A 37-year-old female presented with fever, vomiting, diarrhoea, generalised myalgias and coryza. She was discharged with a suspected viral illness but was readmitted when blood culture isolated S. pneumoniae. She had right lower quadrant pain, was tachycardic and hypotensive. An examination demonstrated generalised abdominal tenderness, with signs of peritonism in the right iliac fossa. Her C-reactive protein (CRP) and white cell count (WCC) were elevated (Table ). At emergency laparoscopy and appendicectomy, there was purulent exudate throughout the abdomen, with an unremarkable appendix and inflammation of the right fallopian tube. A urine pneumococcal antigen was positive (Alere BinaxNOW (Alere Inc., Massachusetts, United States) immunochromatographic antigen assay was used in all four cases). Neisseria gonorrhoeae and Chlamydia trachomatis were not detected in urine by PCR testing. The patient was treated with intravenous benzylpenicillin and discharged well on day six.


A 40-year-old female presented with acute onset central abdominal pain with vomiting and diarrhoea. She was febrile (39.0°C) and tachycardic (120 bpm). On examination, there was a reducible hernia in the right iliac fossa and marked tenderness in the epigastrium and right upper quadrant without peritonism. Her inflammatory markers were elevated (Table ). A computed tomography scan (CT) of the abdomen and pelvis demonstrated mural thickening of the sigmoid colon, and a chest X-ray demonstrated left perihilar opacity. She was treated for sigmoid colitis with ceftriaxone and metronidazole. She developed hypotension, which was treated with intravenous fluids. On the fourth day of admission, blood cultures collected at presentation isolated S. pneumoniae. Treatment was changed to moxifloxacin once daily, and she was discharged. Subsequent colonoscopy and gastroscopy demonstrated no evidence of colitis or colonic abnormalities.


A 41-year-old woman presented with a four-day history of abdominal pain, vomiting and diarrhoea, with fever and rigors for 24 hours. She appeared unwell with a heart rate of 115 bpm and BP of 108/70. She had diffuse abdominal tenderness without any clinical evidence of peritonitis. Her inflammatory markers were elevated (Table ). Her previous medical history included undifferentiated proctitis managed with mesalazine and an intrauterine contraceptive device (IUD) inserted three months prior to her presentation. She was commenced on intravenous ciprofloxacin for a presumptive diagnosis of infective colitis. She developed hypotension requiring fluid resuscitation. A CT scan revealed thickened loops of the small bowel with peritoneal enhancement and bilateral pleural effusions. Blood cultures isolated S. pneumoniae serotype 3. She initially improved when commenced on cefotaxime and lincomycin. However, on day seven of admission, her dyspnoea worsened and she developed diffuse erythema on the anterior abdominal wall. Thoracocentesis revealed a sterile transudate, however, an abdominal paracentesis performed on day 11 of admission revealed purulent fluid (leucocytes 54 x 10^9/mL) with glucose of 0.1 mmol/L and a low serum-ascites albumin gradient (6 g/L). Predominant gram-positive diplococci were noted on stool microscopy. Urine, stool, pleural and ascitic fluid were positive on pneumococcal antigen testing. Despite 15 days of treatment with cefotaxime, her abdominal symptoms persisted and she underwent laparotomy to drain sterile intra-abdominal abscesses. She was discharged well on day 30.


A 49-year old woman presented with a four-day history of profuse, watery diarrhoea, abdominal pain, fevers and rigors. She appeared unwell, with a respiratory rate of 22, heart rate (HR) of 90 and signs of dehydration. Widespread abdominal tenderness was present without peritonism, and some bloating was noted. See Table for investigations. She was commenced on empiric ciprofloxacin and metronidazole. Blood cultures isolated S. pneumoniae and the pneumococcal antigen was positive in urine and, although a non-validated specimen type, was positive in stool. Antibiotics were changed to ceftriaxone and metronidazole. On day four of her admission, she developed melaena. A CT of the abdomen demonstrated enteritis with a thickened bowel wall, widespread ascites and bilateral pleural effusions. She improved and was discharged well on day nine 9.


A 20-year-old pregnant woman with secundum ASD and severe PS presented with progressive dyspnoea and was referred to our clinic for a percutaneous ASD closure and a pulmonary valvuloplasty. She was in the second trimester (16 weeks) of pregnancy. At admission, her arterial blood pressure and heart rate were 120/70 mmHg and 64 beats/min, respectively. The physical exam was unremarkable except for a grade 2/6 ejection systolic murmur best heard over the left second intercostal space and fixed splitting of the second heart sound. An electrocardiogram showed an incomplete right bundle branch block. A two-dimensional transthoracic echocardiography (2D TTE) was done using a Philips (Bothell, WA, USA) iE33 ultrasound system with an x5-1 transducer. It showed a secundum ASD with a left-to-right shunt, severe PS (maximal gradient= 79 mmHg and maximal velocity= 4.4 m/s) (), an enlarged right ventricle (RV) (basal diameter= 4.4 cm), normal left ventricular function and mild tricuspid regurgitation. The RV free wall was 0.4 cm. Tricuspid annular plane systolic excursion were measured at 1.5 cm. Then, 2D transoesophageal echocardiography (TEE) was done using the X7-2t matrix transducer and the same ultrasound system as the 2D TTE. The 2D TEE findings were the same as those of 2D TTE, but the three leaflets of the PV were still not visualized; however, there were thickening of leaflets and a doming motion. For further evaluation, we performed a 3D TEE using the same system and transducer. Full-volume data of the PV and inter-atrial septum were taken, and all images were systematically and sequentially cropped to view both the ASD and PV en face in both non-multiplanar reconstruction (MPR) and MPR modes. The secundum ASD was measured 2.4 x 1.6 cm with an area of 4.5 cm2 and all rims were larger than 5 mm. Thus, the ASD was determined to be appropriate for a percutaneous closure procedure. The PV was noted to be tricuspid () and the PV area was 1.89 cm2 (). PS was classified according to the planimetric method as a mild stenosis (,).
There was an inconsistency between the Doppler and 3D classification of PS severity. During pregnancy, ESC guidelines on the management of cardiovascular diseases during pregnancy () provide follow-up recommendations for patients with mild or moderate PS, but balloon valvuloplasty should be advised for symptomatic severe PS with RV dysfunction as in our patient. Therefore, we decided to follow up our patient during pregnancy. After the pregnancy was completed, the peak PV gradient was reduced to 41 mmHg (a moderate PS according to the gradient/velocity-based classification). The patient then underwent a percutaneous closure of the ASD. After a successful procedure, the peak PV gradient reduced to 26 mmHg (a mild PS according to the gradient/velocity-based classification), and the discrepancy between the Doppler and planimetry-based classification for PS was eliminated. Written informed consent was obtained from the patient.


A 63-year-old African-American male with type 2 diabetes on metformin, rheumatoid arthritis not on oral corticosteroid therapy, chronic low back pain alleviated with intermittent epidural steroid injections, hepatitis C, and chronic myelomonocytic leukemia (CMML) who was on decitabine for chemotherapy presented to the hospital on 6/25/16 for hematemesis and poor oral intake. Prior to arrival, he had been feeling weak and his weakness acutely worsened in the two to three weeks before admission. His other symptoms included nausea and poor appetite. He had vomited at least twice. Two days prior to his admission, he was seen in his outpatient oncologist's office. He told his oncologist that he had not been feeling well and had been experiencing dehydration and fatigue. He said his symptoms started around the time the posaconazole 300 mg daily was started in April of 2016 for fungal prophylaxis. His oncologist held his posaconazole at that visit on 6/23/16. The only relevant steroid exposure was intermittent steroid injections into his spine for low back pain. His last injection had been in March of 2016. It was estimated that he had received a total of five steroid injections into his back prior to admission. The time interval between and the time course of injections are not specified. His full medication list included potassium supplementation, hydroxychloroquine, indomethacin, tramadol, docusate, acyclovir, levofloxacin, decitabine, allopurinol, gabapentin, aspirin, lisinopril, and metformin.
Blood pressure on admission was within normal limits at 125/60 mmHg. Labs on admission showed hypokalemia (3.1 mmol/L) and hypocalcemia (8.5 mg/dL) but normal sodium and glucose. To evaluate his adrenal function, the primary team sent a morning cortisol on 6/26/16 which resulted as 1.9 mcg/dL at 5:39 AM. To further evaluate his adrenal function, he underwent a cosyntropin stimulation test. On the morning of 6/27/16, his cortisol at 5:28 AM was 2.2 mcg/dL. He was then given one dose of cosyntropin 250 mcg IV at 8:00 AM with repeat cortisol measurements resulting in 3.7 mcg/dL at 30 minutes and 4.1 mcg/dL at 60 minutes. A CT scan of the abdomen and pelvis without contrast was done on 6/26/16 and showed bilateral thickened adrenal glands consistent with hyperplasia. During that admission, he was started on hydrocortisone 15 mg by mouth in the morning and 10 mg by mouth in the evening. ACTH measured on 6/27/16 was 154.6 pg/mL. After the ACTH results returned, he was started on fludrocortisone 0.1 mg by mouth daily as the providers concluded that the patient had primary adrenal insufficiency given his elevated ACTH and failed cosyntropin test. There was no renin value measured at the time of initial diagnosis.
He was followed up in the endocrine clinic one month later. During the office visit, it was documented that he had hyperpigmentation of the skin but the patient stated that this had been present for years. After starting hydrocortisone and fludrocortisone, his symptoms improved including increased appetite and resolution of headache and nausea. He was rehospitalized in September 2016 for a stem cell transplant for his CMML. 21-OH antibodies were tested during that admission and were negative (<0.1). On discharge, he was prescribed hydrocortisone 10 mg by mouth in the morning and 5 mg by mouth in the afternoon. He tolerated this regimen well. He re-presented to the endocrine clinic in July of 2017 (one year after discontinuation of posaconazole) for repeat cosyntropin testing. Cosyntropin 250 mcg IV was given after measurement of a baseline cortisol of 5 mcg/dL. One hour after the cosyntropin was given, it rose to 18.5 mcg/dL. Pretesting ACTH was 34.1 pg/mL (7–69 pg/mL) and renin was 0.176 ng/mL/hr (0.167–5.380 ng/mL/hr). Based on his improved cosyntropin testing (), he discontinued the hydrocortisone and fludrocortisone.


A 20-year-old female presented to the emergency department with chest pain, dyspnea, fever, and chills for 3 weeks. She was an active intravenous heroin abuser at the time and had been attempting to wean herself off heroin. During her evaluation, her blood cultures were notable for Streptococcus mitis. The diagnosis of bacterial endocarditis with severe aortic valve vegetation was made after a transthoracic echocardiography was performed. The patient was started on intravenous antibiotics on the day of admission and a cardiothoracic surgery consultation was made. On hospital day number 2, the patient was taken to the operating room for a bovine pericardial patch repair of a fistula and aortic valve replacement with a 21 mm bioprosthetic valve. The patient remained hospitalized for 36 days and was discharged to a drug rehabilitation program once she was medically cleared.
When the patient presented to cardiology for follow-up 1.5 years after her aortic valve replacement, the patient was 22 years old and 20 weeks pregnant with a recorded body mass index of 29 kg/m2. The patient had been enrolled in a methadone maintenance program and had not used intravenous heroin for 6 months. She was promptly referred to our maternal-fetal medicine and cardiology joint program, a multidisciplinary collaboration created to manage pregnant women with preexisting or acquired cardiac conditions. An echocardiogram was performed during her first prenatal care visit showing a heart rate of 61 bpm, peak velocity of 360.5 m/s, peak gradient across valve of 52 mmHg, mean gradient across valve of 28.9 mmHg, and dimensionless index 0.36.
Joint prenatal care and cardiology clinic visits were scheduled, during which routine prenatal care and cardiology evaluations were performed. The patient was placed on 81 mg of aspirin for the duration of her pregnancy to decrease her risk of thrombosis. Echocardiogram was repeated at 32 weeks and 37 weeks of gestation. At 32-week gestation, the echocardiogram showed a heart rate of 69 bpm, peak velocity of 386.9 m/s, peak gradient across valve 59.9 mmHg, mean gradient across valve 36.1 mmHg, and dimensionless index 0.43. At 37-week gestation, heart rate was 76, peak velocity of 339.3 m/s, peak gradient across valve 46.1 mmHg, mean gradient across valve 22.6 mmHg, and dimensionless index 0.45. The patient was asymptomatic and denied any cardiac symptoms.
A multidisciplinary meeting included subspecialists of cardiology, maternal-fetal medicine, anesthesiology, critical-care, and labor and delivery nursing to create a delivery plan. A consensus was reached that a vaginal delivery would be safe for this patient without an assisted second stage, unless obstetrically indicated. A plan was made for telemetry monitoring immediately postpartum given higher risk of arrhythmia at that time.
The patient presented to the labor and delivery triage unit at 40-week 0-day gestation complaining of contractions and was found to be in spontaneous labor. As discussed during our multidisciplinary meeting, the patient received endocarditis prophylaxis and underwent expectant management of her labor. The patient did not require an assisted second stage of delivery and proceeded to have a spontaneous vaginal delivery. Within 10 hours of admission, she delivered a healthy male infant with Apgar scores of 9 at 1 min and 9 at 5 min, weighing 3770 grams with estimated blood loss of 350 ml. Her postpartum care was uneventful. Her echocardiography on postpartum day 1 showed a heart rate of 63 bpm, peak velocity of 325.8 m/s, peak gradient across valve 42.5 mmHg, mean gradient across valve 25.3 mmHg, and dimensionless index 0.36. The patient was discharged on postpartum day 3 without any complications. At her 6-week postpartum visit, the patient received an intrauterine device (IUD) for contraception.


A 10-year-old boy was brought to the Shariati hospital emergency department after a car accident. Avulsion of the maxillary central incisors and intrusion of lateral incisors were diagnosed (). The avulsed central incisors were not replanted and missed.
Panoramic radiograph showed a permanent dentition except second primary molars ().
Four weeks after accident, the boy was examined by an orthodontist. Extraoral examination showed no soft tissue injury probably because of the time of examination. Intraoral examination also showed neither laceration nor alveolar bone fracture. Clinical examination revealed that the patient had an angle's Cl II malocclusion, open bite, and lower jaw space deficiency and crowding. The aim of orthodontic management was to treat the Cl II malocclusion and to relieve crowding by extractions in lower jaw. After the completion of radiographic and clinical examination, mandibular second premolars were selected for the extraction. Due to loss of maxillary incisors, we decided to transplant mandibular second premolars into the place of maxillary incisors at the time of orthodontics extractions.


We describe the case of a 33-year-old male patient who first presented to our clinic in February 2015 with decreased visual acuity in the left eye.
Medical history showed a traumatic brain injury due to a war explosion in January 2012. He suffered a severe craniocerebral trauma with fracture of the temporal bone and an epidural hematoma, which was drained three days after admission.
Two months later, at discharge, the diagnosis was:
1. Traumatic brain injury due to explosion
2. Mixed hypoacusis in the left ear (conductive and sensorineural)
3. Posttraumatic left peripheral facial palsy. Lagophthalmos
From 2012 to 2015, he underwent different kinds of surgeries:
- neurosurgical: drainage of hematoma,
- ENT: 8 surgeries between 2012 and 2014 for ear drum reconstruction, myringotomy and removal of bone fragments that narrowed the ear meatus,
- ophthalmological: total blepharorrhaphy, partial opening of the blepharorrhaphy in March 2013 and total opening of the blepharorrhaphy in December 2014.
Ophthalmologic examination revealed:
OD:
- visual acuity: 1 without correction
- refraction: +0.25/- 0.5* 11˚
- intraocular pressure: 13 mmHg NCT
- slit lamp examination: normal anterior segment
- fundus examination: well defined contour and normal color of the optic disc, C/ D ratio of 0.4, neuroretinal rim respecting the ISNT rule, normal macula and retinal vessels ().
OS:
- visual acuity: 0.8 without correction
- refraction: +0.00/ -0.25*17˚
- intraocular pressure: 12 mmHg NCT
- slit lamp examination: discrete inferior, superficial corneal opacities
- fundus examination: well defined contour and pale color of the optic disc, C/ D ratio of 0.9, superior and temporal narrowing of the neuroretinal rim and absent inferiorly, normal macula and retinal vessels ().
Diagnosis at this stage of the evaluation:
OD: Normal
OS: Optic disc atrophy. Normal-tension glaucoma - under observation
Investigations:
- pachymetry: OD: 540 microns, OS: 541 microns
- visual field examination (Humphrey Field Analyzer, Zeiss): OD: small peripheral defects in all four quadrants; MD: -5.27 dB; but with low reliability indices (), OS: severe decrease in retinal sensitivity, MD: -21.7 dB; glaucoma hemifield test: outside normal limits; subtle inferior arcuate defect, deep superior arcuate defect, no altitudinal defect ().
- retinal nerve fiber layer (RNFL) analysis: OD: decreased thickness in three quadrants, OS: decreased thickness in all four quadrants ().
- retinal nerve fiber layer (RNFL) analysis at the level of Bruch membrane opening: OD: mild temporal, superior and inferior thinning of the RNFL (borderline changes), OS: important thinning of the RNFL (outside normal limits) ().
Diagnosis: OU: Normal-tension glaucoma
Our diagnosis was supported by the following:
- intraocular pressure always below 15 mmHg,
- structural changes:
• OS: specific glaucomatous optic disc cupping,
• OU: changes in retinal nerve fiber layer thickness,
- functional changes: characteristic glaucomatous changes in OS, borderline changes in OD; considering Hodapp’s classification, glaucoma changes in OS were advanced (MD > -12 dB; > 37 points with p< 5%; > 22 points with p< 1%; < 15 dB sensitivity in the 5 central degrees in both hemifields).
Differential diagnosis:
- primary open-angle glaucoma, but intraocular pressure was always under 15 mmHg;
- anterior ischemic optic neuropathy with optic disc atrophy, but the visual field defect was not specific for this disease.
Treatment:
Our decision was to treat the patient and our approach consisted in combining prostaglandin analogues (i.e. latanoprost, once daily at bedtime) and neuroprotective agents (administered twice daily).


A 47-year-old Taiwanese woman, a housewife, who was an HBV carrier, had received renal transplantation in 2002 and was treated with an immunosuppressant. Lamivudine was provided to maintain virological suppression for HBV. She was referred to the Liver Clinic of Chang Gung Memorial Hospital in January 2004 due to elevated HBV DNA levels (31.2 × 106 copies/mL). She denied major systemic diseases other than chronic hepatitis B and renal disease. No documented hereditary diseases or psychological disorders in her family were noted. She had an average socioeconomic status. On physical examination, she appeared normal with no icteric sclera, no hepatosplenomegaly, no spider nevi, and no caput medusae. She was positive for HBsAg, negative for HBV e antigen (HBeAg), and positive for anti-HBe antibody. No clinical evidence of liver cirrhosis was noted. Genotypic analysis revealed genotype B, precore stop codon G1896A mutation (+), basal core promoter mutation (−), and rtM204V/rtL180M mutation (+). She was switched to adefovir monotherapy and HBV DNA declined rapidly (Fig. , lower panel). HBV DNA became undetectable in August 2007. She stopped antiviral treatment in February 2008 against advice. However, relapse of viremia (29.3 × 106 copies/mL) developed and she was treated with lamivudine again for no detectable genotypic resistance (insurance coverage policy), but switched to adefovir shortly afterwards because of emergence of rtM204V/rtL180M mutants accompanied by a mild hepatitis flare: alanine transaminase (ALT) 49 U/L. From then on, maintained suppression of HBV DNA was achieved. HBV DNA was undetectable since March 2010. The flares in 2004 and late 2008 were considered flares of hepatitis B because of the accompanied elevations of HBV DNA levels with normalization of ALT after suppression of HBV DNA.
Our patient suffered from graft rejection after renal transplantation and was treated with immunosuppressant drugs, including tacrolimus (3 mg/day), mycophenolate mofetil (500 mg twice a day), and prednisolone (10 mg/day). Her creatinine levels were between 3 and 4 mg/dL initially, but gradually elevated to 10 mg/dL despite increasing dosage of immunosuppressants. In January 2010, obstruction of graft ureter was found and hemodialysis resumed. Immunosuppressants were withdrawn and an episode of hepatitis flare occurred with ALT elevation to 251 U/L. After normalization of ALT, the renal graft was removed by operation. No HBV DNA elevation was detected before and during the flare. Throughout the flare, HBV DNA was suppressed to less than 104 copies/mL by adefovir. No known hepatotoxic drug was in use during this period. Anti-hepatitis C virus (HCV) antibody was positive since January 2008 but HCV RNA was negative throughout the clinical course. IgM anti-hepatitis A virus antibody, anti-hepatitis D virus (HDV) antibody, and HDV RNA were all tested negative. Subsequently, HEV RNA was found to be positive by reverse transcription-polymerase chain reaction (RT-PCR) and Southern blot analysis (Fig. , upper panel). Sequence analysis revealed genotype 3. Positive HEV RNA could be traced back to January 2005 but before that it was negative. Strikingly, seroclearance of HBsAg occurred in July 2010. Before this flare, the quantitative level of HBsAg was 25,000 IU/mL. It remained negative thereafter and adefovir was stopped in January 2014 with no subsequent virological relapse. Another episode of ALT elevation (to 73 U/L) was found during October to November 2014 with no positive hepatitis A to D markers. HEV RNA continued to be positive (final check was performed in January 2016). IgG anti-HEV was positive. Ribavirin was not given because of the low hemoglobin level in this patient who received hemodialysis. Anti-HBs antibody was negative throughout the course.


The patient was a woman aged 30 years and 2 months at the initial consultation. She visited the hospital with a chief complaint of severe pain in her maxillary and mandibular front teeth and a spaced dental arch. Her face was bilaterally symmetric, and she had a convex facial profile (). The anterior occlusal relationship included an overjet of 2 mm and an overbite of 4 mm; the molar occlusal relationship was bilateral Angle Class I, and the arch length discrepancy was +2 mm for both the maxilla and mandible. The lateral dentition had relatively good occlusion, but the bilateral maxillary central incisors showed mesial rotation, and her previous dentist had joined the mandibular front teeth with resin, presumably to prevent tooth mobility (Figures and ). Cephalometric analysis showed the following: ANB, 6; FMA, 30; U1-SN, 106; and IMPA, 99 ( and ). Therefore, the patient's facial type demonstrated a mesofacial pattern, and she was diagnosed orthodontically with an Angle Class I spaced dental arch.
The radiographic findings indicated vertical bone resorption in the mesial portions of the right maxillary and mandibular first molars, and the maxillary and mandibular front teeth showed high-grade bone resorption (Figures and ). On the periodontal disease chart, there were swelling of the gingiva in the same location and a periodontal pocket exceeding 4 mm. Bleeding on probing was observed (). The front teeth of the lower jaw had been joined with resin at another hospital to prevent tooth mobility. There was also moderate loss of the mesial interdental papilla in the gingival recession area of the bilateral maxillary lateral incisors (Figures and ). Dental findings showed a reduction in the mesial bone level; therefore, the patient was diagnosed as Class III according to Miller's classification of gingival recession []. In this case, given that periodontal lesions were found in the maxillary and mandibular teeth and molar areas, the patient was diagnosed with malocclusion associated with extensive moderate chronic periodontitis. Further, when we examined night-time parafunction using a BC [, ], strong functional contact was noted on the marginal ridges on the mesial side of the bilateral maxillary central incisors and the incisal edges of the bilateral lateral incisors, as well as the right canine, first premolar, and first molar (). These locations generally correlated with the locations of the patient's symptoms of periodontal disease according to the periodontal disease chart (). The dental findings indicated widening of the periodontal space in the lateral dentition, suggesting that the condition may have been associated with occlusal trauma. Written informed consent was obtained from the subject for publication of this case report and the accompanying photographs, figures, and data.
Based on the above findings, the patient was diagnosed with occlusal trauma and an Angle Class I spaced dental arch associated with extensive moderate chronic periodontitis. The treatment objectives were resolution of the discrepancy, establishing appropriate anterior guidance by capturing the correct tooth axis inclinations for the maxillary and mandibular front teeth, and attenuation of the occlusal trauma. If there were stabilization of functional occlusion after use of a retainer and no progression of periodontal disease, we planned to perform palatal gingival grafting to the tooth cervix of the bilateral maxillary lateral incisors.
A periodontal disease specialist treated the periodontal tissue before orthodontic treatment was commenced. We made the patient aware of the importance of her oral environment and explained the importance of being motivated for the ongoing oral management needed. Approximately 3 months later, there was improvement in the pocket depth, and the bleeding on probing and gingival swelling had resolved, indicating improvement of the periodontal disease (). Given that the patient's awareness of the importance of maintaining her oral environment had also improved, we initiated active treatment.
For the active treatment, we used a Roth setup with a 0.022-inch slot bracket and started leveling using maxillary and mandibular 0.012-inch round nickel titanium wires. We then increased the wire size sequentially and were using a 016 × 022-inch stainless steel wire after 6 months. We then attached a hook between the maxillary and mandibular lateral incisors and canines and closed the gap using intermaxillary elastics to exert an extremely weak orthodontic force.
The BC showed strong functional contact with the right maxillary lateral dentition before starting active treatment, so construction of appropriate anterior guidance and molar spacing was considered for detailing. At the completion of active treatment, the patient started using a retainer after night-time parafunction was reassessed using the BC (). The active treatment lasted 1 year and 8 months (Figures –). A Begg-type retainer plate was used for both the mandible and maxilla. Two years after starting use of the retainers (Figures –), the BC assessment was performed again, and the periodontal disease was reexamined (Figures and ). After the state of occlusion and the periodontal tissue were checked, the patient underwent coronally advanced flap repositioning surgery with a connective tissue graft for root coverage of the labial side of the tooth cervix of the bilateral maxillary lateral incisors using palatal mucosal connective tissue ().
In a photograph of the oral cavity taken after orthodontic treatment, the maxillary and mandibular spacing had closed, and a continuous and appropriate overbite and overjet were acquired. The findings indicated acquisition of good lateral incisor interdigitation (Figures and ). Panoramic findings indicated good parallelism of the roots of the teeth (). Dental findings showed tooth root resorption of the left maxillary lateral incisors, but the lamina dura had become clearer. In addition, the widening of the right maxillary first molar periodontal space had disappeared, and bone regeneration was noted in the mesial area ().
The BC findings after completion of treatment indicated weakening of the strong functional contact that was present in the right maxillary lateral dentition and front teeth (Figures and ). In the cephalometric superimposition (), the mandible was slightly rotated clockwise, and the patient's profile was virtually unchanged. Dental findings showed slight elongation of the maxillary and mandibular molars, and the angles of the tooth axis inclinations of the maxillary front teeth had lessened (Figures and , ). After 2 years of using the retainer, when the BC assessment was performed again and periodontal disease was reexamined (Figures and –), there was no major change from that at the end of active treatment (Figures , , and and ). Therefore, the patient underwent coronally advanced flap repositioning surgery with a connective tissue graft for root coverage of the bilateral maxillary lateral incisors. Seventeen months after surgery, the patient had improved oral hygiene, had acquired esthetically good periodontal tissue, had stable functional occlusion, and was satisfied with the outcome ().


A 79-year-old woman with past medical history of stage IV non-small cell lung cancer (NSCLC), heart failure with preserved ejection fraction, and dyslipidemia presented to the emergency department with generalized weakness and fatigue. Patient was initiated on nivolumab 3 months prior to presentation as a second line treatment following failure of chemotherapy with carboplatin and pemetrexed, confirmed by progressive disease on PET/CT scan. Home medications included rosuvastatin, docusate sodium, and low-dose furosemide. Patient received nivolumab 240 mg every 2 weeks. Following her fourth dose, she started complaining of worsening generalized fatigue and progressive weakness. Upon outpatient evaluation, her creatinine was found to be elevated at 2.9 mg/dl from a normal baseline. Nivolumab and furosemide were held, and patient received intravenous fluid hydration in the clinic. A renal sonogram was unremarkable. Repeat blood work few days later showed improved renal function. However, the patient's functional status declined over the next few days limiting her out of bed activity. She was sent to the emergency department for further workup.
On admission, vital signs were within normal limits. Physical exam was unremarkable except for trace lower extremity edema bilaterally.
Initial blood work showed a sodium level of 137 meq/L, potassium of 2.4 meq/L, chloride of 116 meq/L, bicarbonate of 11 meq/L, BUN of 23 mg/dL, and creatinine of 1.67 mg/dL. Arterial PH was acidotic at 7.21 with a CO2 of 27 suggestive of nonanion gap metabolic acidosis with adequate respiratory compensation.
Urine analysis revealed few white blood cells and red blood cells but no casts. Urine studies demonstrated a urine PH of 6.5 and a urine anion gap of 22. The fractional excretion of sodium (FeNa) was calculated at 0.5%.
The clinical picture was suggestive of prerenal AKI (FeNa < 1%) and renal tubular acidosis (RTA). Gentle hydration with sodium bicarbonate drip was started, and the patient was given potassium supplementation.
On further investigation, the patient had a negative autoimmune workup except for an ANA of 1 : 320. SPEP, UPEP, free light chains, and hepatitis serology were negative. Thyroid function tests were within normal range.
The alkaline urine PH in the setting of a significantly low serum bicarbonate level suggested a distal-type RTA. After ruling out common etiologies of RTA, nivolumab was considered as the likely culprit for a drug-induced RTA.
On day 2 of hospitalization, repeat blood work revealed mild increase in serum bicarbonate to 13 meq/L and improved serum creatinine to 1.39 mg/dl. In the context of a suspected drug-induced RTA secondary to nivolumab irAE, the patient was started on dexamethasone 4 mg every 8 hrs and her fluid rate was increased to target administration of 3 mmol/kg/day of bicarbonate.
On day 4 of hospitalization, the serum bicarbonate increased to 19 meq/L and serum creatinine was back to baseline. Patient was transitioned to oral sodium bicarbonate and prednisone. Her functional status improved significantly, and she was discharged on day 6 of hospitalization. Her discharge labs revealed a sodium of 142 meq/L, potassium of 3.3 meq/L, chloride of 112 meq/L, bicarbonate of 21 meq/L, and creatinine at 0.95 mg/dL.
The patient was discharged home on oral bicarbonate and a prednisone taper.
Repeat labs 1 week after discharge were stable. Follow-up with nephrology and hematology was set up. However, the patient returned to the hospital with acute hypoxic respiratory failure due to massive pulmonary embolism secondary to heparin-induced thrombocytopenia and expired.


An 11-year-old Yemeni young girl presented with a history of recurrent urinary tract infections. Her past medical history was insignificant. Radiological investigations revealed that both kidneys are normal in size, position, and echogenicity, with bilateral renal fullness. Voiding cystourethrography was unremarkable, and follow-up ultrasound showed minimal fullness in the right renal pelvis.
At the age of 14 years old, she developed left flank pain along with a frontal headache. Ultrasound revealed a well-defined echogenic lesion measuring three centimeters at the lower pole of the left kidney, demonstrating mild vascularity, which was presumed to be angiomyolipoma. Further follow-up after three months revealed an increase in the size of the mass that measured around 3.22 × 3.8 cm with the same degree of vascularity ().
A subsequent computed tomography (CT) scan showed an enhancing mass, measuring 4 × 5 cm, arising from the mid- and lower-left renal pelvis. No macroscopic intralesional fat was identified with no invasion of the renal vessels or enlarged lymph nodes ().
By magnetic resonance imaging (MRI), we identified a solitary well-circumscribed left renal hilum mass that measured 5 × 3 × 5 cm. No vascular invasion was identified, and the mass showed avid enhancement in the arterial phase and minimal washout in the delay phase ().
The patient underwent laparoscopic radical nephrectomy with an uneventful recovery. On regular follow-up, the patient was found to have persistent right kidney hydronephrosis, along with recurrent urinary tract infections, chronic kidney disease (stage three) with an estimated GFR of 58 ml/min/1.73 m2, and stage 2 hypertension.
A pathology report revealed a well-defined tumor mass measuring 4 × 4 × 4 cm, located at the lower pole of the left kidney, brown, with foci of hemorrhage. No gross invasion of the renal capsule or perinephric fat was identified, and the adrenal glands were unremarkable ().
Microscopic examination revealed a well-defined tumor composed of round to polygonal cells with abundant granular eosinophilic cytoplasm and regular, uniform nuclei, arranged in nests, acini, and tubules. Foci of hemorrhage were noted, and rare mitotic figures were identified. There was no evidence of necrosis. The nonneoplastic renal parenchyma shows only glomerular congestion and focal dilatation of the renal calyces. Hale colloidal iron histochemical staining was negative in the tumor cells. The neoplastic cells were also negative for vimentin and CK7 immunohistochemical stains.


A 67-year-old female patient with a locally advanced distal rectal adenocarcinoma (cT3N+) underwent laparoscopic abdominoperineal resection after short-term radiotherapy. A vaginal resection or repair was not required for the patient as she did not have any intraoperative problems. The patient with the pathology test result of pT2N0 received adjuvant chemotherapy. No complication was observed in the third and sixth month controls; however, the perineal hernia was detected at the ninth month. The abdominal computed tomography (CT) imaging taken without valsalva maneuver revealed no pathological findings except perineal hernia (). The patient was, then, scheduled for follow-up, since she had no complaints. However, surgery was decided for the perineal hernia in the first postoperative year upon the growth of hernia and the restriction of daily activities due to the hernia.
The patient was placed on a Jackknife position. The perineal defect was revealed by dissecting the hernia vesicle through posterior approach. After the hernia content was reduced into the abdomen, the double-sided synthetic patch was placed over the defect and fixed to the levator ani muscle laterally, the vagina anteriorly, and the coccyx posteriorly with the 2/0 polyprolene sutures. The patient was discharged without any complication.
The patient had no complaints related to the perineal hernia during the follow-up using CT imaging (). The patient who was followed in the oncology clinic without problem was admitted to the emergency department with the complaint of prolapsed intestines from the vagina 12 months after the repair of the perineal hernia. During the examination, the small intestines were observed to be freely prolapsed from the vagina and several local ischemic changes were detected (). In the emergency laparotomy, the terminal ileum revealed a herniation out of the posterior vaginal wall of the 110 cm ileum segment from the 10th cm of caecum. The ischemic areas were observed to be developed locally in the ileum. Following the withdrawal of the small intestine into the abdomen, a functional side-by-side ileocolic anastomosis was performed by resecting the ischemic segment with the caecum. The formerly placed mesh material was explored and seen as intact (no folding or detachment) and well placed below the levator ani muscle. As the formerly placed mesh material was located below levator ani muscle level, it was not covering the posterior vaginal wall. Instead, the previous mesh was only anchored to vagina anteriorly below the levator level. The vaginal defect was reconstructed with interrupted sutures by using the 3/0 polydioxanone (). A new double-sided mesh material with antiadhesion barrier site facing the viscera was placed over the pelvic brim and fixed to the pubic bone anteriorly, the sacral promontory posteriorly, and the pelvic wall laterally by using the 2/0 polypropylene sutures. The patient was uneventfully discharged on the postoperative day 4; the wound sites were observed to be healed at three months, and no herniation finding was observed.


A 79-year-old man presented with a six-month history of numbness in his left upper limb. Left motor weakness developed suddenly, and the patient was admitted to our hospital. Neurological examination on admission revealed left hemiparesis with 2/5 in his upper limb and 3/5 in his lower limb and hypoesthesia in his left side from the neck to the foot. The deep tendon reflexes were increased in his left upper limb. Magnetic resonance imaging (MRI) showed an intramedullary tumor that was homogeneously enhanced with gadolinium at the C1 level in the spinal cord (Figure ). The tumor was also surrounded by a signal change that appeared isointense to the CSF and was clearly differentiated from the spinal cord (Figure ). The signal change seemed to represent a presyrinx state.
The patient underwent removal of the tumor under general anesthesia. Laminectomy of the C1 and C2 levels was performed, combined with a suboccipital craniotomy. The tumor was located intramedullary, and the border between the tumor and the neural tissue was unclear. It also invaded into the dorsal root of the C1, and the root was removed with the tumor.
Postoperatively, his motor function recovered to the level of 3/5 in his upper limb and 4/5 in his lower limb. Histological examination of the tumor revealed a diffuse proliferation of large atypical lymphocytes with B cell markers (Figure ). Based on these findings, the tumor was diagnosed as diffuse large B cell lymphoma. A subsequent MRI of the other regions, a bone marrow puncture, and an 18F-fluorodeoxy-glucose positron emission tomography (18FDG-PET) of the whole body showed no abnormalities (Figure ). The patient underwent high-dose methotrexate (MTX)-based chemotherapy and localized external beam radiation therapy (40Gy) for the level of C1 in the cervical cord. An MRI performed three months postoperatively showed total removal of the tumor and complete disappearance of the peritumoral signal abnormality (Figure ).
He has been alive for more than two years since the symptom onset, and without any evidence of recurrence.
Written informed consent was obtained from the patient and his next of kin prior to any procedures.


A 50-year-old man was admitted to the emergency room after a car crash. At the time of admission, the patient was conscious and hemodynamically stable. Therefore, a computer tomography (CT) scan was performed for further diagnostics and revealed a craniocerebral injury that involved a fracture of the skull with concomitant soft tissue lesions and subarachnoidal bleeding. In addition, the patient suffered blunt thoracic trauma with hemopneumothorax due to rib fractures, which was treated with a chest tube. No obvious abdominal pathology was seen. The patient was transferred to the operating theatre for surgical revision of the soft tissue lesions. During general anesthesia, a femoral venous catheter was inserted without any procedural complications. Postoperatively, the patient was monitored in the intensive care unit. At our institution, a repeated ultrasound of the abdomen is performed six hours after the trauma to rule out free abdominal liquid or lesions of the parenchymatous organs, because it has been shown that repeated ultrasound examinations decrease the rate of false negative results and increase the sensitivity to detect intraabdominal liquid [, ]. In our patient, an unclear hepatic gas formation in the liver veins was seen but still no free liquid. For further differentiation and localization of the gas formation, a contrast-enhanced CT scan of the abdomen was performed. Here, the gas formation was localized in the left hepatic vein (Fig. a/b, black arrow). In addition, the central venous catheter in the inferior vena cava was visible without hematoma or gas formation (Fig. b, white arrow), and no additional abdominal pathology was noted.
There was no specific treatment administered for the hepatic venous gas formation. The further course of the patient was uneventful regarding the gas formation in the liver, and an additional ultrasound to check for further gas formation two days later revealed no more gas in the liver. No changes in liver function or liver enzymes were seen.


A 7-year-old previously healthy girl, with a history of persistent dry cough one day before due to a rhinopharyngitis, was brought to the emergency department of maternal and pediatric hospital of Hassan II university hospital, with face, neck and chest swelling responsible for a headache, sore throat and neck pain.
On initial presentation, the girl was slightly short of breath with good arterial saturation (spO2 98%), her blood pressure and heart rate were normal. She had face, neck and chest swelling with crepitation during palpation. During cardiac auscultation there were, also, reduced heart sounds. We note that there were no inflammation signs (erythema and local heat).
The chest X-ray () showed subcutaneous emphysema with pneumomediastinum. The computed tomography (CT) scan () demonstrated, in addition to the findings in chest X-ray, a pneumopericardium without evidence of the origin of this air leak.
Laboratory tests: arterial blood gas: pH: 7.46, paO2 95 mmHg, paCO2 35 mmHg, bicarbonate 24.2 mmol/L. Biochemistry: C reactive protein 14 mg/L; normal renal function tests and electrolyte levels. Hematology: hemoglobin 11.5 g/dL; white blood cell count 12.7 × 109 cells/L; platelet count 245 × 109 cells/L. The bronchoscopy, which was performed one day later, was normal.
The patient was admitted to pediatric critical care and received noninvasive monitoring, analgesia, oxygen (5 L/min), and omeprazole as a prophylaxis for gastric ulcer.
Over of the next few days she improved, subcutaneous emphysema resolved, and she was discharged on the third day.


A 10-year-old boy was admitted for thoracic trauma following a pedestrian accident. At admission, the patient was conscious and hemodynamically stable, with mild dyspnea. The clinical examination showed some straight small abrasions over the right side of the chest; no other external injuries were apparent. The right hemithorax was dull to percussion and the vesicular murmur was abolished. The rest of the examination was unremarkable.
The thoracic X-ray showed an opacity of the right pulmonary field, evocative of an effusion of great abundance, without any fracture of the ribs. The biological balance revealed anemia at 8 g/dl. The diagnosis of haemothorax was made. Drainage of the right hemithorax was performed and allowed the extraction of 200 cc of blood. Forty-eight hours later, no clinical improvement was observed, with persistence of dyspnea. Thoracic and abdominal computed tomographic scan (CT scan) was requested and showed herniation of the right lobe of the liver along with bowel loops into the right hemithorax (). A rupture of the right diaphragmatic dome was confirmed.
The surgical treatment was performed by a right subcostal laparotomy. Exploration found an intrathoracic ascent of the right lobe of the liver, transverse colon, and omentum. Anterior diaphragmatic disinsertion of about 15 cm was found with an L-shaped recess extending about 5 cm posteriorly (). The herniated organs were reintroduced into the abdominal cavity. A pleural drainage and a primary repair of the diaphragmatic defect with nonabsorbable suture were made ().
Postoperative recovery was uneventful and the patient was discharged on day 10. The patient was followed up for 12 months without any symptoms.


A 58-year-old female presented to the emergency department (ED) with severe occipital headache associated with right-sided neck pain and increased sleepiness of five days' duration. Her headache was reportedly 10/10 in intensity and was associated with nausea, drowsiness, and dizziness. She denied having a change in vision, hearing, or history of head or neck trauma. Her past medical history was significant for hypertension, atrial fibrillation, and dyslipidemia. Her medications consisted of Xarelto and she was treated with ablation in the past. Vital signs in ED showed a blood pressure (BP) of 206/98 mmHg, a temperature of 98°F, heart rate of 59 bpm, and a respiratory rate of 14/min. The examination was pertinent for right eye ptosis and right pupil constriction. She recalled that her symptoms started about a week ago when she received lidocaine injection prior to pulpotomy for her upper #5 tooth. Immediately after the procedure, she experienced a severe headache, profuse sweating, and shortness of breath. The dentist, therefore, was unable to complete the procedure and she was asked to follow-up after the symptoms resolved. After few days, she developed right-sided facial swelling and presented back to the ED where she underwent incision and drainage for a right-sided dental abscess. Antibiotic therapy was subsequently started. Two days later, she returned to the ED with above-mentioned chief complaints. Computed tomography (CT) head showed no acute changes. Magnetic resonance imaging (MRI) brain showed right distal ICA dissection with mild inflammatory type signal changes surrounding the carotid artery (Figure ).
Computed tomography angiography (CTA) scan of the neck confirmed a dissection of the right internal carotid artery (ICA) at the C1-C2 level associated with infiltrative changes within the right carotid space (Figure ).
She was started on intravenous (IV) heparin. A blood pressure reduction goal of 25% per day was decided. IV heparin was continued for three days and later the anticoagulation was switched to Xarelto. During the course of hospitalization, her symptoms gradually improved. She was discharged home on Xarelto after 12 days of hospital stay and was encouraged to follow-up with vascular surgery, cardiology, and neurology on an outpatient basis.


A 79- year-old Hispanic woman presented with a one-week history of painful rash on her palms and soles. She reported no recent viral illness, travel, previous rashes, joint pains, new lotion, soap or fabric use. She had metastatic colon cancer previously treated with radiation and hemicolectomy three years prior. She currently completed her second week of Capecitabine therapy (1,250mg/m2 twice a day). She had no other contributory medical history or family history and was on no other medications. She describes never having a similar rash in the past.
On physical exam, she was afebrile, normotensive and appeared chronically ill. Her palms and soles were tender to touch, erythematous, and diffusely edematous with desquamation over the fingertips and toes (
 and
). Biochemical testing including complete metabolic panel and complete blood count were normal. Given her recently administered chemotherapy, it was suspected that the patients’ palmoplantar rash was a result of a medication side-effect from Capecitabine. Other less likely diagnoses were contact dermatitis, tinea pedia/mannum, or dyshidrotic dermatitis.
After Capecitabine was stopped, she had mild clinical improvement over the next two days. She was discharged with resumption of Capecitabine at a lower dose (565 mg/m2 twice daily) and had complete clinical resolution of her rash 3 week later.


A 42 years old male teacher referred to our hospital complaining of the 15-day history of progressive back pain radiating to both thighs. He subsequently developed weakness affecting both lower limbs, but mainly on the left side, with urinary incontinence and constipation. It was associated with low-grade fever, loss of appetite and ended with the inability to walk.
On examination, he looked pale and uncomfortable. He had a pulse rate of 95 beats per minute, blood pressure 110/70, temperature 38.3 °C, and a respiratory rate of 19 cycles per minute.
Inability to walk, severe tenderness in the back around the midline and paraspinal region, and severe limitation of spinal motion.
Sensation: paresthesia below the inguinal ligaments in both lower limbs.
Left side:
grade 2 knee extension; grade 1 knee flexion; grade 1 ankle dorsiflexion; grade 1 ankle plantar flexion.
Right side:
grade 3 knee extension and flexion; grade 2 ankle plantar flexion and dorsiflexion.
diminished knee and ankle jerk; equivocal Babiniski sign.
urinary incontinence; constipation.
Hemoglobin 11.1 g/dL, white blood cell count 11 × 109 with lymphocytosis (60%), essential sedimentation rate 95 mm/hour, C-reactive protein 90, random blood sugar 114 g/dL, blood urea 78 mg/dL, and serum creatinine 1.3.
Plain X-ray of the lumbosacral spine in both Antero-posterior and lateral view revealed no abnormality. MRI of lumbosacral spine in both T1, T2, and STIR showed a localized collection of pus in the canal compressing the dural sac at L3, L4 and L5 levels with a small collection of pus at L2–L3 level. Also, there were multiple pockets of pus in the paraspinal muscles (–).


A 55-year-old male patient came to the emergency room (ER) with complaints of difficulty in passing urine for the past eight hours. He also gave history of chronic constipation on and off for the past ten years. A non-contrast computed tomography scan of the kidneys, ureter and bladder (CT-KUB) was performed on a multi-detector scanner which revealed a large well-defined low attenuation presacral lesion measuring 13 x 11 cm, which was displacing the rectum anteriorly and urinary bladder superiorly with compression over its base, resulting in pressure effects over these viscera (Figure ).
Subsequently, contrast enhanced magnetic resonance imaging (MRI) of the abdomen and pelvis with additional diffusion weighted sequences was performed on a 1.5-Tesla scanner for further characterization of the lesion. The scan revealed a well-defined mass in the presacral space returning hypointense T1 and hyperintense T2 signals with few foci of T2 hypointensities (Figure ). No communication of the lesion with the spinal canal or bony involvement was noted.
There was no post-contrast enhancement or enhancing solid nodule within the lesion (Figure ).
The lesion was showing diffusion restriction, appearing hyperintense on diffusion weighted imaging (DWI) and hypointense on the corresponding apparent diffusion coefficient (ADC) map. There was an additional rare feature which we noticed in the diffusion weighted sequences in which differential restriction was seen in its dependent contents (Figure ).
These MRI features were pathognomonic of an epidermoid cyst. Features did not favor a pelvic abscess, which also shows diffusion restriction on MRI, because the surrounding fat was clear, the adjacent viscera were normal in appearance, and there was no thickened, irregular ring-enhancement of the cyst wall or heterogenous signals within it in any of the sequences. There was also a lack of clinical history of fever, systemic illness, or previous surgery.
The patient subsequently underwent an exploratory laparotomy and complete surgical excision of the cyst with preservation of the adjacent structures. On gross pathological examination, the cyst was filled with keratinous material. Histological sections examined revealed a benign cystic lesion lined by stratified squamous epithelium with keratinization on the luminal surface (Figure ).
The underlying wall did not show any skin appendages or other teratomatous elements. There was no evidence of malignancy. Overall, the features were in accordance with those of a typical epidermoid cyst. No pus cells were noted to suggest secondary infection.


A 68-year-old woman with hypertension and a history of a uterine myoma was admitted complaining of severe back pain and pain in both legs for 12 days. She exhibited no lower limb muscle weakness or dysuria.
On physical examination, she was febrile (temperature of 38 °C). There was local tenderness over the lower lumbar region with no signs of skin infection. No lower limb muscle weakness was observed, and there were no urinary symptoms. Hence, she had a score of 7 on the Japanese Orthopaedic Association scale. MRI revealed a mass in the L3/4 left facet, epidural space, and paravertebral muscles (Fig. ). The erythrocyte sedimentation rate (ESR) was 40 mm/h, C-reactive protein levels (CRP) was 20.97 mg/dL, leukocytosis was 27,710/μL, with 91% neutrophils. Group B beta-hemolytic streptococci (Streptococcus agalactiae) were detected in both blood and urine. With a diagnosis of sepsis due to urinary tract infection. We prescribed ampicillin (2 g × 4/day). We did not consider surgery because neither lower limb muscle weakness nor dysuria was present. The signs of inflammation decreased, and febrile symptoms diminished.
One week after starting antibiotic treatment, a gadolinium-enhanced MRI scan of the lower lumbar region revealed an epidural mass (a finding consistent with an epidural abscess), extending from T12 to L4 on the posterior canal and compressing the spinal cord. The mass had also spread to the iliopsoas and paraspinal muscles (Fig. ). At this time, the patient also exhibited lower limb muscle weakness. The manual muscle test showed that the bilateral iliopsoas, quadriceps, and tibialis anterior muscles were grade 3, and the extensor hallucis longus was grade 2. The patient also exhibited bilateral lateral leg sensory disturbance (4/10) and urinary retention. Her saddle sensory ability remained.
Surgery was performed via posterior approach under general anaesthesia. Left-side hemilaminectomy was undertaken from T12 to L4 along with incision of the right intertransverse ligament between L3 and L4. A white abscess was observed in the left L3/4 paraspinal muscles, epidural space between T12 and L4, and the iliopsoas muscles between the right L1-L5 (Fig. ). The L3/4 facet joint capsule was torn, from which tissue was obtained for pathology examination. Microscopic examination revealed leukocytes in the abscess, and tissue specimen showed streptococcal infection (Fig. ).
Antibiotic administration continued until the abscess disappeared (at 47 days postoperatively). CRP values had dropped to 0.02 mg/dL, and white blood cells count was 5910/μL (normal). Postoperatively, both feet had regained muscular strength (manual muscle test grade 5), and her dysuria disappeared. She did not develop arachnoiditis post-operatively. The Japanese Orthopaedic Association score improved to 27/29 points. Dynamic plain radiographic imaging showed no instability of the lumbar spine 15 months postoperatively (Fig. ), and MRI showed no evidence of the abscess (Fig. ).


A 41-year-old man presented with concerns of headache, diplopia, and left eye strabismus lasting two months. There was no history of nausea, vomiting, and seizure. He had no other medical conditions such as hypertension, diabetes, cardiovascular disease or stroke. A neurological examination showed left eye sixth cranial nerve palsy. There was no sensory or motor deficit in his upper and lower limbs. A magnetic resonance image (MRI) of the brain showed a large heterogeneous, expansile lesion measuring 51 mm x 50 mm, involving the central skull-base and clivus with the erosion of adjacent bones, partially encasing the bilateral internal carotid artery (ICA) suggestive of chordoma (Figure ).
Trans-sphenoidal decompression of the tumor was done by a team of neurosurgeons and head-and-neck surgeons. Biopsy from the lesion showed proliferation of the plasma cells with moderately abundant cytoplasm and was reported as plasma cell neoplasm (Figure ).
Immunohistochemistry analysis showed CD-138 positive, CD-38 positive, CD-56 positive, and CD-45 negative cells (Figure ).
The skeletal survey, bone marrow biopsy, serum protein immunoelectrophoresis (SPEP), serum quantitative immunoglobulins levels, serum lactate dehydrogenase, calcium, albumin, renal function test, and beta-2 microglobulin levels were within normal limits. Bence Jones protein in the 24-hour urine sample was absent. The positron emission tomography-computed tomography (PET-CT) scan showed a single 2-(18F) fluoro-D-glucose (FDG) avid lesion at the base of the skull as described in the MRI of the brain. He was treated with radical radiotherapy with intensity modulated radiotherapy technique to a dose of 50 Gy in 25 fractions over a five-week duration by 6-megavolt (MV) x-rays on a modern linear accelerator (Figure ).
After radiotherapy, he got complete symptomatic relief from headache and diplopia. A second MRI scan to assess the response following three months of radiotherapy showed complete remission of the lesion (Figure ).
One year after radiotherapy, investigations including PET-CT scan, MRI scan, serum quantitative immunoglobulins level, SPEP, and beta-2 microglobulin level were within normal limits with no signs of the recurrence.


An 18-year-old man with no past medical history presented to the emergency department with concerns of bloody diarrhea, abdominal cramps, and nausea for the prior week. The patient was a visitor from the United Kingdom (UK). He denies any sick contacts, fever or rash. He was recently admitted to a hospital in the UK for similar complaints and was treated with two weeks of prednisone, but no diagnosis was established. He remained symptom-free for a month. He was a non-smoker, occasional alcohol user and denied illicit drug abuse. His family history was unremarkable.
On admission, he was afebrile, his blood pressure was 110/60 mm-Hg, and his pulse rate was 100 beats per minute. His abdominal examination revealed a non-distended abdomen that was diffusely tender on palpation.
Initial lab work showed a hemoglobin of 9.5 g/dL with a mean corpuscular volume 105 fl and reticulocyte count of 17%. His white blood cell count was 22x103 μL. His total bilirubin was 2.4 mg/dL with a direct bilirubin of 0.7 mg/dL, alanine aminotransferase of 133 μ/L, aspartate aminotransferase 83 μ/L and alkaline phosphatase 133 μ/L. His haptoglobin was 10 mg/dl.
Further laboratory studies included hepatitis panel, the results of which were negative. His vitamin B-12 and folic acid levels were within normal limits. His peripheral smear showed microspherocytes and hemolysis by a warm antibody, noted in Figure .
The results of the direct Coombs test were positive, and the results of the paroxysmal nocturnal hemoglobinuria testing were negative. The patient was diagnosed with AIHA and started on hydrocortisone (80 mg every eight hours). A complete stool infectious panel was ordered, and it was negative for Shigella, Salmonella, and E. Coli. Moreover, the result of his Clostridium difficile [PME4] toxin assay was negative and later confirmed by polymerase chain reaction. His computed tomography scan of the abdomen and pelvis showed mild wall thickening and featureless appearance of the rectosigmoid colon as noted in Figure . A colonoscopy showed mild to moderate pancolitis from the rectum to the ileocecal valve, and biopsies showed cryptitis, crypt abscesses, and crypt distortion consistent with UC, as noted in Figure .
The patient was started on a mesalamine 1.2-gram delayed-release tablet once daily. Magnetic resonance cholangiopancreatography (MRCP) showed cholangitis with the irregular beaded appearance of intrahepatic and extrahepatic bile ducts as noted in Figure .
The patient tested positive for anti-smooth muscle antibody and anti-neutrophil cytoplasmic antibody. An endoscopic retrograde cholangiopancreatogram (ERCP) was performed, and biopsies were taken from the ducts with chronic inflammation and no evidence of malignancy. A biopsy of the liver was performed to rule out autoimmune hepatitis and overlap syndrome. The patient improved clinically. His hemoglobin level remained stable. He was discharged to follow-up with a gastroenterologist in the UK.


A 14-year-old boy presented to the otorhinolaryngology outpatient department with a history of gradually progressive swelling in the right side of the cheek for three months and pain on opening the mouth for one week associated with on-and-off mild fever. The patient denied any constitutional symptoms and had no cough during the past six months. The patient had similar episodes twice in the past one year, lasting for 10 days, which subsided spontaneously. There was no significant family history or contact history of TB. The patient was averagely built, moderately nourished, and afebrile at the time of examination.
Local examination revealed a firm, tender, non-fluctuant, non-pulsatile, diffuse, right-sided swelling of the submandibular and parotid region with normal overlying skin (Figure ).
On an intraoral examination, the teeth were in good condition and there was no intraoral swelling or ulcer. Multiple, firm, 1.0 X 1.5 cm, enlarged, non-tender lymph nodes (the largest node measuring 2 X 2 cm) were palpable in the bilateral submandibular region. Respiratory system, cardiovascular system, and abdominal system examinations were normal. An ultrasound neck showed a diffusely enlarged right parotid gland with loss of normal echotexture and an enlarged submandibular gland. A provisional diagnosis of parotitis was made based on clinical history, regional swelling, and ultrasound features. The patient was started on intravenous antibiotics for seven days, but the patient did not improve well.
All hematological (Hb 12 gm/dl, total leukocyte counts - 6100 cells/cubic mm, differential leukocyte count: neutrophils - 74%, lymphocytes - 22%, eosinophils - 3%, and monocytes - 1%) and biochemical investigations (blood sugar - 92 mg/dL, blood urea - 10 mg/dL ) were within normal reference ranges except for increased erythrocyte sedimentation rate (ESR) of 60 mm in the first hour. The enzyme-linked immunosorbent assay (ELISA) test for the human immunodeficiency virus (HIV) and the surface antigen of the hepatitis B virus (HBsAg) were negative. The chest x-ray was normal.
Fine needle aspiration cytology (FNAC) was performed on the swelling in view of the poor response to systemic antibiotics on day 10 of admission. However, FNAC was non-diagnostic. Since his symptoms did not improve, a contrast-enhanced computed tomography (CECT) of the head and neck with a 2-mm slice width was performed, which revealed an osteolytic lesion of the mandible with extension into the adjacent part of the body of the mandible. There was associated soft tissue swelling showing central hypodense areas with rim enhancement (Figure ).
The CECT findings were suggestive of lytic lesions of the mandible with a surrounding soft tissue abscess along with submandibular lymphadenopathy. The image morphology of the lesion was consistent with osteomyelitis. The Mantoux tuberculin skin test using five units of purified protein derivative was done keeping the suspicion of TB, but it was negative (induration size – 2x2 mm). So, an intraoral incisional biopsy of the tissue was taken behind the right second molar tooth (Figure ).
A histopathology examination of the intraoral biopsy specimen revealed fibro-collagenous tissue with multiple epithelioid cell granulomas admixed with numerous plasma cells and occasional Langhans Giant cells (Figure ).
Acid-fast staining for acid-fast bacilli was negative. These findings were strongly suggestive of TB mandible. The sputum examination was negative. Based on the above radiological and histological findings, a diagnosis of primary tuberculous osteomyelitis of the mandible was made. The patient was started on ATT for six months, and at the end of the six months, there was complete resolution of the swelling. Orthopantomogram (OPG) imaging was done after the completion of ATT, which was normal. If the OPG showed an abnormality, it warranted a repeat CECT of the head and neck to find out if any sequestra had formed within the mandible.


The 28-year-old woman complained intermittently lower abdominal pain combined with cold sweating and relieved after vomiting for 3 years. The painful sensation was description that lower abdominal tenderness without rebounding pain. There was no difficulty in urination. She had single sexual partner and no history of pregnancy. She didn’t take any oral contraceptives and regular menstruation. There was no dysmenorrhea and menorrhagia found. Her physical examination didn’t find obvious abdominal mass lesion and previous surgical scar. The labor test revealed normal result expect for mild elevated aspartate aminotransferase and alanine aminotransferase (AST/ALT: 128/132 U/L). Her abdominal ultrasound revealed a well-capsulized cystic lesion about 6 cm in diameter located at right ovary and mild fluid accumulated at pelvic region. The contrast abdominal CT also revealed a tumor lesions (2.3 × 3 × 2.1 cm in size) located at fundus of gallbladder with adjacent wall thickening and one small contrast decreased lesion located at segment 4 of liver (Fig. a–d). Initially ovary cancer with gallbladder and liver metastasis was impressed. But serum tumor marker was in normal range (AFP: 2.27 U/mL, CA-125: 27.51 U/mL, CEA: < 0.3 U/mL). She underwent laparoscopic cholecystectomy and wedge resection of liver nodule, segment 4 and debulking operation with salpingo-oophorectomy bilateral, biopsy of the left ovary, and supra-colic omentectomy. During the operative period, smooth shape gallbladder and right ovary were seen and resected (Fig. a–e). There was no obvious irregular surface performed on the resected gallbladder and ovary. There were 2 nodules located at upper abdominal wall. We did nodules resection and sent to frozen pathologic examination. The pathologic report confirmed it was abdominal carcinomatosis. The gallbladder and right ovary were explored and there were fixed, dense, adenomatosis hypertrophy seen inside. The finally pathologic report revealed that the gallbladder was the original source by two pathologists. The accurate diagnosis was adenocarcinoma of gallbladder with liver, abdominal wall and right ovary invasion. Now she starts to undergo following chemotherapy with Paclitaxel and Cisplatin. Unfortunately, after followed up for 2 years, she was expired due to carcinomatosis.


A 27-year-old G3P22002 female presented at 19 weeks and 1 day of gestation by last menstrual period for scheduled prenatal visit. Ultrasound study was performed and revealed a single fetus and adequate amniotic fluid with limited fetal measurements consistent with estimated gestational age of 17 weeks, that is, an age 2 weeks less than the estimated gestational age. Diffuse subcutaneous edema was seen, with possible multiloculated nuchal cystic hygroma. Fetal heart tones could not be detected and a three-vessel umbilical cord could not be documented.
The maternal history included 2 previous uncomplicated term vaginal births of children with no anomalies. Age at menarche was 13 years. The mother is a nonsmoker and she was taking supplemental vitamins. She reported no alcohol, caffeine, or illicit drug intake. She is sexually active with a single partner. Most recent cervical pap smear was approximately 4 years ago, with normal results. Prior to this pregnancy, her periods were regular and heavy. Her IgG for rubella was positive approximately at 8 weeks' gestation. The patient denied any significant family history for congenital conditions.
Because of fetal demise, labor was induced with misoprostol and resulted in a spontaneous vaginal delivery of a stillborn female fetus followed by spontaneous delivery of the placenta. The fetus and placenta were transferred to our institution for autopsy and placental examination.
At autopsy, a slightly growth-restricted previable, immature female fetus with grade 1-2 maceration and moderate-to-marked hydrops was examined. The posterior nuchal fluid accumulation was prominent. The ears were low-set and posteriorly rotated. The fingers were short bilaterally (), and the right foot showed absence of the second and third digits (). The pulmonary artery was slightly narrow, with no other cardiovascular findings. Microscopic examination showed desquamated epidermis and nuchal edema. Evaluation of the organs showed predominantly marked autolysis consistent with retained stillbirth.
Placental examination revealed membrane laminar necrosis, consistent with acute hypoxic injury. The undersurface of the chorionic plate showed focal pseudovillous papilliform cytotrophoblastic proliferation (). This was highlighted by double immunohistochemical stain for E-cadherin/CD34 (). The chorionic villi were large and cellular, with convoluted outlines and presence of both trophoblastic pseudoinclusions (), secondary to villous scalloping, and focal robust ferrugination of the basal lamina (), highlighted by iron stain (). Rare clusters of villous cytotrophoblasts were seen, with normal villous vascularity (), highlighted by E-cadherin/CD34 immunostain (). The number of cell islands was increased. The chorion laeve showed an uneven distribution of perpendicularly oriented and elongated clusters of sclerotic chorionic villi ().
G-banded karyotyping of placental tissue revealed a 48,XXX,+18 karyotype (). Due to maceration, karyotype of fetal tissue was not obtained. Fluorescence in situ hybridization testing for chromosomes X and 18 was performed on relatively well-preserved thymic tissue and highlighted double trisomy of these chromosomes (), which rules out an isolated placental mosaicism.


A 41-year-old woman was hospitalized because of 1 week history of worsening tachypnea and post-exercising chest congestion, and 2 days of severe pain in back. The patient had a medical history of hyperthyroidism diagnosed more than 10 years ago, as well as a medical history of right breast fibroma diagnosed 3 years ago, for which she received a minimally invasive surgical operation, and her post-operative condition had been stable. Two weeks ago, she visited a dentist for gingivitis, which was successfully controlled with antibiotics and drainage therapies.
Her primary diagnosis of admission to hospital is valvular disease. And at initial presentation, the patient had a body temperature of 36.6 °C, blood pressure of 132/82 mmHg, and pulse of 75 beats per min. Upon physical examination, diastolic murmurs were heard along the left sternal border, loudest in the third or fourth left intercostal space. Laboratory tests revealed a normocytic normochromic anemia, with haemoglobin at 95 g/L. Serum rheumatoid factor (RF) was elevated (207.0 IU/mL) when admission. Low serum albumin level (29.1–32.9 g/L), low serum iron (5.4–6.1 µmol/L) and low serum cholinesterase level (3855–4029 U/L) were detected throughout the hospitalization.
Blood cultures were sampled after admission (aerobic and anaerobic bottles; two sets of cultures). In the meantime, ceftizoxime sodium of 3 g twice per day for 7 days as empiric antibiotic therapy was administrated to the patient until the operation. The two aerobic blood cultures became positive for Gram-negative bacilli after an incubation period of 74–80 h in the Biomerieux BacT/Alert 3D blood culturing system. The chest X-ray plain film showed cardiac image enlargement, obviously in left atrium, right ventricle and left ventricle, together with bilateral pulmonary congestion (Fig. a). Echocardiography examination showed mitral valve prolapse and multiple vegetations, and the largest one was about 14 mm. In addition, severe mitral regurgitation, and tricuspid valve prolapse, together with moderate regurgitation and pulmonary hypertension were also observed, indicating infectious endocarditis (Fig. b). At the same period, the computerized tomography (CT) scan of the brain was performed and showed mild ischemia at bilateral basal ganglia (Fig. c).
With the results of blood cultures and image examinations, the diagnosis of “infectious endocarditis, mitral insufficiency and tricuspid insufficiency” was made. And then, the patient received MVR, TVP and vegetation removal operation under general anesthesia on day 7 of admission. In order to control postoperative infection, meropenem of 1 g every 8 h were administrated to the patient for 10 days according to the susceptibility testing, and the increasing CRP level and elevated total white blood cell began to decrease to normal after 5 days of antibiotic treatments. And then the antibiotic administration was changed to ceftizoxime sodium of 3 g twice per day for 5 days until the abrupt cerebral hemorrhage occurred on the 15th day after operation. The coagulation test and the platelet aggregation function test were normal on admission. Warfarin of 3 mg per day was taken for anticoagulation treatment since day 2 after operation, and the international normalized ratios (INRs) were 1.6–2.76. Notably, the platelet showed increase since day 7 (405–622 × 109/L) after operation together with the high platelet aggregation function (52.4%). Infectious markers and coagulative function indicators before and after the operation were listed in Table . Blood cultures kept negative since the antibiotic treatments. After aforementioned treatment, the patient did not have a fever, cough, dyspnea or chest pain, under a stable condition, except complaining about slight dizziness and headache infrequently.
On the early morning of day 23 of admission, 15 days after operation, a sudden loss of consciousness together with bilateral mydriasis occurred. At that time, the patient had a high blood pressure of 180/90 mmHg, heart rate of 69 beats per min, and breathing rate of 15 times per minute. Antihypertensive therapy, temporary pacemaker and tracheotomy auxiliary ventilation were used for symptomatic supportive therapy, and the patient’s condition tended to be stable. An urgent computerized tomography (CT) scan of the brain showed large high intensity areas at right frontal lobe, parietal lobe and temporal lobe that indicated spontaneous cerebral hemorrhage and broken into bilateral ventricles combined with hernia, together with subarachnoid hemorrhage (Fig. d). An urgent large craniectomy hematoma operation was performed on the day, and then the patient was transferred to the intensive care unit for observation. During the surgery, a neoplasm (1.1 cm × 1.0 cm × 0.7 cm) was found in the right temporal lobe, and pathologically diagnosed as an intravascular thrombus. After the urgent large craniectomy hematoma operation, the patient fell into a stupor. Necessary nursing and treatment were kept, but the patient remained in a coma. During the long-term mechanical ventilation of intensive care unit, the patient obtained the lung infection of Acinetobacter baumannii. After the infection was controlled, the patient was transferred to the neurology department for continued nutrition support therapy. Eventually, the patient was discharged after 2 months of treatment.


We present a case of an 80-year-old male patient with a traumatic laceration of his left pinky with intact extensor apparatus (Fig. ), which was first treated by the ER department. On the 5th posttraumatic day, the patient presented to our department with partial necrosis and exposed extensor tendons. With an intact 4th web space perforator, the patient was scheduled for operation with a distally based DMCA-4 flap. After thorough debridement, only a weak signal at the level of the 4th web space perforator remained, and therefore we included the 3rd web space perforator into our transposition flap with an additional soft tissue island extension (Fig. a, b). Elevation of this flap started from proximal to distal in a standard fashion. When reaching the most distal perforator of the 3rd web space, we prepared this perforator with keeping the deep transverse ligament intact. This provided enough pivotal range to mobilize and rotate the flap into the defect. The donor site defect was closed by full thickness skin coverage (Fig. ), and the wound was treated with cast immobilization for 3 weeks. The patient was satisfied with the result albeit a remaining flexion contracture of about 50 degrees (Fig. ) resistant to further occupational therapy. After 6 months, range of motion was limited to PIP 0/50/90 and of his DIP joint 0/0/35.


A 35-year-old Indian male presented with insidious onset left ear fullness and decreased hearing since six months followed by intermittent mucopurulent discharge from the left ear. The discharge later turned mucopurulent with foul odour. No associated vertigo, imbalance, tinnitus, facial asymmetry, altered sensorium, nausea, or vomiting was reported. There was no history of aural trauma, ear procedure, or surgery.
Otoscopy showed an opalescent lesion at the bony-cartilaginous junction of the left external auditory canal. The lesion was completely occluding the left EAC and obscuring the view of the tympanic membrane. On gentle probing, the lesion was firm, non tender, and non-bleeding. Tuning fork test showed a negative Rinne test on the left side and Weber lateralized towards the left ear. A pure tone audiogram showed a flat curve with moderate conductive hearing loss (50-55 dB) in frequencies ranging from 250 Hz through 8000 Hz on the left side.
High-resolution computed tomography (HRCT) of the temporal bone revealed ill-defined, mildly hyperintense soft tissue opacification of the left middle ear cavity with bulging into the cartilaginous portion of the left EAC. Bony septae within the roof of the left temporomandibular joint were absorbed, associated with severe cortical erosion of the anterior bony wall of the left EAC. The lesion was noted abutting the incus and the malleus. Erosion of mastoid air cells septae and opacification of the mastoid antrum were noted. The sinodural plate appeared intact (Figure ).
Canal wall down modified radical mastoidectomy with meatoplasty was undertaken under general anaesthesia. The lesion along with granulation tissue was removed from the external auditory canal, mastoid cavity, and middle ear in a piecemeal fashion (Figure ) and was sent for histopathological examination. Necrotic incus remnant was removed and ossiculoplasty was undertaken. Gel foam was placed in situ, post-auricular closure suturing was done in three layers, and mastoid dressing was applied. The dressing was removed on the third postoperative day, and the external suture was removed on the tenth postoperative day, displaying a healthy wound. No recurrence or complication was noted until the seven-month postoperative follow-up.
Histopathological findings revealed bony trabeculae with extensive calcification enmeshed in a fibrocollagenous stroma (Figure ). These findings were consistent with a diagnosis of benign fibro-osseous lesion.


We recently recruited a 55-year-old female (hereafter referred to as “patient 1”), diagnosed in 2014 with giant cell tumour of the clivus. Since 2013, she complained holocranial headache associated with vomiting, tongue numbness and difficulty with swallowing and speech. Computed tomography (CT) showed a lytic mass 5 cm in size involving the clivus. Magnetic resonance imaging (MRI) revealed a lobulated mass (5 × 2,8 × 3,8 cm) originating from the clivus and extending into the sella and the epistropheus. In 2014, she underwent surgical removal of the mass through suboccipital approach and from the postoperative histopathology the diagnosis of Clival GCT was made. The tumour was highly vascularized and composed of numerous osteoclast-like giant cells that were bigger than those usually described in GCTs, with 50 to 70 nuclei, scattered on a background of mononuclear cells (Fig. ). However, one month after the surgical intervention, the tumour mass grew, symptoms presented again and the mass was newly removed. Postoperatively, the patient received tomotherapy against the residual lesion but only dysphonia improved. Nevertheless, so far in 2016 she suffers of worsening headache, tongue paralysis and dysphagia. MRI demonstrated that a recurrence occurred and showed growth of the tumour (5,3 × 2,1 × 3,9 cm), with compression of hypoglossal nerve (Fig. ). She has been planned for resurgery.
In 2013, the patient 2 was operated through endoscopic endonasal approach to remove the giant cell tumour of the clivus, responsible for his progressive headache and diplopia. After surgery, the patient was asymptomatic and did not undergo radiation therapy. Brain MRI, regularly performed up to six years after the operation, revealed that he did not present any relapse of the disease []. The haematoxylin and eosin staining that we performed on tumour sample confirmed the clinical diagnosis, even though the size of giant cells was remarkably smaller than in patient 1 (Fig. ).


A 35-year-old male presented to the STI clinic at the All India Institute of Medical Sciences, New Delhi, India, for evaluation of urogenital discharge and generalized lymphadenopathy involving the cervical, axillary and inguinal groups of lymph nodes. He had undergone surgical excision of ano-genital warts (AGWs) previously. He was bisexual, with multiple homosexual and heterosexual casual partners, with a history of unprotected receptive and insertive oral and anal sex. There was no history of past blood transfusion or intravenous drug abuse. He reported never being tested for HIV nor any other STIs. His medical history did not reveal any significant systemic abnormalities. On examination, he had scanty mucoid urethral discharge and multiple AGWs, with no lesions nor inflammation in the oropharynx and rectum. A Gram-stained smear of the urethral discharge under an oil-immersion objective of a microscope revealed 4–5 white blood cells, but no Gram-negative intracellular diplococci were seen. Microscopic examination of the urethral discharge was negative for any motile trophozoites, yeast cells and pseudohyphae. The patient was diagnosed clinically as a case of recurrent HPV infection with urethritis.
On investigation, his venereal disease research laboratory (VDRL) test was reactive (titre of 1 : 16) and his T. pallidum haemagglutination assay (TPHA) was positive. The patient was tested for HIV as per National AIDS Control Organisation (NACO) guidelines strategy 2B, in which three rapid tests were done for confirmation of diagnosis. CD4+ counts were estimated on a FACS Count microbead-based system, as recommended by the National Guidelines on the Enumeration of CD4 Lymphocytes []. The patient was HIV-1 positive, with a CD4+ lymphocyte count of 123 cells µl−1. He was seronegative for both hepatitis B surface antigen and anti-hepatitis C antibodies. Clinician collected urethral, rectal and oropharyngeal swabs were sent for detection of N. gonorrhoeae, C. trachomatis and genital mycoplasmas. Culture of the discharge for N. gonorrhoeae was negative on gonococcal agar with vancomycin, colistin, nystatin and trimethoprim sulfate, and so was the PCR assay for C. trachomatis targeting cryptic plasmid at genital, rectal and oropharyngeal sites. PCRs for Mycoplasma hominis and Mycoplasma genitalium were negative. Culture for Ureaplasma spp. was carried out in pleuro-pneumonia-like organism (PPLO) broth containing urea (a) and PCR was based on amplification of the urease gene (b) []. The isolate of Ureaplasma was further biotyped in a second PCR targeting the multiple banded antigen (MBA) gene. Species identification is based on an amplicon size of 408 bp for U. parvum (biovar 1) and an amplicon size of 448 bp for U. urealyticum (biovar 2) []. Ureaplasma was positive by culture and PCR in samples taken from the urethra and oropharynx, but negative in the rectal sample.
Histopathology of the warty lesion confirmed the diagnosis of AGWs. The patient was diagnosed to have oropharyngeal and urethral U. urealyticum infection, co-infected with HIV, T. pallidum and HPV. Contact tracing was attempted, but the patient refused to share any information about his partners.
The patient was treated with doxycycline, 100 mg twice daily for 7 days, and a weekly dose of 2.4 million IU benzathine penicillin for 3 weeks, for Ureaplasma infection and syphilis, respectively, as per Centers for Disease Control and Prevention guidelines for STI, 2015 []. Azithromycin and doxycycline have been recommended for non-gonococcal urethritis; however, considering the better response to doxycycline for extragenital Chlamydia, this was given. Penicillin remains the drug of choice for syphilis, with no resistance reported to date. The AGWs were treated with 10–20 % podophyllin resin, applied once a week for 8 weeks, and the patient was referred to an anti-retroviral therapy (ART) centre for management of the HIV infection. On evaluation at 6 weeks, he reported a cessation of the urethral discharge with healing of the warty lesions. A post-treatment, oropharyngeal swab and first-void urine sample of the patient were negative for Ureaplasma spp. both by culture and PCR. The patient was counselled for safe sex practices and advised to have regular follow-ups.


A male, 39-year-old Caucasian, diagnosed with CF since age 9 years old, homozygous
for the F508del mutation, had exocrine pancreatic insufficiency, CF-related
diabetes mellitus, obstructive azoospermia, chronic lung
disease, bronchiectasis and chronic Pseudomonas aeruginosa
infection. Prior spirometry, with severe airflow limitation and reduction of forced
vital capacity, is presented in .
In June 2015, he was admitted to the emergency room of the Hospital de
Clínicas de Porto Alegre, with continuous fever for 2 days (>
38.5ºC), severe cough, increased volume and purulence of expectoration, prostration,
headache and progressive dyspnea. He denied myalgia. He reported that his wife, son
and two other family members previously had respiratory symptoms, high fever and
myalgias in the last week. He had regularly taken the flu vaccine and had received
the trivalent vaccine in April 2015.
At the physical examination, the patient had a blood pressure of 70/45mmHg, a heart
rate of 105bpm, a respiratory rate of 30rpm, was cyanotic with accessory breathing
muscle and prolonged expiratory time and had a peripheral oxygen saturation
(SpO2) of 57% in ambient air. Cardiac auscultation revealed a regular
two-beat rhythm; lung auscultation indicated vesicular murmur present in both lung
fields, with diffuse fine and coarse rales; the patient's abdomen was without
changes, and his extremities were well perfused.
Initial laboratory tests showed a 34% hematocrit, 10.2g/dL hemoglobin, 22,660
leukocytes/mm3, 2% band-shaped, 86% segmented, 6% monocytes, 5%
monocytes, 1% metamyelocyte, 95mg/dL urea, 2.37mg/dL creatinine (prior it was
0.79mg/dL), 6.6mEq/L potassium, 3.2mmol/L lactate, 145mg/dL C-reactive protein and
189U/L creatine phosphokinase (normal up to 190U/L). Common urine test results
revealed citrine yellow urine, 26 leukocytes/µL, 13 red blood cells/µL
and negative hemoglobin. An arterial blood gas test revealed 5 L/min oxygen per
external nasal catheter, with a pH of 7.21, a partial carbon dioxide pressure
(PaCO) of 56.1mmHg, 24.4mEq/L bicarbonate, a
partial oxygen pressure (PaO) of 68.4mmHg and an oxygen
saturation of 97%. The patient's chest X-ray is shown in .
He received volume replacement with saline, correcting the systemic arterial
pressure. Antibiotic coverage with piperacillin/tazobactam and intravenous
tobramycin was initiated based on the sensitivity test of the last bacteriological
examination of the sputum. Still within the first 24 hours of admission, noninvasive
ventilation (NIV) and antiviral coverage with oseltamivir were initiated. After 48
hours of hospitalization, he evolved with respiratory failure and was transferred to
the intensive care unit (ICU), requiring orotracheal intubation and mechanical
ventilation. Initially, the patient was ventilated with controlled pressure, an
inspired oxygen fraction (FiO2) of 0.40, a positive end-expiratory
pressure (PEEP) of 8cmH2O, a pressure over PEEP of 14cmH2O, a
respiratory rate of 18 breaths/minute, a tidal volume of 340mL and a
PaO/FiO of
198mmHg, fulfilling the criteria for acute respiratory distress
syndrome.(
There was also worsening renal function with an increase of creatinine to 5.87mg/dL
and oliguria. Dialysis treatment was initiated with continuous hemodialysis. The
antibiotic scheme was modified to ciprofloxacin and vancomycin, maintaining
piperacillin/tazobactam.
On the fifth day of hospitalization, a viral investigation was performed via
polymerase chain reaction from a nasopharyngeal secretion sample, collected at the
time of admission. The test was positive for influenza A non-H1N1 (an investigation
of a universal gene of influenza A strains was positive, but the swine lines by gene
amplification of H1 hemagglutinin and virus nucleoprotein were negative). The use of
oseltamivir was maintained for 5 days.
There was favorable evolution and, 7 days after hospital admission, the patient could
be extubated and was placed on NIV again. He was then on intermittent dialysis and
was discharged from the ICU. In the ward, 1 week after discharge from the ICU, he
experienced sudden worsening and was returned to the ICU but was managed with NIV,
with a 2-day stay. Angiotomography of the thorax excluded the possibility of
pulmonary embolism. The antibiotic scheme was modified to meropenem and polymyxin B
(a new sputum culture evidenced multi-resistant P. aeruginosa). He
experienced progressive clinical improvement of his respiratory condition and
resolution of acute renal failure. Hospital discharge occurred 39 days after
admission.
On discharge, he received standard treatment for CF and continuous home oxygen
therapy and was referred to a pulmonary rehabilitation program. Since the event, he
has not required a new hospital stay. The patient's last spirometry is presented in
. In December 2016 (18 months
after the event), the patient was in pulmonary rehabilitation with oxygen therapy
for exercise and at night, and he had been referred for lung transplantation (but
not yet active on the list due to clinical stability).