e. hyperparathyroidism, hypothyroidism, bone tumours or metastases, calcium-phosphorus metabolism disorders, and vitamin D deficiency) was performed. All these tests yielded normal results, except for vitamin D [25 ng/L (range 30–80)]. This slight hypovitaminosis D does not seem to be clinically relevant, and is thus insufficient to induce this kind of fracture, involving three parts of the sternum. The results of densitometry carried out in May 2014 were consistent with total femur osteopenia and lumbar spine osteopenia (Table ); therefore, other factors that could have contributed to the development of this fracture were ruled out. Due to suspicion of an alendronate-related fracture, the alendronate plus cholecalciferol combination was discontinued and the specialist who followed this patient decided to prescribe denosumab. The patient was treated with calcium and vitamin D during the entire process.
After the withdrawal of alendronate, the patient showed clinical improvement, with a decrease in pain, and is currently having routine checkups.
The causality algorithm of the Spanish Pharmacovigilance System [] shows a score of 5, indicating a possible relationship between the patient’s sternum fracture and her use of the suspect drug (Naranjo scale 6, probable).


A 49-year-old male was admitted to the emergency department with the complaint of squeezing chest pain for 30 minutes. On 12-lead electrocardiography (ECG), anterior myocardial infarction was diagnosed, and we performed primary PCI for the left anterior descending (LAD) coronary artery. Successful reperfusion was achieved according to angiographical, clinical, ECG, and laboratory parameters. We used approximately 100 mL ioversol, a low-osmolar contrast medium. During the follow-up period, at 36th hour after the primary PCI, ventricular fibrillation occurred, and after a successful resuscitation, heart rhythm was stabilized without any neurological deficit. On 12-lead ECG, QTc interval was shown to be slightly prolonged (550 msn), and there was no new ST-segment elevation. Control coronary angiography was performed to rule out possible stent thrombosis, but LAD stent was open with a TIMI III distal flow. We detected a severe electrolyte imbalance with deep hypocalcemia (serum ionized Ca++ was 2.5 mg/dL, reference level 4.5–5.3 mg/dL). Serum parathormone (PTH) level was 588 pg/mL (reference level 15–68 pg/mL). Blood urea nitrogen level was 24 mg/dL, and serum creatinine was 0.9 mg/dL. We collected a 24-h urine sample to determine the cause of hypocalcemia and detected an increased Ca++ output (347 mg/day, reference level 100–300 mg/day). Twenty-four hour urine volume was 3100 mL, and urine creatinine clearance was 122 mL/min. We did not detect any other serum or urine electrolyte deficiency. We also assessed serum vitamin D and albumin levels, and they were within normal refe-rence limits. We initiated Ca++ replacement and calcitriol therapy for 3 weeks, and serum Ca++/PTH measurement and 24-h urine collection was renewed. Blood urea nitrogen level was 22 mg/dL, and serum creatinine was 0.8 mg/dL. Serum ionized Ca++ was within normal reference limits (4.6 mg/dL), and serum PTH level was substantially decreased (82 pg/mL). We detected urine Ca++ level to be within normal reference limits (192 mg/dL). Twenty-four hour urine volume was 3200 mL, and urine creatinine clea-rance was 137 mL/min. QTc interval was 435 msn on 12-lead ECG.


A 62-year-old man with ESRF, with a history of CABG surgery of a LIMA–LAD bypass, was referred to our cardiology department with the complaint of retrosternal angina happening in the course of each hemodialysis session for last 2 months. The patient had undergone bioprosthetic aortic valve replacement for severe degenerative aortic stenosis and single-vessel CABG surgery with a LIMA graft to LAD for 70% stenosis at the ostium of LAD 4 years ago. On physical examination, a low-flow thrill was palpated on his left forearm as a sign of AVF, and a difference of at least 70 mm Hg between systolic blood pressures of the right and left upper extremities was observed (154/78 mm Hg and 84/55 mm Hg, respectively). Coronary angiography revealed moderate stenosis of LAD and no significant stenosis of the left circumflex or right coronary arteries. Left coronary angiography revealed a reverse flow in LIMA and a flow in the left SCA and brachial artery from LIMA (). Aortography showed total occlusion in the left SCA and severe stenosis of the ostium of the right vertebral artery (VA) (). For this reason, the patient underwent right VA and left SCA revascularization. The lesion at the ostium of the right VA was passed with a guide-wire (Guide-wire®; Montmorency, France), and a 5x15 mm Powerflex balloon (PTA Dilatation Catheter®; Cordis Corporation, California, US) was used to dilate the stenotic segment before stent placement. Then a 5x15 mm Herculink stent (Vascular Stent®; Abbott Vascular, Diegem, Belgium) was placed, and reconstruction of VA was provided. Totally occluded segment of the left SCA was passed with a guide-wire and predilated with the help of a 7x20 mm Powerflex pro-balloon catheter. Then a 10x40 mm, self-expanding nitinol stent (Misago Vascular Stent®; Terumo Corp, Tokyo, Japan) was placed. Post-dilation was performed using an 8x20 mm diameter angioplasty balloon catheter. Angiography of SCA showed antegrade flow in LİMA to LAD after subclavian artery stenting (). Endovascular treatment of the right VA and left SCA was successfully performed (). The patient was asymptomatic after the procedure and at 6-month follow-up.


A female patient, 73 years old, was diagnosed with herpes zoster and received medical treatment at another medical clinic. However, when her serious pain did not subside after treatment, she visited our pain clinic. Her pain was severe, 10/10 on the numeric rating scale (NRS) at the first visit. She appeared to have herpes zoster involving the fifth cervical spinal nerve root on the right and was diagnosed with post-herpetic neuralgia. We explained our plan to perform a cervical epidural block along with medical treatment and received informed consent. A cervical epidural block was performed with the patient in the sitting position. The patient was instructed to flex her neck so that her interlaminar space was easily distinguished. Skin over the C6-7 interlaminar space was sterilized with betadine solution and topically anesthetized with 2 ml of 2% lidocaine. Using the midline approach, we checked the epidural space through a 20-gauge Tuohy needle using the loss of resistance method; after assuring that there was no cerebrospinal fluid or blood aspirated, 5 ml of 1% mepivacaine and 2 mg of dexamethasone were injected. Immediately after the injection, the patient reported that her pain temporarily decreased; but after about 40 minutes, she said the pain was again as severe as it used to be. We explained the use of an epidural block with epidural catheter insertion and received agreement from the patient to proceed. The epidural space was checked using an 18-gauge Tuohy needle at C6-7 using the same technique as for the cervical epidural block. The depth of the epidural space from the skin was 5.2 cm. A 20-gauge epidural catheter (Smiths Medical ASD, Inc. Keene, USA) was advanced by 7 cm cephalad through the epidural needle; after the needle was removed, the catheter was pulled out by 2 cm and inserted 5 cm from the epidural space. The patient did not experience any discomfort except mild paresthesia of the right arm. After insertion of the epidural catheter and confirming that no blood or cerebrospinal fluid had been pulled in, 3 ml of 1% mepivacaine was injected. The patient reported that her pain was subsiding, so she was given 2 ml of 0.18% ropivacaine per hour through an infusion pump. We prescribed pregabalin 225 mg, tramadol 150 mg, and amitriptyline 10 mg per day, and the patient was discharged. She visited our clinic every day for the next four days and received additional injections of 5 ml of 1% mepivacaine through the epidural catheter, maintained by infusion pump. After this, she reported that the pain was decreased to 5–6 on NRS, and that she could finally sleep at night. On the fifth day, she reported her pain to be 3–4/10 on NRS, and that she wanted to remove the epidural catheter, while remaining on her prescribed medication. We attempted to remove the catheter from the patient in a seated posture; however, after it was pulled out about 3 cm, there was resistance, and it stopped moving. When asked if there was any pain or discomfort of the neck, the patient answered that there was not. After asking the patient to repeat bending and then straightening her neck a few times and pulling the catheter out with slightly stronger force, the catheter suddenly snapped out. The patient reported no pain in the neck or arm, so our medical team sterilized the area where the catheter had been installed and applied a dressing. When the removed catheter was thoroughly examined, a knot was discovered 1.5 cm from the tip ().


A 17-year-old boy had been diagnosed with an ASD during evaluation for cardiac murmur. Transthoracic echocardiography (TTE) showed a 14-mm ASD and moderate dilation of the right ventricle. Transesophageal echocardiography during cardiac catheterization revealed a 16-mm ASD with the balloon sizing technique. The pulmonary-to-systemic flow ratio was 2.8. An 18-mm ASO was successfully implanted, and the patient was discharged with the prescription of aspirin (300 mg/day) for 6 months. TTE 4 weeks, 3 months, and 6 months after the procedure showed the device in place.
At the 1-year follow-up, TTE revealed huge mobile thrombus with a diameter of 34×62 mm attached to the left atrial disk of the device ( and ). He was taken to surgery for removal of the thrombus and the device. After right atriotomy, a well-endothelialized occluder device was seen and was excised with the large thrombus (). There was no device fracture or dislocation. The newly created ASD was closed by pericardial patch. The patient had an uneventful recovery and was discharged the third day after surgery. The pathological examination of the material was compatible with thrombus formation. The thrombus consisted of peripheral blood elements and fibrin. There was no acute inflammation and granulomatous inflammation.
Coagulation assays were performed in order to identify an inherited thrombotic disposition. The screening, which included the measurement of protein C and S, antithrombin III, homocystein, anti-phospholipid antibodies, and lupus anticoagulance were normal. Furthermore, the patient had no factor II or factor V Leiden mutation.


Woman, 29 years old, born in Fortaleza, Brazil, referring history of anemia since childhood. The patient reported episodes of breathlessness associated with asthma, as well as malaise, asthenia and difficulty concentrating which has worsened since 2010, when she sought medical assistance and was diagnosed with Hashimoto’s disease. She was referred to the hematology department of a tertiary hospital for persistent anemia, despite levothyroxine replacement therapy. Her previous history revealed hypertrophic allergic rhinitis, bronchial asthma and hypothyroidism in use of levothyroxine. Laboratory tests: hemoglobin: 8.4 g/dL, hematocrit: 23.4%, mean corpuscular volume: 75.0 fL, white blood cell count: 9745 mm3, platelet count: 384×109/L, reticulocyte count: 4.8%. peripheral smear featuring anisocromia, microcytosis and polychromasia, with normal serum iron, transferrin saturation index and ferritin.
Study of hemoglobin by high-performance liquid chromatography (HPLC): HbA: 54.4% HbF: 0% HbA2: 0.0% *HbS: 44.9%. The chromatographic profile was suggestive of Hb Willamette in heterozygosis () and a mutation survey for HbS by molecular analysis study (PCRRFLP) was negative.
Patient’s parents were also investigated for mutated Hb with HPLC. Father Result: HbA: 97.5%, HbF: 0% Hb A2: 2.5%. Mother Result: HbF: 0%, HbA2: 0%, HbS : 55.1%, HbC: 41.0%. The chromatographic profile of the mother revealed Hb Willamette as heterozygosis, the study by technique of molecular analysis (PCRRFLP) showed no mutations for HbS, but Mutation for HbC.
This paper has been approved by an ethical committee and thus meets the standards of the Declaration of Helsinki.


A healthy 56-year-old-woman was admitted to the emergency department for a painless left flank fluctuating mass, progressively growing over 3 months [], with recent externalization of pus. Blood tests were almost normal, excepted a slight elevation of white blood cell (11.5 G/L), and of C-reactive protein (47 mg/L).
Initial ultrasonography showed a subcutaneous left parietal dorsolumbar multiloculated collection, abutting the posteroinferior aspect of the left kidney with associated left hydronephrosis [].
The patient then underwent a contrast-enhanced abdominal computed tomography (CT) with uro-CT protocol. The left kidney was smaller than the contralateral kidney, with diffuse cortical atrophy and hydronephrosis [], suggestive of a chronic obstructive nephropathy. There were small confluent renal cortical abscesses, irregular perinephric fluid attenuation collections, and inflammatory changes in the perinephric fat []. This phlegmon surrounded the distal portion of the left renal vein, which was occluded []. Infiltrative changes extended into the left psoas muscle [] and a fistulous tract was demonstrated between the perinephric collections and the skin [Figure and ].
A large obstructing calculus was present in the left lumbar ureter [], and there was no excretion of iodinated contrast from the left kidney on excretory phase images [] of uro-CT.
First, the calculus was removed endoscopically with a left ureteral stent placed, and antibiotics were administrated.
Because the clinical condition of the patient did not improve after few days of antibiotic therapy, a renal scintigraphy with 99 mTc-dimercaptosuccinic acid (DMSA) was proceeded and revealed a nonfunctional left kidney with normal radionuclide uptake by the right kidney []. Decision was then made to perform total left nephrectomy.
Pathology of the operatory specimen revealed subacute pyelonephritis with severe glomerular sclerosis and tubular atrophy, with an aspect of pseudothyroidization. This thyroid-like appearance is a common finding in chronic pyelonephritis, obstructive nephropathy, and sometimes in renal allograft specimens, which is made up of a colloid-like hyaline cast formation of Tamm-Horsfall glycoprotein.[]
Many conglomerate microcalculi were seen in the ureter []. Chronic fibroinflammatory tissue was present in the perinephric fat and cultures grew Escherichia coli.


A 26-year-old male patient reported to the Department of Periodontics, Faculty of Dental Sciences, Sri Ramachandra University, complaining of an unesthetic space in relation to the front tooth region and also had difficulty in pronouncing certain alphabets due to the space between the teeth. Examination revealed papillary recession due to inadequate osseous support []. It was classified as Class III based on the Nordland and Tarnow's classification[] and estimated to have a poor periodontal prognosis. The teeth were triangular in shape with a thin periodontal biotype. Baseline clinical parameters were recorded in millimeters using a manual periodontal probe (UNC-15, Hu Friedy Co., Chicago, IL, USA) []. Intraoral radiographs revealed that distance from the bone crest to the contact point was 12.03 mm [].
Despite the prognosis being poor, due to the patient's concern esthetically and phonetically, reconstruction of the lost papilla was planned in two stages. In Stage I, augmenting the inter-radicular bone and achieving a distance of 5 mm between bone crest and contact point were planned, followed by which the second surgery to augment the soft tissue was planned.
Nonsurgical therapy which included scaling and root planing was carried out. On the day of surgery, local anesthesia was achieved in the facial and palatal regions using 2% lidocaine hydrochloride with adrenaline (1: 100,000).
Intrasulcular incisions and two vertical releasing incisions were made on either side of the papilla to raise a full thickness flap []. Root conditioning was done using tetracycline for 30 s to aid in root demineralization. After achieving sufficient anesthesia in the maxillary tuberosity region, cancellous bone was harvested. The bone graft was trimmed to form a saddle shape and was then stabilized at the recipient site using stainless steel screws []. To switch the periodontal biotype, subepithelial connective tissue was harvested from the palate using the trap door technique.[] Hemostasis was achieved using 3-0 silk sutures in the palatal region. The connective tissue graft was trimmed and placed over the recipient site and stabilized []. Flaps were coronally advanced and sutured using resorbable 5-0 Vicryl with suspensory sutures as described by Nordland et al.[] [].
On gaining satisfactory healing in 2 weeks, sutures were removed and the site was irrigated using saline. The patient was reviewed at regular intervals for three months, and oral hygiene instructions were reinforced.
On reviewing the patient in 3 months, two goals had been achieved: The preoperative thin biotype had been switched to thick periodontal biotype [] and bone crest to contact point distance was decreased to 5 mm []. In Stage I of surgery, the modification of semilunar technique by Han and Takei was used.[] Intrasulcular incisions were given around the mesial and distal aspect of the papilla, and a semilunar incision was given at the level of the mucogingival junction []. Connective tissue graft was harvested from palate using trap door technique,[] and trimmed to the desired amount. It was then tucked into the recipient site, and the bulk of tissue that formed the gingivopapillary unit was advanced coronally to occupy the interdental embrasure space []. Suspensory sutures were placed along with orthodontic brackets that were bonded to the tooth [].
The patient was given postoperative instructions and advised Ibuprofen 400 mg twice daily for 3 days. The patient was advised to use chlorhexidine (0.2%) mouthrinse twice daily and avoid mechanical tooth cleaning of the surgically treated area. On reviewing the patient after 6 months, 90% papillary fill was achieved and the healing was satisfactory [].
All images were taken using Canon IXUS132 16MP Digital camera and analyzed using the imaging software (Image J Processing Software, the National Institute of Health, Bethesda, Maryland, US). The pixel measurements of ImageJ software were compared with UNC probe calibrations and set to a standard scale of 1 mm = 14.6 pixels []. The preoperative [], after Stage I [], and after Stage II [] were compared to the surface area, perimeter, and length of the lost interdental tissue (measured from the most apical point of the interdental papilla to the contact point) using ImageJ software []. The values were recorded according to the set scale [] and graphically represented [].


A 43-year-old female presented to our emergency department with severe shortness of breath, diffuse neck swelling, and neck pain, of 1 day duration. She had a Stage III ovarian immature teratoma diagnosed 6 months back and was treated with bilateral salpingo oophorectomy followed by 6 cycles of chemotherapy with bleomycin, etoposide, and cisplatin. She had shortness of breath for the last 4 months. One week prior to the admission, she had fever and severe cough which was treated from a local hospital.
On examination, she had respiratory distress with a respiratory rate of 32/min. Her SpO2 was 82% in room air, blood pressure 110/70 mmHg, and heart rate 110/min. Further examination revealed subcutaneous emphysema in the neck and chest wall. Examination of the respiratory system showed equal breath sounds on both sides with bilateral fine basal crepitations and muffled heart sounds. She had leukocytosis with predominant neutrophils and a normal metabolic panel. The values for the blood gas analysis were a pH of 7.42, PCO2 of 34 mmHg, and PO2 of 65 mmHg.
Chest X-ray showed [] features suggestive of subcutaneous emphysema and mediastinal emphysema with bilateral haziness and alveolar opacities in lower zones. A computed tomography (CT) thorax [] with findings of ground-glass opacities and peripheral consolidation, confirmed the diagnosis of pneumonia and mediastinal emphysema.
With this clinical presentation of a pulmonary air leak syndrome and radiologic picture of bilateral predominant ground glass opacities with patchy consolidations, we considered the possibility of pneumocystis jiroveci pneumonia or a drug-induced lung disease like diffuse alveolar damage/OP.
Since the patient had severe respiratory distress and hypoxemia, she was immediately taken up for surgical management. A video-assisted thoracoscopy was done [], and the mediastinum dissected revealing multiple paracardiac blebs. These blebs were ablated; the pneumomediastinum drained into left hemithorax, and an intercostal drainage tube was inserted in left hemithorax. A lung biopsy was taken.
Patient's condition improved dramatically with rising oxygen saturation. She was shifted to the Intensive Care Unit and was treated with antibiotics, steroids, and supportive treatment. Biopsy of the lung specimen [] revealed bronchiolitis obliterans organizing pneumonia (BOOP). None of the serologic parameters or tissue cultures was positive for any infectious cause. Soon the air-leak disappeared, and she was discharged from the hospital with a long-term course of steroids and macrolide. She is now kept on regular follow-up.


A 37-year-old woman was referred to our emergency department of our hospital. She dropped during the second prostration in prayer and decreased her mental state, with no prior history of syncope, shortness of breath, or chest pain. She had no significant past medical history, but she had a positive family history of early cardiovascular disease. At presentation, the patient was afebrile and had normal vital signs (heart rate 80 bpm, blood pressure 110/70 mmHg, oxygen saturation 97% while breathing room air) and jugular venous pressure (JVP) was normal.
A 12-lead electrocardiogram revealed normal sinus rhythm with nonspecific minor ST-T abnormalities. On cardiac examination, S1 was accentuated and S2 was normal. There was an early diastolic sound that was compatible with a tumor plop.
A transthoracic echocardiogram (TTE) was performed which showed the presence of a pediculated mass in the left atrium, with an appearance suggestive of atrial myxoma, that was prolapsed through the mitral valve towards the left ventricle by changing patient's position [Figure –].
The patient was referred for urgent surgery. The intraoperative findings included a mass, and histopathology confirmed an atrial myxoma. She recovered without major complication and was discharged. At 2-year follow-up, she remains with excellent cardiac function.


A 30 year old female patient presented with complaints of nasal regurgitation of foods, slurring of speech and low grade fever for 2 months. There was no history of cough or expectoration. No epistaxis, no weight loss, focal deficit, weakness of any limb were reported.
On examination, the patient's vitals were normal; she was afebrile, and she had no pallor, icterus, cyanosis, clubbing, and lymphadenopathy. Oral examination suggested of perforation of size 3 cm × 2 cm in the hard palate []. Systemic examination was within normal limit (WNL). On biochemical examination, renal function test, liver function test and serum electolytes was WNL range. Complete blood count was also WNL. Urine routine/microscopy and hepatitis B surface antigens and hepatitis C virus antibodies were negative.
Chest X-ray was WNL, contrast-enhanced computed tomography of the chest was WNL. HIV was nonreactive. Venereal disease research laboratories were nonreactive.
Biopsy from the margin of perforation was suggestive of granulomatous inflammation with possibilities of TB and granulomatous polyangiitis. Antinuclear antibodies and antineutrophil cytoplasmic antibody were negative. PCR for mycobacterial TB was positive from the biopsy. The patient was started on anti-tuberculous regimen and she improved d.


A 40-year-old Korean female patient with ophthalmologic discomfort, osteoporosis, and unexplained hypokalemia was admitted. She had undergone ptosis surgery multiple times due to discomfort in the eyes (three times in 2010 and four times in January of 2015). She had no reported use of steroid other than one time in March of 2015 for eye discomfort. However, the patient started to display prominent cushingoid appearance including moon-face, extremity weakness, amenorrhea, penetrative-looking skin, easy bruising, and buffalo-hump ().
In laboratory workup, elevated serum ACTH at 108.6 pg/ml (normal range: 7.2-63.3 pg/ml) and urinary free cortisol at 721.6 µg/day (normal range: 20-90 µg/day) were noted. In addition, serum cortisol was elevated at 29.3 µg/dl (). Cortisol level was not suppressed with high-dose dexamethasone suppression test. Sella MRI revealed no abnormal signal intensity or abnormal mass lesion. Abdomen-pelvis computerized tomography (CT) showed no mass lesions in the abdominal organs (). However, endoscopic ultrasonography (EUS) confirmed a hypoechoic, homogenous, solid mass with size of 1.8 cm in the pancreatic tail (). In addition, PET revealed a low-density lesion at the pancreatic tail showing prominent FDG uptake (). Under the suspicion of ACTH producing pancreatic NET, venous sampling was performed to verify autonomous hormone production. ACTH was measured from six different locations. At all locations, the ACTH level was above normal (). Therefore, we decided to perform surgical resection. Laparoscopic distal pancreatosplenectomy using modified lasso technique, which includes isolation and ligation of the splenic artery prior to lasso technique, was performed. The operation time was approximately 90 mins. The patient was transferred to the department of endocrinology for close monitoring of the hormonal status on postoperative 7th day with no clinically relevant complications. The pathological examination revealed a 1.5 cm-sized grade 2 neuroendocrine tumor of the pancreas, which was encapsulated within the pancreatic parenchyma (). No lymph node metastasis was noted (pT1N0M0). The resection margin was free from tumor. Tumor cells were strongly positive for chromogranin A, synpatophysin, and ACTH in ().
The serum ACTH and cortisol values were restored to the normal cut-off values immediately after the surgical removal of the neuroendocrine tumor (). In correlation with the decreased cortisol level, the patient no longer displayed cushingoid features; and central obesity and the moon-face characteristic were improved significantly ().


A 47-year-old female patient was admitted to our hospital with left limb weakness. She had no prior medical history of hypertension, diabetes, or atrial f ibrillation. The initial neurologic examination demonstrated a drowsy state, left hemiparesis, and dysarthria with a NIHSS score of 8. Her vital signs were stable with a blood pressure of 170/90 mmHg and a serum glucose level of 71 mg/dL. Non-enhanced brain CT revealed no hemorrhagic density and CTA showed an occlusion in the distal basilar artery (). DWI revealed a subtle high signal in the right pons.
Endovascular mechanical thrombectomy was performed under conscious sedation. A 6-Fr guide catheter (Chaperon, MicroVention, Tustin, CA, USA) was introduced from the right femoral artery to the distal V2 segment in the left vertebral artery. A DAC (Navien 058; ev3/covidien, Irvine, CA, USA) coaxilally with a .021-inch microcatheter (Prowler select plus; Cordis, Miami, FL, USA) and a .014-inch microguidewire (Synchro-14; Stryker, Kalamazoo, MI, USA) was advanced to the proximal end of the occluded segment (). After retraction of the microcatheter and microguidewire, direct aspiration with the DAC was performed using a 50-mL syringe. The retrieved catheter showed a large thrombus wedged within it, and complete reperfusion was achieved (). One-day follow-up with brain CT revealed no hemorrhagic complications.


A 71-year-old male patient with a medical history of hypertension and hyperlipidemia was admitted to our hospital with right limb weakness. On arrival, his blood pressure was 115/65 mmHg, his blood sugar level was 113 mg/dL, and electrocardiography showed a sinus rhythm. Initial neurologic examination revealed right facial palsy, global aphasia, and right hemiparesis with a NIHSS score of 19. Non-enhanced brain CT revealed no hemorrhagic density, and CTA showed an occlusion of the M1 segment of the left MCA ().
A 9-Fr balloon guide catheter (Optimo; Tokai Medical, Aichi, Japan) was advanced from the right femoral artery to the left cervical ICA. Steam shaping of the tip of the DAC (Catalyst 6; Stryker, Kalamazoo, MI, USA) was performed to facilitate passage through the ophthalmic segment. Under roadmap guidance, the DAC with a .021-inch microcatheter and a .014-inch microguidewire (Traxcess 14 EX; MicroVention, Tustin, CA, USA) was advanced to the proximal M1 segment of the left MCA (), and the microcatheter and microguidewire were removed. The DAC was wedged to the thrombus with direct manual aspiration using a 50-mL syringe. The BGC was inflated after confirming arrest of blood aspiration into the syringe, and the DAC was gently retrieved maintaining manual aspiration. During retrieval of the DAC, blood was aspirated into the syringe and the aspirate contained a large thrombus. Follow-up angiography revealed complete reperfusion (). There was no hemorrhagic complication on the 1-day follow-up brain CT.


A 71-year-old female patient with no medical history of hypertension, diabetes mellitus, or arrhythmia was admitted to our hospital. The initial neurologic examination revealed a stuporous mental status and quadriparesis with a NIHSS score of 28. On admission, her blood pressure was 134/69 mmHg, her blood glucose level was 110 mg/dL, and electrocardiography revealed sinus tachycardia. Non-enhanced brain CT was unremarkable, and CTA showed an occlusion of the distal basilar artery ().
A 6-Fr guide catheter (Envoy; Cordis, Miami, FL, USA) was positioned from the right femoral artery to the distal V2 segment of the left vertebral artery. Under roadmap guidance, the 5-Fr DAC (Sofia; MicroVention, Tustin, CA, USA) with a .021-inch microcatheter and a .014-inch microguidewire was advanced to the proximal end of the occluded basilar artery (), and the microcatheter and microguidewire were removed. And then, direct manual aspiration using a 50-mL syringe through the DAC was conducted and a large thrombus was aspirated into the syringe. Follow-up angiography revealed complete reperfusion (). On 1-day follow-up, brain CT showed no hemorrhagic density.


Mrs A was an 84-year-old Japanese woman. One year before consulting our hospital, she realized that her visual acuity was impaired. When she was admitted to the previous hospital, she showed blindness with light perception. Serum antiaquaporin-4 antibody was positive by enzyme-linked immunosorbent assay. In addition, brain magnetic resonance imaging (MRI) showed right optic neuritis and did not meet Paty’s diagnostic criteria for MS, indicating the diagnosis of NMOSD based on 2015 IPND criteria. She had been treated with 8 mg/d prednisolone and had been mentally stable for about 1 year. However, she suddenly began to cry loudly and became aggressive to her husband. Moreover, she became violent and began slapping her husband occasionally. Olanzapine was not effective in treating these symptoms, which encouraged her to consult us.
She showed bilateral total blindness without light perception when admitted to our hospital. Brain MRI revealed right optic neuritis (), although it was unclear whether it was a new one or not (gadolinium enhancing scan was not performed). Psychomotor agitation was noted; she was irritable, yelling “Do it quicker!” and hitting nurses repeatedly.
As “other mental disorders due to NMOSD” were diagnosed in Mrs A, we started treating her with prednisolone, methotrexate, and risperidone. Risperidone, at 2 mg/d, was only partially effective, but she could not tolerate the dose of 3 mg/d because of occurrence of dysphagia. Therefore, we added trazodone at 25 mg/d instead of titrating risperidone. After maintaining the combination dose of trazodone and risperidone for 3 days, she no longer shouted out loud or resorted to violence. At the time of discharge, she was more observant and insightful enough to be adherent to medications.


A 14-year-old female patient reported to the Department of Oral and Maxillofacial Surgery at Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, complaining of painless swelling in the right cheek for 1 year. The patient was apparently alright 1 year back; then she noticed a small peanut-sized soft swelling accompanied with pain in the right inner cheek region which was slow growing. There was no history of trauma to the area, no history of discharge, and no other swelling in the body. The patient gave a history of mixed dietary habit and belongs to low socioeconomic status. Her medical history was noncontributory.
On extraoral examination, mild facial swelling present on right side of the cheek and the overlying facial skin appeared normal []. An intraoral examination revealed a well circumscribed with intact overlying mucosa, smooth submucosal, nodular swelling of approximately 1.5 cm × 1 cm in diameter in right buccal mucosa. Swelling was soft on palpation, nontender, and noncompressible []. No limitation in mandibular movement was noted. Neither any palpable lymph node was present in the head and neck nor any neurological deficit, or no history of seizures was present.
Differential diagnosis of fibroma, neurofibroma, focal fibrous hyperplasia, and mucocele was made. On further investigations, the orthopantomogram was found to be nonremarkable. Ultrasonography (USG) revealed well-defined oval-shaped intramuscular cystic lesion in muscle of right side of the cheek. It measures approximately 8.7 mm × 7.3 mm in dimension. A small echogenic eccentric mural nodule is seen within it. Surrounding muscle fibers are mildly thickened and inflamed. Findings were suggestive of cysticercosis [].
The patient was also referred for medical evaluation. Blood, urine, and stool examination were performed, which were in normal limit and did not showed any involvement of other areas. In our case, we instituted the conservative management with albendazole and prednisolone.


A 42-year-old female with a known HIV seropositivity for past 6 years reported to our department with a complaint of nonresolving swelling over left side of the face of past 2 months duration. She also gave a history of noticing intraoral growth in the mandibular left posterior region for the past 3 weeks. The swelling was accompanied by progressive decrease in mouth opening, loss of appetite, rapid increase in size of intraoral growth, and significant weight loss of more than 6 kg for the past 2 months. She also complained of fever, night sweats, and easy fatigability. The patient was referred to our institute by a general physician due to nonresolving nature of the swelling. After going through her medical records it came to our notice that patient was diagnosed as HIV positive in the year 2010 and was on art for the same. Her CD4 counts at the time of presentation were 58. On local examination, there was gross facial asymmetry with a single diffuse swelling over left side of the face extending suproinferiorly from the zygomatic arch to about 2 cm below the inferior border of the mandible into the submandibular region. Antero-posteriorly the swelling extended from the angle of the mouth up to the tragus of the ear measuring approximately 8 cm × 5 cm × 3 cm with obliteration of nasolabial fold on the left side. The skin overlying the swelling had a taut and shiny appearance [].
On palpation the swelling was firm, tender and nonfluctuant. Lymph node examination revealed single, oval-shaped, mobile node in the left submandibular region.
Intraorally there was single, diffuse large proliferative growth extending from the mandibular incisor region to the retromolar trigone and crossing over to the lingual side up to the premolar region measuring 8 cm × 4 cm × 4 cm in greatest dimension. The overlying mucosa had a corrugated appearance with areas of hyperpigmentation and slough []. Oral hygiene was poor and carious teeth were present in all four quadrants. A computer tomographic scan was taken to see for the extent of bony involvement which revealed erosion of buccal and lingual cortices. It also revealed an expansile lesion involving buccal and submandibular space [].
Chest X-ray (postero-anterior view) revealed multiple radiopaque foci which were suggestive of old-treated Koch's [].
The swelling was subjected to incisional biopsy under local anesthesia. The hematoxylin-eosin stained section showed diffuse sheets of monotonous lymphocytes homogenous in size and shape with intensely basophilic vacuolated cytoplasm. A large number of abnormal mitotic figures were seen. Dilated blood vessels and areas of extravasated erythrocytes were seen between undifferentiated lymphocytes [].
The histopathologic diagnosis was suggestive of NHL.
To identify the subtype of NHL, immunohistochemistry was performed using CD45, CD20, and CD3 markers. The patient upon definitive diagnosis of NHL was started on palliative chemotherapy. Although partial regression of primary tumor was present, unfortunately the patient was lost to follow-up following 6 months after chemotherapy after being discharged from our unit.


A 2-year-old male neutered Siamese cat, weighing 4.0 kg, was referred to the
Valentine Charlton Cat Centre with a 2 day history of weakness, open-mouth breathing
and inappetence. Since the age of 8 months, the cat had been treated by the primary
veterinarian for suspected anxiety with fluoxetine (Reconcile, 4 mg PO q24h;
Elanco).
On examination, the cat had a poor body condition (body condition score 4/9),
cyanotic oral mucous membranes and a grade II/VI systolic heart murmur with sternal
peak murmur intensity. Open-mouth breathing was intermittent, and was exacerbated by
stress and handling. Blood oxygen saturation (SpO2) was 85–88% and did
not improve after nasal catheter oxygen supplementation (0.5 l/min). The packed cell
volume (PCV) was 48 (reference range 30–45 l/l) and total plasma protein (TPP) was
90 (reference range 59–78 g/l). On three-view thoracic radiographs, the vertebral
heart size (VHS) was 7.9 (upper limit of reference range 8.0), and the pulmonary
lobar arteries were dilated and tortuous ( and ). An electrocardiogram showed narrow QRS
complexes with deep S-waves and right axis deviation suggestive of right-sided
cardiac enlargement. Echocardiography revealed severe right ventricular (RV)
concentric hypertrophy (RV diastolic free wall measurement 6.4 mm, left ventricular
diastolic free wall measurement 5.8 mm), with paradoxical intervertebral septum
motion. The right atrium was subjectively severely enlarged, and there was severe
dilation of the main pulmonary artery (PA) and right PA branch (PA:aorta ratio 1.9)
( and ). An insufficiency jet
between the dilated PA and RV measured across the pulmonic valve was 4.1 m/s
(estimated peak instantaneous diastolic pressure gradient of 68 mmHg), consistent
with moderate-to-severe pulmonary hypertension (PH) ( and ). A 5.7 mm atrial septal defect (ASD) was
identified with right-to-left shunting on colour Doppler, with a maximum velocity of
approximately 0.45 m/s (estimated peak instantaneous pressure gradient of 0.81 mmHg)
(). An agitated
saline microbubble contrast study performed via the left cephalic vein confirmed a
right-to-left shunt across the interatrial septum.
The cat was diagnosed with ASD and suspected pulmonary vascular obstructive disease
leading to PH (Eisenmenger’s syndrome). Symptomatic treatment for PH to alleviate
right-to-left shunting was commenced with sildenafil (0.25 mg/kg PO q12h). A low
dose was chosen because of the unknown pharmacokinetics of sildenafil in cats with
heart disease, especially considering that cats often vary in their ability to
metabolise drugs when compared with other species.
After an initial increase in activity and resolution of dyspnoea lasting
approximately 2 weeks, the cat became more lethargic with short episodes of
open-mouth breathing when anxious or excited. The dose of sildenafil was increased
to 0.5 mg/kg PO q12h. At re-evaluation 5 weeks after presentation, the cat was
reported to have had fewer episodes of open-mouth breathing that lasted for shorter
periods than before treatment. The owners also reported increased activity. PCV was
38 and TPP was 82 g/l. Pulse oximetry revealed an SpO2 on room air of
80%. Repeat echocardiograph showed bidirectional shunting (with some left-to-right
flow), and subjectively less right-to-left shunting.
Three and a half months after initial presentation, the cat developed recurrent
respiratory distress following the introduction of a new kitten to the household.
The episode consisted of a prolonged episode of open-mouth breathing and weakness
that lasted several minutes. The cat had also developed progressive intermittent
coughing and wheezing prior to presentation. Repeat radiographs showed persistent
dilated, tortuous pulmonary lobar arteries, and that cardiomegaly had progressed
(VHS increased to 9.0). The cardiomegaly was considered to be most likely due to
ongoing RV hypertrophy and right atrial dilation secondary to severe PH. In
addition, there was a subtle bilateral bronchointerstitial pattern throughout the
lung fields, suggestive of a component of airway disease contributing to the
coughing and wheezing, such as allergic airway disease (considered the most likely
given the signalment and history). Less likely considerations included lungworm,
neoplasia or mild primary bronchopneumonia. The patient’s anaesthetic risk was
considered significant, and the owners elected not to proceed with bronchoalveolar
lavage to further investigate primary respiratory disease. Empirical treatment was
commenced with doxycycline (6.5 mg/kg PO q12h) to treat potential secondary
bacterial infection. An echocardiogram and agitated saline microbubble contrast
study showed significant right-to-left shunting. The sildenafil dose was increased
to 0.75 mg/kg PO q12h (2.8 mg PO q12h). The owners reported a reduction in both
open-mouth breathing and coughing/wheezing.
The patient remained relatively stable for a further 4.5 months. At 8 months after
initial presentation the cat deteriorated again, having several episodes of collapse
and open-mouth breathing over the course of a week. These episodes occurred
following exercise or play. Clinical examination revealed jugular pulses extending
halfway up the neck. An echocardiographic study revealed further advancement of
right-sided heart enlargement (RV diastolic free wall measurement 7.94 mm). The
insufficiency jet measured across the tricuspid valve had a velocity of 3.34 m/s,
which equated to a pressure gradient of 45 mmHg and an estimated RV diastolic
pressure of 55 mmHg. Sildenafil was increased to 6.25 mg PO q12h (1.6 mg/kg PO
q12h). However, 2 months after this re-evaluation (a total of 10 months after
diagnosis), the cat became persistently lethargic and had multiple syncopal
episodes, accompanied by loss of faecal and urinary continence, within a week. The
owners elected euthanasia and declined necropsy.


A 14-year-old girl presented to gynecology out patient department with complaints of abdominal distension for past 3 months. Distension was insidious in onset and gradually increasing in size with presence of abdominal pain for past 1 week. Past history was unremarkable. Patient had irregular menses with oligomenorrhoea for past 3 months. General physical examination was unremarkable.
Abdominal examination showed generalized abdominal distension from epigastric to hypogastric region with presence of fluid thrill. No hepatosplenomegaly was noted. Vaginal examination revealed uterus in anteverted position with free fornices.
Tumor markers were evaluated and showed marked elevation in CA 125 level of 243 U/L (normal, 0 to 35 U/L). β-human chorionic gonadotropin, alpha feto protein, carcino embryonic antigen and lactate dehydrogenase were within normal limits. Complete hemogram, liver function test and coagulation profile were normal.
Plain X-ray chest and abdomen revealed a solid cystic lesion occupying whole of the abdomen. Contrast enhanced computed tomography scan of abdomen revealed well defined multi-loculated predominantly cystic abdominopelvic intraperitoneal mass lesion with enhancing septas and solid components within and extending from sub-hepatic location to pubic symphysis inferiorly.
Patient underwent explorative laparotomy and a large left sided ovarian tumor measuring 20×17 cm with intact capsule was noted adhered to the omentum however surrounding peritoneum and contralateral ovary appeared unremarkable. Two hundred milliliters of ascitic fluid was aspirated and sent for cytological examination for malignant cells. In addition, macroscopic deposits were seen in the omentum. Left sided salphingo-oophorectomy was done and sent for frozen section. Subsequently patient underwent infracolic omentectomy and the specimen was sent for routine histopathological examination. Frozen section findings revealed an enlarged ovary measuring 20×10×5 cm with intact capsule. Cut section was multi-loculated with presence of solid cystic areas. Cysts ranged in size from 0.5 to 4.5 cm and were filled with thick, viscous mucinous fluid (). Microscopy revealed ovarian stroma with suspicious atypical cells lying in the pools of mucin, however no definite invasion was seen in the stroma. Therefore, possibility of borderline mucinous tumor was suggested.
Microscopic sections, on routine histological examination, revealed solid cystic areas displaying multiple layers of mucin producing atypical epithelium, with large areas of necrosis, focally infiltrating the stroma (). Sections from the omentum revealed metastatic tumor deposits. Thus, a final diagnosis of malignant mucinous cystadenocarcinoma with metastasis to omentum was rendered. Ascitic fluid cytology was positive for malignant cells.
Postoperative course of the patient was unremarkable with fall in CA 125 levels. Patient was given 3 cycles of chemotherapy with cisplatin and paclitaxel. Eight months postsurgery, patient showed no signs of recurrence and is still under follow up.


A 37-year-old male presented with irritation, pain and reduced vision in the left eye after mud contamination. On examination, his best-corrected visual acuity in the left eye was hand movements and the right eye was 6/6. The left eye revealed a central, irregular, 6.8×7.4 mm infiltration with a feathery edge and satellite lesions. The hypopyon level was about 2–3 mm (). Corneal scraping revealed numerous septate hyphae. The patient was first treated with topical 5% natamycin, 0.15% amphotericin B eye drops hourly and oral itraconazole 200 mg daily. Intracameral and intrastromal amphotericin B (5 μg/0.1 mL) injections were also undertaken. However, there was no significant clinical improvement. Three days after presentation, infiltration began to deteriorate.
The patient was then treated with topical 1% voriconazole every 1 h, and topical natamycin was discontinued. Additionally, intracameral and intrastromal injections of voriconazole (50 mg/0.1 mL) were given. Two days after treatment, slit-lamp examination showed marked improvement with a decreased corneal infiltrate and hypopyon. Chrysosporium sp. was identified by corneal cultures 3 days later. After 7 days of voriconazole treatment, the corneal infiltration was decreased to 5.4×6.2 mm surrounded by corneal scarring, and no hypopyon was detected. The topical and systemic medications were continued and tapered according to clinical findings. Finally, the lesion healed to be corneal scar and visual acuity was 4/60. One month later, the patient underwent penetrating keratoplasty for corneal scar (). Immediate postoperative visual acuity in his left eye was 6/36 and final best-corrected visual acuity was 6/18 at 3 months after the procedure.


A 48-year-old woman with a history of MO presented at our outpatient clinic with persistent pain after intensive treatment for symptomatic osteochondromas. In the past, multiple surgical procedures had been performed, including excision of osteochondromas located at the knees, left scapula, and left foot. At presentation, she complained of a painful and residual, though very small, osteochondroma originating from the left scapula, and persistent pain from symptomatic osteochondromas at the 5th digit of the left foot and in the trochanter region (, , ). Pain medication was not sufficient, and the effect of multiple corticosteroid injections in both her left scapular region and trochanteric region only lasted for a few weeks. Because previous treatment, including surgical removal of the osteochondroma, local injection therapy with corticosteroids, and analgesics, only had minimal effect for a limited period, we decided to treat her with autologous fat grafting.
The adipose tissue was collected from the abdomen and inner thigh after infiltration with sodium chloride 0.9% mixed with 2% lidocaine (2 mg/mL) and 1-milliliter epinephrine (1 mg/mL). It was then centrifuged at 3,000 rpm for 5 minutes. The central layer, consisting of usable fat, was then separated from the upper layer (oil) and lower layer (blood and liquid infiltrations) and injected into the body. During the first operation, 70 cc autologous fat was harvested from the abdomen and injected into the painful region of her left scapula. The patient was very satisfied with the result and she experienced relief of her pain for 1 year. Subsequently, surgery was repeated 1 year later and 51 mL autologous fat from the abdomen and flanks was injected into her left scapula as well as 2 mL into the 5th digit of the left foot. This procedure was repeated again 1 year later with harvested fat from the abdomen and an injection of 60 mL into the left scapula, 3 mL into the left foot, and 12 mL autologous fat into both trochanter regions. The postoperative courses were uneventful, besides hematomas at the donor site (). She reported a 5-step reduction in pain according to the visual analogue scale (from 8 to 3), and she was able to stop taking pain medication during and following these years of treatment. After the treatment, she reported only partial recurrence of the pain, which was also not as severe as before the treatment.


A 75-year-old man, involved in a traffic accident, was admitted to the orthopedic department due to multiple trauma including pelvic bone fractures and hemoperitoneum. He underwent surgery and was ordered by doctor to take absolute bed rest in the intensive care unit. On the 6th post-operation day, he developed dyspnea with blood tinged sputum and left calf swelling. The ultrasonography revealed DVT in the left calf vein, and the computed tomography of chest showed pulmonary hemorrhage without evidence of PTE. He should have had an installation of retrievable IVC filter (OptEase™; Cordis Europa, Roden, the Netherlands) to prevent PTE because he could not take any kind of anticoagulant. Fortunately, there was no embolic event at that period. Eighteen days later, there was no evidence of active bleeding. Thereafter, we tried to remove the filter according to the manufacturer's recommendation. However, we barely managed to retrieve it against our expectations because the filter won't come into the catheter (, only online). There were several pieces of trapped tissue in the retrieved filter (arrow heads in ). Post-retrieval cavography demonstrated mobile rugged filling defects at the filter-detached vascular wall side suggesting a significant vessel wall injury (circles in ) (, only online). Pathological examinations, such as immunohistochemical staining of the tissue, were positive for smooth muscleactin and CD34, and confirmed that they were parts of vessel including smooth muscle cells (red arrows and rectangle in ) and endothelial cells (blue arrows and rectangle in ), respectively.


A 27-year-old woman with TN during 11 years in the left V2 and V3 divisions was submitted 6 years ago to microvascular decompression in the posterior fossa due to neurovascular conflict. Her symptoms disappeared for 4 years and she was resistant to standard drug therapy at the time. Percutaneous balloon rhizotomy was performed in another service. Massive bleeding during the procedure was described, and the patient presented with proptosis, eye pain, chemosis, and paralysis of extraocular movements in the left eye a few hours after the procedure, with worsening of symptoms over the following days. A brain magnetic resonance image (MRI) [] showed an oval structure of 14 × 13 × 11 mm adjacent to the left cavernous sinus. Moreover, a prominent and serpiginous tubular image in intraconal situation located caudal to the superior rectus muscle and cranially to retrobulbar segment of the optic nerve with significant hypointensity similar to that displayed in the cavernous portion of the ipsilateral ICA suggested a flow void compatible with vascular abnormality of high flow. This structure corresponded to the superior ophthalmic vein, which captured contrast and presented with ventral extraorbital insinuation and dorsal insinuation to the orbital apex through the superior orbital fissure with gradual reduction of its caliber. After 10 days, she was referred to digital subtraction angiography (DSA) of the intracranial vessels, which confirmed the diagnosis of a high flow CCF. The fistula was indirect [] because it filled the cavernous sinus retrogradely through an abnormal communication between the final segment of the posterior petrous portion of the ICA and veins draining to the sinus (vidian artery communicating with the inferolateral trunk). There was no other vascular abnormality involving the right ICA and external carotid artery bilaterally or posterior circulation []. Transarterial embolization of the fistulous orifice was performed using coils, with immediate cessation of early venous filling []. The patient showed complete regression of ocular symptoms in a period of 5 days. During a 6-month follow-up, the patient confirmed complete remission of the TN.


A 7-year-old female had a 6-month history of multifocal joint swelling with mild pain but without joint dysfunction, fever, or rash. She had experienced no trauma and had no relevant family history. The initial suspected diagnosis determined at a local hospital was polyarticular juvenile idiopathic arthritis with negative rheumatoid factor. After undergoing treatment with naproxen, methotrexate, infliximab, and pavlin for 2 months, the joint swelling remained, although pain had been relieved. The child was then referred to our hospital. Physical examination revealed a 4.5 cm × 4.5 cm symmetric cystic mass in the region of the bilateral shoulder joints (Fig. ) without signs of redness, tenderness, or high skin temperature. Slightly swollen knees, wrists, and fingers were also noted, and the fluctuation test was positive. Results within normal ranges were obtained for all laboratory examinations, including routine blood tests; assessments of C-reactive protein, erythrocyte sedimentation rate, biochemistry, coagulation function, autoantibodies, rheumatoid factor, transfusion immunity, mycoplasma antibody, and bone marrow; rheumatism screening; the fungal G test; and the tuberculosis skin test. No abnormal signs were found in thoracic and abdominal enhanced CT examinations. Joint effusion and synovial thickening in the bilateral hips, knees, ankles, shoulders, elbows, and metatarsophalangeal joints 1–5 were observed via ultrasonography. Erosion of the humerus bone was visible on the right shoulder x-ray (Fig. ). Magnetic resonance imaging (MRI) revealed obvious joint effusion, diffuse synovial thickening, and hemosiderin deposition within synovial masses (Fig. ). Puncture fluid from the left shoulder joint was bloody, and its smear and culture were negative. Pathological examination of the joint fluid demonstrated the presence of many lymphocytes and phagocytic cells but no tumor cells. Biopsy of the left knee joint synovium and capsular tissue indicated the obvious expansion of villous nodules, the invasion of foam cells, and hemosiderin deposition (Fig. ), confirming the diagnosis of PVNS.