A 70-year-old man presented in the ophthalmology OPD on 13th May, 2009 with complaints of foreign body sensation and redness of the right eye since 1 day, with no history of trauma or injury to eye.
Ocular examination revealed a localized subconjunctival congestion and swelling near medial canthus with some motility. A slowly moving worm in subconjunctival space was detected on slit lamp examination. A live intact worm was gently extracted from the subconjunctival space under local anesthetic agent. The worm was white and actively motile on removal.
Both eyes were otherwise normal. No abnormality or swelling was detected on systemic examination by dermatologist. Stool examination ruled out presence of parasitic ova or cysts. On hematological investigations, absolute eosinophil count of the patient was higher i.e. 576 cells/mm3. Peripheral blood smear was negative for microfilaria. The serum was sent to JB Tropical Disease Research Centre and Department of Biochemistry, Sevagram, Wardha for filarial serology and was reported positive for immune-complexed antigen by “Seva Filacheck” but was negative for antibody to microfilarial antigen.
As the species of the worm was yet to be identified; patient was prescribed antihelminthic drugs. Symptoms resolved promptly following surgical removal with no ocular or systemic recurrences over a follow-up period of 1 year.
The extracted worm was preserved in 10% formalin and sent to Parasitology Department of Anand Veterinary College and Hospital in Anand, Gujarat for further identification. Grossly, the worm was slender about 6.5 cm in length []. Histopathological sections of the worm showed thick cuticle with external longitudinal cuticular ridges and a thick muscle layer [Figs. –]. Based on the morphologic features, the worm was identified as Dirofilaria repens.


A 30-year-old unmarried male presented with an 8-month history of tense fluid-filled lesions over the back of both hands leaving behind erosions and scars. There was history of photosensitivity, weight loss and high-risk behavior over the past 1 year. He reported moderate alcohol intake in the past, but denied drinking during the previous 1 year. There was no history suggestive of liver disease or of having similar complaints in the family. Physical examination revealed multiple erosions with crusts, scars over the dorsum of both hands [] and face. Minimal hypertrichosis of the face was present [].
Examination of oral mucosa and genitals were within the normal limits.
Blood investigations revealed: Hemoglobin level 13.4 g/L, total count 4,200 cells/cumm, iron 146 mcg/mL, ferritin 429.2 ng/mL. Except for the elevated aspartate aminotransferase (AST) levels of 128 U/L, the remaining parameters of liver function tests were within normal limits. On serological testing, patient was found to be HIV positive with a CD4 count of 32 cells/mm3. Serological screening for hepatitis-B and C were negative. No abnormality was detected on abdominal ultrasonography.
Examination of urine under Wood's light revealed a bright pink fluorescence consistent with the presence of porphyrins []. Histopathological examination revealed a subepidermal bulla with scanty lymphocytic infiltrate and hemorrhage. There was deposition of periodic acid–Schiff (PAS) stained material around the dermal capillary blood vessels [].
Direct immunofluorescence study showed linear IgG deposition along the basement membrane. Urinary porphyrin levels were elevated.
Based on the clinical presentation and laboratory findings, a diagnosis of PCT was made. The patient was treated with low-dose hydroxychloroquine 200 mg twice weekly, antiretroviral drugs and was advised photo protective measures. Three months following the initiation of treatment, there was clinical remission of the skin lesions [] with a CD4 count of 232 cells/mm3.


A 46-year-old woman presented with sudden and progressive erratic movements of the right hand and arm that had developed 3 days before visiting our hospital. On inspection, initial myoclonus of the right hand turned into a tonic contraction that spread to the wrist and forearm and persisted for approximately 30 seconds. The frequency of seizures gradually increased from once an hour at initial symptom onset, to once every 5 minutes 3 days later. She reported feeling tingling sensations in her right hand and arm prior to seizure onset. She was having diabetes mellitus for more than 15 years, but reported no previous stroke or seizure. The patient was alert and oriented. No focal neurological abnormality, other than partial seizures, was observed. Serum glucose level, osmolality, and sodium level were 690 mg/dL, 312 mOsm/L, and 128 mEq/L, respectively. Test for ketone bodies was negative.
Electroencephalogram (EEG) was normal during the ictal phase. MRI demonstrated a small focal acute infarction in the left frontal subcortical area on a diffusion-weighted image (DWI). A focal cortical hyperperfusion in the left central area was observed on 99m-Tc ECD single photon emission computed tomography (SPECT), which disappeared 2 weeks later. Magnetic resonance angiogram (MRA) and transfemoral cerebral angiogram (TFCA) revealed atherosclerotic stenosis of the left internal carotid artery (ICA) ().
We administered antiepileptic drugs (carbamazepine CR [600 mg/d after loading with 20 mg/Kg] and valproate [1,000 mg/d]) for 2 weeks and maintained her glucose levels below 250 mg/dL with insulin. The clinical seizures were not observed after 2 days, and she was discharged without sequel. After discharge, glucose control was performed at the Department of Endocrinology.
Two years later, she visited the Department of Neurology because of recurrent generalized tonic-clonic seizures. During the previous month, she had experienced 2 seizures while sleeping. Her fasting and 2-hour postprandial glucose levels were 125 mg/dL and 198 mg/dL, respectively. HbA1c level was 7.5% (2.7–5.8%). Routine chemistry and assays for electrolytes and serum osmolality did not indicate any abnormality, except for mild elevation of serum creatinine level (1.4 mg/dL). A follow-up MRI failed to indicate recurrent strokes or lesions other than a previous small infarction, and interictal EEG was normal. She has been seizure-free for 3 years with carbamazepine treatment.


A 53-year-old, right-handed female (height 1.54 m; weight 48.2 kg) sustained a hemorrhagic right middle cerebral artery stroke 3 years earlier. The patient presented with left spastic hemiparesis involving, among others, the finger flexors. In addition, she exhibited weak voluntary finger and wrist extension. The patient underwent extensive physical and occupational therapy after the stroke and up to the time of presentation. A total of 50 units onabotulinum toxin A (BOTOX™, Allergan, Irvine, CA, USA) was administered to the left flexor digitorum superficialis (FDS) and flexor digitorum profundus, respectively. The injection was guided by percutaneous electrical stimulation of the motor points of these muscles.
After providing written consent, the subject attended three laboratory sessions before (Pre = Day 0), after (Post 1 = 10 days), and at the follow-up (Post 2 = 2.5 months) injection. Delays in grip initiation and release were assessed using electromyographic (EMG) signals in paretic and non-paretic sides, respectively. The Modified Ashworth Scale (MAS) was used to assess hypertonia. Bilateral grip strength was measured using a hand-held dynamometer (Lafayette Instruments, Lafayette, IN, USA), and the Functional Independence Measure (FIM) was used to evaluate clinical improvement.
During grip initiation and release tasks, the subject sat comfortably in a chair with a backrest to provide proper trunk support. The limb was supported and secured firmly on a customized apparatus on a desk and was placed with 45° shoulder abduction and flexion and a 90° elbow flexion. The wrist was placed and secured in a neutral position (with thumb pointing upward), and the hand was placed around a customized hand-held apparatus. The apparatus was fixed to the table and was adjusted to accommodate hand size, adjusting for comfort and a firm grip. First, the non-paretic hand was tested, followed by the impaired hand. In each 20-second trial, the subject was asked to relax the fingers for the first 10 seconds, maximally grip the apparatus and hold for 5 seconds, and then relax the hand for 10 seconds. Computer-generated audible tones cued the subject when to start and stop grip efforts. The subject was instructed to grip the apparatus as quickly as possible in response to the first tone (start), and then relax the hand as quickly as possible when the second tone (stop) was played. The patient practiced five trials prior to the grip initiation and release task, which allowed for familiarizing with the setting and task. After the practice sets, five trials for each side were performed.
Bipolar active surface electrodes (Delsys, Boston, MA, USA) were placed over the muscle bellies of FDS and extensor digitorum communis (EDC). The FDS muscle is the primary mover in power grip, and EDC muscle activity was recorded to monitor antagonist muscle activity. For consistency, electrode locations were recorded, and electrodes were placed at identical locations for all sessions. EMGs were recorded at 1 000 Hz using a Delsys amplifier and data acquisition system (National Instruments, Austin, TX, USA) controlled by custom LabView program (National Instruments). EMG signals were processed and analyzed offline using a custom Matlab program (The MathWorks, Natick, MA, USA). EMG signals were initially band-pass filtered (10-400 Hz), rectified, and then root-mean-square smoothed with a 40-ms time constant to create envelopes that clearly displayed aggregated muscle activity.
Delays in grip initiation and release were determined from the FDS EMG. The Teager-Kaiser energy operator was used to analyze surface EMG to improve the signal-to-noise ratio, as well as to optimize EMG onset/offset detection[]. The baseline FDS EMG was calculated as values for the EMG averaged across a 0.5-second window during the initial resting period of each trial. The FDS EMG onset time was identified when the EMG value increased more than the mean value plus 3 standard deviations of the baseline values. Grip initiation delay was calculated as the time difference between EMG onset and the “start” audible tone ().
The FDS EMG offset time was identified as the time when EMG values fell below the mean plus 3 standard deviations of the baseline values. The release delay was then calculated as the time difference between EMG offset and the “stop” audible tone ().
After BT injection to the finger flexor muscles (FDS and flexor digitorum profundus) of the paretic left hand, grip strength decreased at 10 days post-injection and returned to pre-injection levels at 2.5 months post-injection (Pre vs. Post 1 vs. Post 2: 2.3 vs. 1.0 vs. 2.2 kg), while grip strength of the non-paretic hand remained stable (Pre vs. Post 1 vs. Post 2: 22.7 vs. 20.4 vs. 22.2 kg). In parallel, the MAS scores of the affected finger flexors were as follows: Pre vs. Post 1 vs. Post 2: 2 vs. 0 vs. 1 for FDS; 2 vs. 0 vs. 1 for flexor digitorum profundus. FIM scores remained unchanged (FIM = 6 for Pre, Post 1, and Post 2), but the subject reported an improved overall ability for handling objects, as well as bimanual activities at home while performing activities of daily living in Post 1 and Post 2 measures.
Release delay time in the paretic hand resulted in dynamic changes (Pre: 2 223 ms; Post 1:1 024 ms; Post 2: 1 333 ms), without dramatic changes in grip initiation delay times in the paretic hand (Pre: 417 ms; Post 1: 439 ms; Post 2: 378 ms). It is noteworthy to mention that a decreased FDS release delay time was paralleled by shortened EDC and EDC EMGs (). In contrast, both grip initiation and release delay times in the non-impaired hand remained relatively stable in all measurements (Pre vs. Post 1 vs. Post 2: 468 ms vs. 404 ms vs. 371 ms for grip initiation delay; 725 ms vs. 740 ms vs. 691 ms for release delay).


An 81-year-old Japanese woman visited our outpatient clinic with a 2-year history of a developing, asymptomatic nodule on her left thigh. On her initial visit, physical examination revealed a brown, hyperkeratotic plaque, 26 × 20 mm in size on the lateral side of the left thigh (fig. ). Dermoscopy of the thinner, brownish part of the tumor revealed characteristic features, namely whitish globular structures surrounded by homogenous, pigmented lines (fig. ). At the dark brown, thick part of the tumor, these whitish globular structures were covered with gatherings of the thick, oval keratotic materials, referred to as ‘muskmelon appearance’ (fig. ). A biopsy specimen showed well-demarcated nests within the epidermis (fig. ). The nests were mainly composed of cuboidal basaloid cells, which surrounded necrotic cells with abundant melanin granules (fig. ). From the above findings, we diagnosed this patient as having HAS. We excised the lesion with a 3-mm surgical margin, and there has been no sign of local recurrence for 1 year.


A 73-year-old Japanese woman experienced light-headedness and dementia of unknown cause for 6 months. She had had diabetes for 20 years and had a history of surgical excision of breast cancer and laparoscopic cholecystectomy 10 and 20 years before, respectively. Her neurological disturbance had advanced, and she sought treatment at Kansai Medical University Kori Hospital.
At the first medical examination, no abnormalities were detected by brain computed tomography (CT) scan. However, 1 month after the consultation, the patient experienced general hypotonia with progressive dementia and was hospitalized. At the time of admission, her blood coagulation tests were as follows (normal range in parentheses): platelets 6.8 × 104/μl (14–34 × 104/μl), fibrinogen 74.0 mg/dl (180–355 mg/dl), D-dimer 101.6 μg/ml (0–0.9 μg/ml), prothrombin time 81.2% (75–130%) and activated partial thromboplastin time 27.9 s (23–35 s). Her serum albumin had decreased to 1.8 g/dl (3.8–5.0 mg/dl), and γ-GTP had increased to 172 U/l (8–45 U/l). The serum CA19-9 level was 376,100 U/ml (<37 U/ml), and the CA15-3 level was 124 U/ml (<27 U/ml), both of which were significantly increased. Upper abdominal CT scan revealed a large ill-defined mass in the periphery of the right liver lobe and multiple ischemic lesions in the spleen. Because of her poor condition, further examination of the liver mass was impossible. Cerebral magnetic resonance imaging showed multi-regional hypointense areas in the hemisphere of her right cortex, which were compatible with acute cerebral infarction. Cardiac ultrasound showed abnormal movements in the mitral and aortic valves.
Despite continuous anticoagulant therapy, her consciousness deteriorated and she died 3 months after the hospitalization due to multiple organ failure. The postmortem examination was performed 8 h after her death. The main object of the autopsy was to elucidate the pathological cause of the cerebral infarction.


A 41-year-old mulatto, male, bricklayer, reported to our institution with a chief complain of an ulcer located in the palate with 5 months of duration that, in his own words, “caused a nuisance during meals”. He reported that he smoked 20 cigarettes a day for 20 years and that lived at rural area of the city. The patient also reported having lost weight (4 kg in the previous month), nocturnal sudoresis and dry cough. General clinical examination revealed an ulcer and a nodule, on the right shoulder skin []. Intraoral examination revealed an ulcerative lesion with punctuate and hemorrhagic appearance involving gum and palate [Figure and ] and poor oral hygiene habits. He also referred itching and discomfort in the throat for the previous month. The first diagnosis hypothesis was “infectious disease”.
An incisional biopsy of the palate lesion was performed. A sample was retrieved from the posterior portion of the palate, near midline []. Then, the specimen was fixed in 10% neutral buffered formalin and paraffin embedded. Histological sections were submitted to hematoxylin and eosin staining for routine diagnosis. Histopathological examination revealed pseudoepitheliomatous hyperplasia with microabscesses. Moreover, it was observed granulomatous inflammation with epithelioid macrophages and multinucleated giant cells. These cells presented small round birefringent structures indicating presence of fungi, whose size and morphology were suggestive of PMC [].
Blood test indicated leukocytosis and neutrophilia, suggesting the presence of infection. Radiographs of the thorax revealed reticulonodular infiltrate distributed in lungs, reinforcing the presence of infection.
Taken together, clinical, histopathological, laboratory, and radiographic findings led to a final diagnosis of PCM. The patient was referred to pneumology treatment, which included itraconazole (200 mg/day for 6 months). The patient was also referred to dental practitioner to perform scaling and root planning procedures, but he did not follow the recommendation. After 5 months, the follow-up consultations were recover, and patient showed regression of skin [] and oral [Figure and ] lesions, which leaved scar areas. Radiographs of the thorax confirmed the remission of lung lesions. After 12 months, there was no signal of recurrence.


A five-year-old boy was presented to our clinic with refractory pain in the low back and left extremity for approximately one year. There was no history of precedent trauma or underlying disease. The parents declared that they repeatedly observed the patient awaken from sleep due to pain although it was not severe enough to hinder his play with peers. Within a year, the pain did not get much worse or better. The mother quoted that she was sometimes obliged to use ibuprofen to relieve the pain, and it was completely effective.
On physical examination, the child suffered from antalgic gait. His pain was mainly located around the lower back of the trunk and left lower limb and aggravated by coughing. He was not able to flex his lumbar spine. The range of motion of the left hip and knee joints was normal, but straight leg rising was severely limited. There was a mild tenderness without any swelling on the lumbosacral area. Deep tendon reflexes were completely intact, yet, the strength of the left big toe extensor was grade 2, according to the medical research council scale for muscle strength []. The boy did not complain of any remarkable associated paresthesia in his extremities.
There were no significant abnormalities in the laboratory studies. Due to the sciatalgic presentation, magnetic resonance imaging scan was undertaken. However, intervertebral discs and vertebral bodies had normal signal intensity and shape, and this modality did not help much. The first radiographs were reported as normal. On closer examination of recent radiographs, it was found that the left pedicle of the fifth lumbar vertebra has probably lost its normal elliptical hollow shape (). There was no evidence of spinal deformity as well.
Because we suspected a bony lesion, technetium-99m bone scan was requested. It showed an increased uptake in this area; ultimately, computerized tomography exactly localized the location of the lesion ().
With the initial diagnosis of a benign latent lesion (probably osteoid osteoma, acute on chronic unilateral spondylolysis, or some kind of infection such as Brodie's abscess), surgical resection was discussed and offered to the parents and the boy himself. They accepted and his father assigned the informed consent. Early after surgery, the pain completely disappeared and he was ambulated and discharged one and two days later, respectively. Histologic examination revealed characteristic nidus (contained immature osteoid with osteoblastic rimming)and reactive bone in the region of the sclerotic border compatible with osteoid osteoma. At the 3 year follow-up postoperatively, the patient did not have any significant problem and is able to perform all his daily activities, although he complains of occasional trivial low back pain.


The case we present here is about a 42-year-old male, who was hypertensive (on amlodipine 5 mg bd), with history of left hemiglossectomy and modified radical neck dissection for carcinoma tongue, a renal transplant recipient (on triple dose immunosuppression), and hepatitis C virus positive status was admitted with an alleged history of consumption of 100 tablets of amlodipine (5 mg each, total dose 500 mg) around 5 h prior to presentation. On admission, he was drowsy but was responding to painful stimuli. His heart rate was 52/min, blood pressure was 40 mmHg systolic, respiratory rate was 8/min and was afebrile. Systemic examination was within the normal limits. He was intubated electively, given fluid boluses and started on dopamine and noradrenaline infusions. His blood gases showed acute respiratory and metabolic acidosis with hyperlactatemia (4.5 mmol/l). A 12-lead electrocardiograph was normal. Gastric lavage was done with 100 g of charcoal. He was given 3 g IV calcium gluconate as a slow bolus followed by 50 mg/h infusion along with 5 mg IV glucagon over 15 min followed by an infusion at 5 mg/h. He was also started on injection insulin and 50% dextrose as hyperinsulinemia-euglycemia therapy.
His condition continued to deteriorate, despite aggressive resuscitation. Terlipressin infusion at 2-3 μg/min was also started along with injection hydrocortisone 100 mg tds as an immunosuppressant as the patient was postrenal transplant recipient. Mean arterial pressure (MAP) could not be maintained more than 50 mmHg despite very high doses of vasopressors (dopamine 20 μg/kg/min, norepinephrine 20 μg/min, epinephrine 20 μg/min and terlipressin 10 μg/min). In view of refractory shock and anuria, with severe metabolic acidosis, continuous veno-venous hemodiafiltration (CVVHDF) with charcoal hemoperfusion using HA Resin hemoperfusion cartridge (Model HA 280, Jafron Biomedical Co., Ltd.) along with 250 ml of 20% intravenous (IV) lipid emulsion given prior to CVVHDF was started as rescue therapy [].
The patient's condition started improving with increase in MAP around 6 h after starting CVVHDF. Another session of CVVHDF with charcoal hemoperfusion with IV lipid emulsion was given after 24 h. Vasopressors were progressively weaned off in the next 96 h and stopped on day 7. The infusions of glucagon, calcium and insulin-dextrose were continued for 96 h and then gradually stopped. CVVHDF without charcoal hemoperfusion was stopped on day 12 as patient's renal functions started improving. Total dose of glucagon used was 252 mg, calcium gluconate was 64 g and insulin was 2000 IU. The patient was extubated on day 11 and transferred to wards on day 13.


A 75-year-old woman presented to the emergency department with the complaints of fatigue and abdominal pain after coughing. The patient had been started on new oral anticoagulant agent rivaroxaban therapy for nonvalvular atrial fibrillation for 3 days. The dose of 20 mg/day rivaroxaban was started because the creatinin clearance of the patient was above 50 mL/min. She had a blood pressure of 70/40 mmHg and an irregular heart rate of 115 beats/min on admission. Physical examination revealed tenderness and mild abdominal swelling with no skin discoloration. The patient had no history of any trauma or surgery; she reported that the symptoms started after vigorous coughing. The patient also denied taking any other drugs that could cause bleeding. Blood analyses revealed leukocytosis (26.5 k/uL) accompanied by severe anemia (5.4 g/dl). Platelet counts were within normal ranges and her international normalized ratio (INR) was 1.48. Her abdominal X-ray was normal and the stool occult blood test was negative. Anticoagulant treatment was stopped and was resuscitated with fluid and packed red blood cells. After the first treatment, the patient was transferred to the intensive care unit (ICU). Repeated abdominal examination in the ICU revealed increased tenderness and a palpable mass on the left side of the umbilicus. Noncontrast abdominal computerized tomography scan showed a left-sided RSH, 102 × 45 mm in size []. A specific antidote for rivaroxaban is not available then the patient was treated with fluid resuscitation and packed red blood cells. The patient was referred to surgery because of the hemodynamic instability.


We report the case of a 73-year-old White male patient who was a retired construction
worker, having worked as a mason's assistant most of his economically active life. The
patient was a former smoker (smoking history, 10 pack-years). Over a 6-month period, he
had daily episodes of dry cough, dyspnea, and wheezing that improved, albeit partially,
with the use of intravenous xanthine and an inhaled β2 agonist, having often
sought emergency room treatment. The patient was referred to our hospital after the
identification of a lung tumor on a chest X-ray. He reported no fever, chest pain, or
bloodstained sputum. In addition, he reported weight loss (3 kg) during that period.
The patient had systemic arterial hypertension and reflux esophagitis, both of which
were controlled. He reported no diabetes, dyslipidemia, chronic respiratory diseases, or
contact with tuberculosis patients.
The patient reported no alcoholism. In addition, he reported that he had raised animals
when he was young and that he had been exposed to smoke from wood-burning stoves until
the age of 25 years.
Physical examination revealed good general health. The patient had pallor of the skin
and mucosa, and his body mass index was 29.7 kg/m2. He was well hydrated and
was breathing normally, having no jaundice or cyanosis. In addition, he had no digital
clubbing or lymph node enlargement. Respiratory findings included increased
anteroposterior chest diameter, normal breath sounds, and diffuse wheezing. Arterial
oxygen saturation was 90% on room air. Cardiovascular and abdominal examination was
normal. No leg edema, varicose veins, or ulcers were observed.
Spirometry revealed mild obstructive lung disease unresponsive to bronchodilators. The
Mantoux tuberculin skin test (TST) was performed, and the induration was 15 mm.
Counterimmunoelectrophoresis for antifungal serum antibodies was negative for
cryptococcosis, aspergillosis, histoplasmosis, and paracoccidioidomycosis.
A CT scan of the chest () showed a
hypodense tumor mass located in the right upper lobe and measuring 5.0 × 3.5 cm. The
major axis of the mass was directed toward the pulmonary hilum.
Wegener's granulomatosis was ruled out by negative antineutrophil cytoplasmic antibody
test results associated with an absence of specific upper airway and nervous system
symptoms.
Fiberoptic bronchoscopy was performed on two occasions, having shown extrinsic
obstruction of the right upper lobe bronchus and its segmental bronchi. In addition, the
bronchial mucosa appeared to be infiltrated. However, analysis of the biopsy samples was
inconclusive, a surgical approach being therefore adopted.
The surgical specimen consisted of a cavitary mass in the right upper lobe (the contents
of which were thick) and enlarged mediastinal lymph nodes.
Pathological examination of the mass revealed a dense chronic inflammatory infiltrate
that was granulomatous and exudative, as well as extensive areas of caseous necrosis,
fibrosis, and giant cell reaction (); none
of the various sections examined met histopathological criteria for malignancy. The
presence of intracytoplasmic crystalloid structures in the adjacent lung parenchyma (as
revealed by H&E staining) constituted evidence of silicosis (). The mediastinal lymph nodes showed a marked chronic
inflammatory infiltrate that was granulomatous and exudative, as well as extensive areas
of necrosis, lymph node architecture being extensively effaced.
Serial histological sections were examined under oil immersion (total magnification,
×1,000). Ziehl-Neelsen staining and the Grocott-Gomori methenamine-silver stain
technique were used in order to screen for AFB and fungi, respectively, and the results
were negative for all histological slides. However, culture was positive for
Mycobacterium tuberculosis.
The lung mass was tested in an automated culture system, and there was M.
tuberculosis growth. In this technique, the tubes containing the biopsy
material (classically macerated and decontaminated) are monitored in an automated
culture system (BACTEC Mycobacteria Growth Indicator Tube (MGIT) 960; Becton Dickinson,
Sparks, MD, USA) for up to 42 days of incubation, and any microorganism growing in a
given tube emits fluorescence detectable by the system sensors, which indicate the tube
as positive. Ziehl-Neelsen staining was used in order to screen the positive material
for AFB, and the material was cultured on Löwenstein-Jensen medium for approximately 10
days. Mycobacterial colonies were analyzed by polymerase chain reaction, which
identified M. tuberculosis by insertion sequence
IS6110. Culture of the lung tissue surrounding the mass was
negative; the lymph node samples were lost.
Lung tissue and mediastinal lymph node samples were cultured on Sabouraud agar,
Cryptococcus neoformans having been isolated after 72 h of
incubation. For metabolic recovery of the yeast and identification of
Cryptococcus sp., a subculture of that isolate was performed, also
on Sabouraud agar. The genus and species were confirmed by the VITEK 2 Compact and 21343
YST Test Kit VTK 2 automated system (bioMérieux, Marcy I'Étoile, France). The turbidity
of the final suspension of saline solution containing the isolated colonies was analyzed
with a DensiCHEK Plus device (bioMérieux), the results being within the 1.80-2.20 range,
as established by the manufacturer. A fragment of the lung mass was cultured, and the
results were negative.
The patient received pharmacological treatment, being treated with a regimen of
rifampin, hydrazide, pyrazinamide, and ethambutol for 2 months, followed by rifampin and
hydrazide for 4 months, in accordance with current recommendations for the treatment of
tuberculosis.(
) In addition, he received itraconazole for 6 months.
At 5 months of pharmacological treatment for tuberculosis, the patient presented with a
symmetric and painful increase in the mammary glands, which remained increased after the
end of the treatment. We attribute this to a rare side effect of hydrazide, which has
been reported by other authors.(
)


A 21-year-old Japanese male presented at the outpatient department with sporadic nausea, abdominal discomfort, and worsening headache. Cysto-peritoneal (CP) and VP shunts were implanted 11 months after birth by another doctor for the treatment of hydrocephalus due to a suprasellar arachnoid cyst. His VP shunt had been replaced twice by the age of 13 years. At the time of last surgery, the CP cranial tube was removed while the extra-cranial tube was left in place because it passed through the mediastinal space rather than the subcutaneous tissue and adhered to the surrounding organs. During this course of treatment, the patient had been diagnosed with slit ventricle syndrome but had no current restrictions on daily activity except for mild mental retardation. He had no remarkable medical history to suggest systemic abnormalities or risk factors for infection and had not traveled to foreign countries.
Nausea was reported for 2 months and abdominal pain for 1 month before admission. A few days before presentation, the patient developed fever and mild consciousness disturbance. Initial physical examination revealed a fever of 38.9°C, restlessness, and significant abdominal distension but no meningeal irritation or focal signs of neurological dysfunction. White blood cell count was 10,900/mm3, and serum C-reactive protein level was 31.8 mg/dl. Chest X-ray was negative but brain and abdominal computed tomography (CT) scans revealed enlarge lateral ventricles, a huge peritoneal cyst surrounding the distal end of the peritoneal tube, and fluid in the sheath surrounding the peritoneal tube, indicating possible shunt blockage and a concomitant increase in intracranial pressure (ICP) []. In contrast, chest CT revealed no abnormalities in bilateral lung fields or subcutaneous tissues of the chest. The tentative diagnosis was shunt malfunction resulting from some undefined peritoneal abnormality.
Continuous external drainage was established to remove CSF from the lateral ventricles and peritoneal cyst. The CSF was clear and the fluid in the abdominal cyst was xanthochromatic. Chemical screening of CSF was negative. The cyst fluid contained 1495 cells/mm3 (69 monocytes and 1426 polycytes/mm3) and 1.4 g/dl total protein. Antibiotic therapies for abdominal infection were empirically administered and bacterial cultures analyzed, but no causative pathogen was identified.
Preoperative clinical symptoms immediately improved after surgery to insert an external drainage system. However, the cyst fluid gradually recollected and signs of mild inflammation remained despite antibiotic therapy. In the second stage of treatment, transcutaneous drainage of the cyst under CT guidance was performed; however, again cyst fluid recollected []. In the third stage of treatment, laparotomy was performed, which revealed no membrane surrounding the abdominal cyst (defining it as a pseudocyst), no malignancies within the omentum, and no ascites within the abdominal cavity.
Throughout the course of treatment, all cytological examinations for malignancies were negative and bacterial cultures did not reveal a causative pathogen. Two months after initial surgery, inflammation of his left knee joint became apparent. The fluid taken from the joint was xanthochromatic, similar to the pseudocyst fluid, and Mycobacterium tuberculosis was detected in a culture from the fluid. Thus, the patient was diagnosed with an abdominal pseudocyst associated with TBP and successfully treated by anti-TB agents following insertion of a ventriculo-pleural shunt []. At follow-up 2 years after treatment, he again presented with signs of inflammation, and the abscess around the CP shunt was strongly suspected as the cause. He was again treated with anti-TB agents, and all signs of inflammation subsided after the removal of the previous CP shunt tube by thoracoscopic surgery.


A 49-year-old woman with a history of asthma, NF-I, and chronic smoking presented to the emergency room with chest pain. It was sudden onset of sharp, continuous pain in the right upper chest and radiating to the right lower chest, moderate in intensity, exacerbated with inspiration and cough. Her family history was positive for NF-1. Physical examination revealed the presence of decreased breath sounds at the base of the right lung. She had neurofibromas all over the skin. Computed tomography of the chest confirmed the presence of a large amount of right pleural effusion with mediastinal shift [].
Thoracentesis was done without successful drainage. Her hemoglobin dropped gradually from 11.2 mg/dL to 9.6 mg/dL. She underwent right thoracoscopy with evacuation of 2700 mL of blood. During the procedure, an apical mass with sentinel clot was demonstrated. The frozen section reported the absence of malignancy. We were unable to find the exact source of bleeding. Histology showed the segments of hyperplastic nerve tissue, consisting of cells that were S-100-positive by immunohistochemistry, confirming the diagnosis of neurofibroma []. The patient improved after surgery and she was discharged to home in stable condition.


A 12-year-old adolescent girl, in a suicide attempt, consumed an organophosphorus pesticide, Fenthion, and developed profuse frothing, lacrimation, and vomiting soon after. She was taken to a nearby rural hospital and treated with gastric lavage, atropine, antibiotics, and intravenous fluid. There was no history of fever, seizures, jaundice, bleeding manifestation, head trauma, delayed developmental milestones or any neurocognitive decline. Her family history was also noncontributory. She was referred to our institute when no significant improvement was noted.
Following admission, treatment was continued with atropine and other supportive measures with close monitoring. Four days after admission, she developed loss of speech, tremor and intermittent jerky movements, in all four limbs with extension of neck. On day 7 she became unconscious and examination revealed a Glasgow Coma Scale (GCS) score E2V2M2. Her vital signs included: A blood pressure of 100/60 mmHg; heart rate of 94/minute; respiratory rate of 45/minute; and temperature of 38.5°C. She was shifted to Intensive Care anticipating respiratory failure. She started recovering with supportive management and responded to verbal stimuli on day 12. She regained full alertness during the next two days. The tremor and intermittent jerky movements persisted. In addition she developed rigidity, mask-like face, and intermittent hypertonia []. The laboratory studies were unremarkable. Examination of her cerebrospinal fluid (CSF) was normal. Magnetic resonance imaging (MRI) of the brain, done on day 15, revealed no abnormality. Her speech returned partially on day 16 and it was slow, with slurring and a monotonous tone. She started walking slowly with short steps on day 17. She was discharged on day 18 and referred to the Department of Psychiatry for evaluation. At follow-up after three months, all her signs and symptoms had completely reversed.


Herein, we report the case of a 62-year-old man who had previously undergone tumor resection for primary high-grade cardiac angiosarcoma () at a university hospital 4 months previously. The patient was referred to the Nuclear Medicine Department for 18F-FDG PET-CT imaging to assess residual and/or metastatic disease.
The tumor was surgically approached by medial sternotomy, but complete tumor resection was not possible because of the extensive tumor infiltration. Palliative intervention consisting of partial excision of the tumor mass was aimed at releasing the right ventricular outflow tract.
PET-CT scans revealed a residual or relapsed mass in the right atrium, with significantly increased uptake of 18F-FDG (maximum standardized uptake value of 12). The mass extended to the mitral valve, septum, and left ventricle and infiltrated to the pericardium and adjacent mediastinum (). The mass encased and almost completely replaced the atrial wall and nearly filled the entire cardiac chamber. Increased activity in the sternum was concomitant with sternotomy. PET-CT images also revealed multiple distant metastasis in the lung, liver, and bones (). Despite receiving subsequent aggressive therapy, including radiotherapy, the patient died 8 months later.


A 37-day-old female child, fourth born of second degree consanguineous parents, admitted with seizures, lethargy, poor feeding, and failure to gain weight. She was born of a cesarean delivery with a birth weight of 2.9 kg. She cried immediately at birth and there was no history of respiratory distress or neonatal jaundice. Her two elder siblings died in the newborn period with history of seizures. Mother noticed an abnormal odor of urine at times. Examination revealed a lethargic child weighing 1.8 kg with no lateralizing signs or neurocutaneous markers. Complete hemogram, renal parameters, liver function tests, and serum electrolytes were normal. Seizures were controlled with phenobarbitone. Serum lactate, pyruvate, and ammonia were within normal limits. Urine screening was negative. Cerebrospinal fluid (CSF) analysis did not reveal any abnormality. Magnetic resonance imaging (MRI) brain showed bilateral symmetrical lesions involving posterior limb of internal capsule, thalmi, brainstem, and centrum semiovale [Figures -]. Serum high-performance liquid chromatography (HPLC) amino acid profile showed an elevation of leucine — 4,529 (47-155), isoleucine — 286 (31-86), and valine — 575 (64-294) suggestive of maple syrup urine disease (MSUD). Urine for organic acids did not reveal any abnormality. Baby was started on carnitine and thiamine supplementation. Enzyme assay could not be done due to want of facilities. Baby developed respiratory distress and died ten days after hospitalization.


A 26-year-old female patient was referred from the Department of Plastic Surgery for the fabrication of ear clip for ear keloid. She complained of swelling on the helix of right ear since 1½ years. There was history of first ear piercing of lobe of the ears at the age of 10 years without any swelling following piercing. Additional ear piercing was done at the age of 24 years at the helix of both ears. A small swelling appeared on the superior aspect of helix of ears bilaterally after 3-4 months of piercing, which gradually increased in size and continued to grow until it reached the present size on the right ear in 1½ year duration. Swelling appeared first on the left ear and was larger in size. That was excised surgically after 1½ years. Surgical excision of keloid on the left ear was done 1 week back.
On examination, a small, oval, sessile, non-tender, smooth-surfaced swelling was present on the upper part of helix of the right ear, measuring 8 mm superoinferiorly and 6 mm anteroposteriorly. On the left ear, there was a healed scar on the superior aspect of the helix. There was no pain, pruritus, or other adverse accompanying symptoms except that it caused emotional stress due to impaired esthetics. A clinical diagnosis of keloid was given. It was planned to use pressure therapy to reduce the size of the growth on right ear and to prevent recurrence on the left ear. Custom-made methyl methacrylate pressure appliances were planned to be used for presurgical compression of the keloid on the right ear and passive methyl methacrylate pressure appliance for preventing recurrence on the left ear.
Patient's skin over the right ear and keloid was lubricated with petroleum jelly and external auditory meatus was blocked. Impression compound (DPI Pinnacle; DPI, India) was used to make beading around the auricle for the confinement of the impression material []. Then thin mix of irreversible hydrocolloid impression material (Zelgan 2002; Dentsply, India) was poured within the confinement of the beading with patient's head tilted opposite to the side for which impression was being made. Bell pins were placed in the partially set hydrocolloid for the retention of backing material. Thin mix of plaster of Paris (Kaldent; Kalabhai Karson Pvt Ltd, Mumbai, India) was poured over the irreversible hydrocolloid as the backing material. Completed impression was retrieved after the impression materials were set. The impression was poured in dental stone (Kalstone; Kalabhai Karson Pvt Ltd) with adequate land area to make the cast []. A spring was designed using 21″ gauze stainless steel wire that was made as a V-shaped loop with a helix at its apex and adapted over the growth on the cast. A custom-made pressure appliance was fabricated incorporating this loop in clear methyl methacrylate and characterization was done to make the appliance more esthetically acceptable and unnoticeable to others []. Care was taken to ensure adequate space for acrylic resin between the wire loop and the skin to avoid direct contact of the stainless steel wire with the skin. The design of the appliance involved covering the whole of the surface of the growth with gap between the two almost equal halves to permit activation in order to ensure sustained pressure, thus allowing adjustments to accommodate the reduced size and negating the need for fabrication of a new appliance.
The master cast for the left ear was obtained following the same procedure as that for lubrication, blocking, and impression of the right ear []. A custom-made passive pressure appliance was planned with incorporation of magnets for retention. It was fabricated by adapting methyl methacrylate without any spacer, around the scar over the helix. Two pairs of 2 × 2 mm magnets (TT magnets, Mumbai, India) were incorporated in the acrylic resin with two similar poles of magnets in each half [Figures and ]. As there was no gap planned between the two halves of the appliance, it did not put any active pressure on the scar that could cause soreness. However, it would prevent any growth above the surface by confinement of the soft tissue to the internal dimensions of the appliance. Color matching of the appliance was done to make it less evident.
The appliances were finished, polished, and adjusted to remove any sore spots. These were delivered and patient was instructed to wear them all the time. She was also instructed about their use, maintenance of hygiene, and regular follow-up. Patient was counseled about any probable post-surgical nodule and close monitoring for recurrence. The periodic activation of the active pressure appliance was done by closing the coil of the spring. Patient was monitored for use of the appliances regularly. During follow-up, a 1 mm reduction in overall size of the right keloid was achieved after 3 months and the growth appeared shrunken in appearance []. No recurrence was observed in the left keloid scar []. No other complication was observed during treatment.


A 16-year-old female patient visited our outpatient clinic because of a six-year-old left wrist mass and pain that occurred accidentally, without any special traumatic history. According to the patient's history, the mass was first detected on her left wrist dorsal area when she was 10 and the mass had grown increasingly bigger since then. She was first diagnosed with a ganglion cyst at other hospitals, but the conservative treatment was not effective. An open excision was implemented four years later. However, the cyst recurred and gradually became bigger about six months after the operation. One year after the operation, an aspiration was implemented and even a steroid injection was executed. However, the mass still became bigger and the pain grew stronger, so the patient eventually came to our hospital.
A visible mass with a surgery scar was detected on her left wrist dorsum upon physical examination (). The mass felt very similar to a firm rubber ball and was well tethered in place. Tenderness was not clear at palpation. Neither heating sense nor erythema was seen and no pulsation was felt. The range of motion (ROM) of the left wrist showed a 50° limit of flexion and the patient expressed an excruciating pain from 30° on between point 6 and 7 on the visual analogue scale (VAS). Her left wrist extension was slightly limited to 50°. The manual muscle testing (MMT) of the wrist flexion was diminished at the 3+/5 point, possibly because of the influence of pain, and the wrist extension was evaluated as 4/5. The sensory examination results were normal. No fracture, bony erosion and osteophyte were seen on the simple X-ray of the wrist. The blood test also showed a normal erythrocyte sedimentation rate (ESR) of 3 mm/hr, C-reactive protein (CRP) of 0.1 gm/dL, and anti-cyclic citrullinated peptides (anti-CCP) of 0.1 U/mL. No cervical radiculopathy or carpal tunnel syndrome was observed in the electromyography. A 1.46×1.01-cm cystic mass was observed on the left wrist dorsum area via ultrasonography ().
We first explained the procedure to the patient and obtained her consent for the experimental method. We used ONJ P-702 (Hyumedi, Seoul, Korea) as electroacupuncture equipment (). The size of the sterile needle was 0.35×30 mm. The patient maintained a supine position with 20° shoulder abduction, 15° elbow flexion, full-ROM forearm pronation, and 10° wrist flexion by using the roll. One of the needles was located on the muscle belly of the extensor digitorum communis muscle and the other was located on the ganglion site (). The electroacupuncture was connected to the needle and implemented for 20 minutes with 1 Hz direct current. The intensity of the current was increased to the highest degree that could be tolerated by the patient.
The patient received the procedure once a week for eight times' altogether. The decrease of ganglion size could be seen with bare eyes after eight weeks (). The size was diminished to 0.53×0.58 cm in the follow-up ultrasonography () and the left wrist pain improved to point 2 on the VAS scale. The left wrist flexion ROM recovered to 80°. The wrist flexion and extension MMT also improved to 5/5 and the procedure was halted after the patient expressed her satisfaction.


A 52-year-old female homemaker patient visited our clinic. Her main complaint was a mass on her right wrist dorsum that she accidentally discovered a month earlier. The patient reported her wrist was bent while it was pressed against her body five or six years earlier and she had been experiencing intermittent wrist pain since then. The pain increased when she used her wrist to wipe something with a cloth or when she held a mouse for too long. A visible soft mass well tethered in place that felt like a firm rubber ball was observed on her right wrist dorsum area upon physical examination. No inflammation signs, such as a heat sensation or erythema, were observed and the tenderness was not prominent. The wrist flexion/extension ROM were normal at 90°/70° and the pain degree was point 5 at the VAS scale with a wrist flexion of 45°. Both, the right wrist flexion and the extension MMT were evaluated as 4/5. The sensory examination results were normal. No fracture line, bony spur or bone erosion was observed in the simple X-ray of the right wrist. The blood tests also showed normal results with ESR 5 mm/hr, CRP 0.4 gm/dL, and anti-CCP 0.5 U/mL. The size of the cyst was determined as 1.45×0.62 cm in the ultrasonography ().
As in case 1, we explained the procedure to the patient and obtained her consent on the experimental method. She received electroacupuncture once a week for 20 minutes eight times altogether. Eight weeks later, the cyst shrunk to 0.64×0.25 cm as seen in the ultrasonography (), and the degree of the wrist pain dropped to point 1 on the VAS. The MMT also improved to 5/5 on both the wrist flexion and extension, and the procedure was halted after the patient expressed satisfaction.


A 3-year-old female presented with high-grade fever and abdominal pain for 4 days, and non-bilious vomiting for 1 day. There were no bladder/bowel complaints, cough, cold, altered sensorium, convulsion, or icterus. The child was previously healthy with no past admissions. Birth and perinatal history were normal. On admission, she was febrile with a heart rate 130/min, respiratory rate 44/min, and blood pressure 98/60 mmHg. Mild pallor was present. There was no icterus or edema. Liver was tender with a span of 10 cm in the midclavicular line. Bowel sounds were sluggish. Rest of the systemic examination was normal. She was started on intravenous fluids and ceftriaxone. Investigations on the day of admission are shown in . Patient developed icterus and had one episode of generalized tonic-clonic convulsion lasting for about 10 min on the 2nd day of admission. Her sensorium became altered after the convulsion. Ultrasonography (USG) of abdomen done on the second day of admission revealed: 3.6 × 3.7 × 4 cm abscess in segment VII of right lobe, 3.3 × 3.6 × 3.5 cm sized abscess in segment II of left lobe, mild ascitis, and bilateral mild pleural effusion. As the abscesses had not liquefied, pediatric surgeons advised conservative management. Correction for hyponatremia, intravenous metronidazole, and calcium gluconate were started. Cerebrospinal fluid examination and computed tomography (CT) scan of brain were normal. Blood culture showed Pseudomonas aeruginosa sensitive to piperacillin, amikacin, and ciprofloxacin. Accordingly, the antibiotics were changed to piperacillin-tazobactum and amikacin on the 5th day. Syrup lactulose and oral ampicillin were added. On the 7th day, sensorium further worsened with increase in abdominal distension. Investigations on the 7th day are shown in . Packed cell transfusion and fresh frozen plasma transfusion were given. Ascitic fluid examination showed: 1,020 cells (80% neutrophils, 20% lymphocytes), protein 4.8 g%. Serial USG of the abdomen were done every alternate day to monitor the liver abscesses. USG on the 7th day showed increase in the size of previous liver abscesses with liquefaction and several new small abscesses throughout the liver parenchyma. USG guided aspiration was done. However, on the 8th day, the abscess in segment II ruptured and a pigtail catheter was inserted. CT scan of the abdomen showed: Hepatomegaly with multiple varying sized peripherally enhancing hypodense lesion noted in the liver parenchyma with the largest being in segment VII measuring 5.1 × 4.9 × 4.3 cm, gross ascitis, mild splenomegaly, and portal vein filing defect at pancreatic head region suggestive of thrombosis [Figures , , and ]. Subcutaneous low molecular weight heparin was started. Cultures of the pus revealed Pseudomonas aeruginosa with a similar sensitivity pattern. However, patient continued to deteriorate, went into multiorgan dysfunction, and was ventilated on the 10th day of admission. Inotropes were started for the septic shock. Repeat blood cultures on the 10th day also revealed Pseudomonas aeruginosa with a similar sensitivity pattern. Human immunodeficiency virus testing by enzyme-linked immunosorbent assay was negative. Work up for primary immunodeficiency was done which was normal (complete blood count, absolute neutrophils count, mean platelet volume, lymphocyte subset analysis, serum immunoglobulin levels, and nitroblue tetrazolium test). On the 14th day, despite all resuscitative measures, patient died of septic multiorgan failure.


A 64-year-old man, who had experienced sudden weakness and numbness in the left lower extremity for 4 weeks, visited our emergency department for evaluation and treatment. Over several days, his gait disturbance gradually worsened and the numbness had extended to the left upper chest region. There was no evident traumatic episode before admission. A physical examination conducted at presentation revealed gait disturbance with spasticity. He was able to stand by himself, but needed a crutch for walking. A neurological examination showed motor weakness of left lower extremity (Grade IV). In addition, sensory disturbances of vibration and positional sensation were present on the left side below the T4 dermatome. Impaired perception of pain and temperature stimuli were also noted on the right side below the T4 dermatome. Brown-Séquard syndrome of the cervicothoracic or thoracic spine was then suspected. Plain radiographs of the cervical spine showed multiple degenerative changes. Accordingly, magnetic resonance imaging (MRI) of the whole spine was performed. Sagittal T2-weighted MR images revealed a left-sided cystic extradural lesion at the C7-T1 junction (), and axial images showed that the extradural cystic lesion markedly compressed the spinal cord (). The lesion appeared homogenously isointense on T1 weighted images and exhibited heterogeneous high signal intensity on T2 weighted images. Under a presumptive diagnosis of a cystic lesion in the lower cervical spine, emergent surgery was performed. Because there were additional osteophytes causing cord compression at C4-5 and C5-6, modified expansive laminoplasty of C5-6 and a laminectomy of C7 followed by complete removal of the extradural cyst were performed. The lesion was homogeneous, bright yellow in color, firm in consistency, and slightly adherent to dura mater, and contained a small amount of serous fluid. Pathological examination showed the cyst to be composed of fibrous connective tissue and to have a distinct synovial cell lining with focal calcification (). The diagnosis was confirmed as a synovial cyst. Immediately after surgery, motor power and impaired sensation were improved. At his 6-month follow-up, he was able to walk without any assistance and returned to work. At his 8-month follow-up, no recurrence of symptoms, except for mild numbness, was evident.


A 55-year-old female patient presented with a four-month history of a continuous burning sensation of the oral mucosa. It was initially present only on the tongue but gradually involved the entire mouth. The burning sensation was not associated with an altered taste sensation or dry mouth. It developed in the morning and progressively increased in intensity throughout the day. It was aggravated by spicy food and not relieved when taking analgesics.
Her medical history revealed that the patient had been in menopause for four years. The patient had witnessed an accident and suffered from major depression 3 years prior to visiting our clinic. The patient had been on the following medication for 3 years: Monoprolol 40 mg, Benzhexol (Parkin) 2 mg, Sodium valproate (Valprol) 50 mg, Haloperidol (Trancodol) 5 mg and Fluoxetin 100 mg.
In the course of managing her depression, the dosage of the drug fluoxetin was briefly increased one year prior to her visit from 100 to 200 mg per day for a month. During this period, the patient experienced a mild burning sensation in her mouth, which returned to normal when the dosage was decreased. The dosage of the same drug was again increased from 100 to 200 mg six months prior to her visit, and the patient had been experiencing symptoms of burning mouth for the last four months.
On examination, the patient was apparently healthy, conscious, co-operative, well-oriented, well-built and nourished. Her vital signs were within the normal range. Intraoral examination revealed that the oral mucosa appeared normal and healthy; there were no mucosal lesions to explain the pain. Salivary secretion appeared adequate, and saliva was thin and copious.
The intensity of the burning sensation was rated on a visual analogue scale, with a score of 8. Laboratory analysis of her bloodwork revealed that all parameters were within the normal range.
The patient was referred to her psychiatrist with a request to alter or reduce the dosage of the drug fluoxetin. The drug was discontinued, and her depression was managed instead with the drug Colostrinin (Cognate). Following this change, the patient's glossodynia disappeared completely within one month.
Based on her history, clinical features and response after drug cessation, a final diagnosis of selective serotonin reuptake inhibiter (SSRI) antidepressant-induced BMS was arrived upon. The patient is under constant follow-up and remains pain-free.


A 69-year-old female presented for elective stent-assisted coiling of a 7 mm, unruptured right middle cerebral artery (MCA) bifurcation aneurysm. She was started on aspirin 325 mg and clopidogrel 75 mg daily seven days prior to undergoing the elective procedure. She was taken to the endovascular suite and underwent general endotracheal anesthesia without complication. Neuromonitoring with electroencephalography (EEG) and somatosensory evoked potential (SSEP) were set up with good quality baseline signals prior to starting the procedure.
A 6-French Neuron guide catheter (Penumbra Inc., Alameda, CA, USA) was advanced over a 5-French Berenstein catheter for selection of the patient's right common carotid artery. Using a roadmap technique and over-the-wire technique, the diagnostic catheter was used for selection of the patient's right internal carotid artery. A microcatheter (Excelsior SL-10, Stryker Neurovascular, Fremont, CA, USA) and a wire (Synchro-14, Stryker Neurovascular) were then used for selective catheterization of the MCA and coiling of the MCA aneurysm was started.
During coiling of the aneurysm however, the neurophysiologist reported severe attenuation of SSEPs in the bilateral upper and lower extremities along with near flatlining of the EEG. The EEG and SSEP electrodes were verified to have good contact with the patient. There was no change in anesthetics, blood pressure, or body temperature prior to the SSEP and EEG change. A cerebral angiogram was performed and showed patent large cerebral vessels. An intraoperative DynaCT was then obtained and showed multiple, hypodense cortical vessels consistent with cerebral air embolism (). At this time, it was noted that the pressure bag was depleted and a small amount of air was present in the drip line tubing. The drip line and catheter were flushed immediately and cleared of air. The FiO2 was increased to 100% on the ventilator, intravenous levetiracetam was administered, mean arterial blood pressure was increased, and intra-arterial verapamil infusion was administered in order to facilitate vasodilatation and to maximize cerebral perfusion. The SSEP and EEG signals showed gradual improvement approximately 30 minutes after the initial change.
Given the patient's improvement on neuromonitoring and risk of coil migration, an Enterprise stent (4.5 × 22 mm; Cordis, Bridgewater, NJ, USA) was deployed successfully across the aneurysm for completion of the procedure. The patient was heparinized with adequate activated clotting time prior to stent placement. The catheter was retracted out of the body. A 6-French Angio-Seal closure device (St. Jude Medical, St. Paul, MN, USA) was deployed successfully.
The patient was taken to the intensive care unit postoperatively and remained intubated. Neurological examination revealed hemiparesis on the left. Magnetic resonance imaging (MRI) of the brain showed only a small focal area with restricted diffusion in the right parietal region (). The patient's left hemiparesis showed gradual improvement over the next few days and she was eventually discharged with near baseline strength. Follow-up angiogram at four weeks showed Raymond grade 1 occlusion of the right MCA aneurysm () and she was doing well without any clinically significant deficit.


In 1999, a 31-year-old male farmer, who was a resident in the forest zone of
Pernambuco, was admitted to the Clinics Hospital of the Federal University of
Pernambuco. At the time of admission, he presented with asthenia and headache, and had
diarrhea for at least 30 days. He was diagnosed with HIV, and began receiving
antiretroviral therapy (ART) with stavudine, lamivudine, and efavirenz. Meanwhile, his
25-year-old partner and 9-month-old daughter were diagnosed with HIV infection.
Five years after initiating ART, the patient presented virological failure;
after genotyping, his treatment was changed to tenofovir, lamivudine, and
lopinavir/ritonavir. In 2005, he was diagnosed with VL as assessed by directly testing
Leishmania in the bone marrow aspirate and initially treated with
N-methyl-glucamine-antimony. However, because of pancreatitis, the patient began
receiving amphotericin B, which was then replaced by a liposomal formulation because of
the onset of renal failure.
In 2011, the patient presented disseminated cutaneous lesions caused by
Leishmania, as assessed by histopathological analysis of skin biopsy
samples. In July 2012, the patient was readmitted for presenting febrile disease with
splenomegaly and pancytopenia, in addition to showing positive results for laboratory
tests for leishmaniasis (). After
administration of liposomal amphotericin B deoxycholate, the patient's condition
improved, and he was discharged upon recommendation of a secondary prophylaxis by
administering liposomal amphotericin B twice a week. Between 2005 and 2012, seven VL
infections occurred, as shown in the .


An 18-year-old girl presented in September 2003 with a 9 month history of personality change, anxiety, tearfulness and withdrawal. She performed unexpectedly badly in school examinations and in July developed forgetfulness and unsteadiness walking. The cognitive problems progressed and were associated with fleeting delusions and auditory hallucinations. She developed unpleasant sensory symptoms in the feet, slurring of speech and fidgety movements of the hands and arms. On examination there was cognitive impairment, together with dysarthria, limb and gait ataxia and choreiform movements in the limbs.
There was a past history of vertigo in 2002, with normal MRI brain scan, but no history of treatment with human growth hormone or prior neurosurgery and no family history of a similar disorder. MRI brain scan in 2003 showed the ‘pulvinar’ sign and no other cause for the presentation was apparent on extensive investigation. The clinical diagnosis was probable vCJD. Testing for abnormal PrP in blood in August 2011, using the novel assay described by Edgeworth et al, was negative.
After careful and full consideration of ethical and legal issues in a patient who lacked capacity, the clinicians accepted the wishes of the patient's family to begin treatment with iPPS which commenced in October 2003. Biventricular catheters were inserted using a stereotactic procedure and a programmable pump was implanted subcutaneously. Treatment with iPPS was given at a dosage of 11 μg/kg/day and following replacement of the catheters in 2011 the treatment was continued at 11 μg/kg/day up until the patient died. In 2007, additional systemic treatment with PPS was given by programmable pump via the external jugular vein in a dosage increasing from 1µg/kg/day to 4 μg/kg/day. The treatment was stopped after 12 weeks because of persisting infection and haematoma at the pump site, and the pump was removed.
Despite the treatment there was neurological deterioration and by December 2003 the patient was unable to walk and needed assistance to dress, bathe, wash and feed. There was difficulty with swallowing and a percutaneous endoscopic gastrostomy tube was fitted in June 2005. Over subsequent years the patient's condition was relatively static with only subtle further clinical deterioration. She was wheelchair bound and fully dependent for activities of daily living. There was no verbal or clear sentient response, but at times the parents reported transient responsiveness to outside stimuli such as the pet dog or family videos, contrary to clinical observations. The patient received excellent care from her family, with additional nursing support and regular treatment by a physiotherapist.
The patient died suddenly in November 2011 and postmortem was carried out at the request of the coroner. The patient's family gave consent for detailed pathological investigation of the brain and peripheral tissues.


A 38-year-old woman was diagnosed with tongue cancer and received a hemiglossectomy. A tongue reconstruction was performed using a radial forearm free flap, leaving a defect 90×50 mm in size (). A dermal substitute was applied to the defect site (). After six months, the graft area was stable without any complication and with a good cosmetic outcome (). On skin analysis, the values for elasticity, humidification, skin barrier and melanin/erythema levels of the grafted skin were 0.63, 22, 9.6 g/hr/m2, and 165/356 AU, respectively. The values of the elasticity, humidification, skin barrier and melanin/erythema level of the surrounding normal area were 0.77, 33, 6.8 g/hr/m2, and 120/214 AU, respectively.


A 63-year-old man sustained a third-degree scalding burn involving his left foot (). After performing debridement, the dermal substitute was applied to the wound (). Ten months postoperatively, the incorporation of the graft and the aesthetic outcomes were good (). On skin analysis, the values of the elasticity, humidification, skin barrier and melanin/erythema levels of the grafted skin were 0.82, 29, 10 g/hr/m2, and 334/405 AU, respectively. The values of the elasticity, humidification, skin barrier and melanin/erythema levels of the surrounding normal area were 0.75, 51, 9 g/hr/m2, and 214/351 AU, respectively.


Our first patient was a 4-year-old Thai boy who had several wheat anaphylaxis since 9 month of age. The episode involved swelling of eyes and mouth, dyspnea, and abdominal cramping 5 minutes after licked a piece of cake roll.
At 18 months of age, he had similar symptoms after eating a French toast (size, 0.5 cm), then was diagnosed as wheat allergy. Later, he had another anaphylactic episode after eating macaroni soup. The investigations were performed when he was 3 years of age. Specific immunoglobulin E (IgE) to wheat and ω-5 gliadin were 518 kAU/L and 37.8 kAU/L, respectively. He also had allergic to egg white (specific IgE, 15.5 kAU/L), but not allergic to cow's milk, soy, or peanut.
Due to the severe nature of the symptoms after repeated unintentional exposures, the parent requested OIT which was conducted after informed consent was obtained from his father.
The patient underwent oral wheat challenge in semi-intensive care unit. The challenge procedure started with 1 mg of wheat flour (Kite All-purpose flour, 100% wheat; UFM Food Centre Co., Bangkok, Thailand), that was mixed with tomato sauce (all ingredients had been tested to assure that the patient does not allergic to them). Anaphylaxis was elicited at the dose of 300 mg. On the next day, oral montelukast, intravenous chlorpheniramine, and ranitidine were given 1 hour prior to OIT as premedications. The OIT was started with 150 mg of wheat flour, was then doubled every 2 hours, 2 or 3 times per day. The protocol, adverse events, and treatments are shown in . After 1 week, he was discharged with daily maintenance dose of wheat 500 mg for two months.
The total of 3 admissions for rush OIT protocol, intervening with maintenance period at home (2-5 months) was successful. The maintenance doses in each admission are shown in . He is currently taking 3 slices of bread (45 g of wheat flour) daily as maintenance dose at home, with urticaria once due to intake wheat more than the maintenance dose. His specific IgE to wheat and to ω-5-gliadin declined as shown in .


The second patient was a 14-year-old Thai boy who had his first wheat anaphylaxis episode at 4 months of age. After strict avoidance, he continued to have accidental exposures to wheat and developed repeated anaphylaxis about 1-2 episodes per year. The skin prick test was performed when he was 2 years of age, and showed positive result to wheat, but negative result to other food. His specific IgE to wheat and to ω-5 gliadin were 439 kAU/L, and 8.35 kAU/L, respectively. OIT was conducted after an informed consent was obtained from his parents.
The patient underwent double-blinded placebo controlled food challenge in semi-intensive care unit as in patient #1. The challenge procedure was started with 1 mg of wheat flour. The eliciting dose for anaphylaxis from wheat was 30 mg.
OIT was then started with a starting dose 8 mg with the same premedication as patent #1. The OIT protocol, adverse events, and treatment are shown in . At the end of the first week, he was discharged and was maintained at 160 mg of wheat per day.
One week later, he developed an anaphylaxis at home. So, the maintenance dose was reduced to 80 mg per day, and 300 mg of anti-IgE (Xolair, Novartis, Basel, Switzerland) was given with repeated dose every 4 weeks. Three weeks after the first dose of anti-IgE, he was admitted and could tolerate 1,200 mg of wheat per day, within five days. The amount of wheat intake in each admission, specific IgE for wheat, and ω-5 gliadin were shown in and . He is currently taking 60 g of wheat flour (4 slices of bread) per day without any symptoms. The anti-IgE was stopped after the 5th dose.


A 45-year-old woman with a 30-year history of palpitations presented herself for an electrophysiologic (EP) study and a catheter ablation. Her present arrhythmia was a LBBB morphology tachycardia (LBBB-T) at 200 beats/min which was converted into a sinus rhythm with intravenous adenosine. During the EP study, multipolar catheters were placed in the high right atrium (HRA), His-bundle region (His), right ventricle (RV), and coronary sinus (CS).
At the beginning of the EP study, the surface ECG did not show any BBB or intraventricular conduction delays (), and the baseline conduction intervals were within normal limits. The AH interval was 72 msec, and the HV interval was 54 msec. However, an RBBB occurred due to mechanical trauma during His-bundle catheter placement (). The baseline EP study showed ventriculo-atrial (VA) conduction was present through both the atrioventricular (AV) node and the concealed accessory pathway (AP) in the left posterior, which was blocked by 250 msec pacing with an AV Wenckebach cycle length of 310 msec. The clinical LBBB-T (cycle length: 330-350 msec) was easily induced by catheter-manipulation and spontaneous premature atrial complexes (). LBBB-T has several possible mechanisms including orthodromic atrioventricular reentrant tachycardia (ORT) with an LBBB aberration using a concealed AP, antidromic atrioventricular reentrant tachycardia (ART) using various types of right-sided APs anterogradely, RV VT, and bundle branch reentry VT.
shows that the LBBB-T terminated spontaneously and was followed by a sinus beat with a RBBB.
The LBBB-T terminated without any following atrial activation; therefore, VT with 1:1 retrograde conduction was ruled out. The His-bundle activation during the tachycardia preceded the beginning of the QRS complex, which ruled out an ART. The site of the earliest atrial activation during the LBBB-T was in the mid-CS rather than in the His-bundle. Delivery of premature ventricular stimulus during the His-bundle refractory terminated tachycardia without atrial activation. This confirmed that the tachycardia was an ORT using a concealed left posterior AP. Ablation was successful and the tachycardia could no longer be induced. After ablation, VA conduction was present through the AV node only, but a VA conduction block occurred at the VH level with a Wenckebach pattern (), which suggested a conduction abnormality in the His-Purkinje system or between the His-Purkinje system and the ventricle.


A 22-year-old female presented with fever off and on for 4 years and dull, aching, non-radiating pain in the epigastric and right loin region for 2 months. There was no associated hematuria. She complained of significant weight loss, mild loss of appetite and generalized weakness over the last 1 year. There was no history of hemoptysis, jaundice or bone pain. Examination revealed a thinly built young lady with normal blood pressure and no pallor, icterus, pedal edema, palpable lymph nodes or clubbing. Abdominal examination revealed a 15 × 12 × 12 cm ballotable lump in the right lumbar region that moved with respiration. There were no dilated superficial veins over the abdominal wall.
Blood investigations revealed a hematocrit of 34%, ESR of 20 mm in the first hour, platelet count of 126,000 with giant platelets on the smear and normal renal and liver function tests. Urine microscopy and chest X-ray were normal. On contrast-enhanced computed tomography (CECT) of the abdomen and pelvis, an 8.5 × 8.4 cm heterogeneously enhancing renal mass with solid and cystic components was seen extending into the right renal vein and IVC below the hepatic segment []. On delayed images, it was seen extending into the pelvicalyceal system with resultant hydronephrosis. Posteriorly, fat planes were preserved between the tumor and the abdominal wall; medially, it was in relation to the uncinate process of pancreas (with infiltration considered unlikely) and laterally it was abutting segments 5 and 6 of the liver (where infiltration could not be excluded). There were no other visceral or lymph nodal lesions.
She underwent open right radical nephrectomy with IVC thrombectomy using a transperitoneal approach (Chevron incision). The tumor was removed en bloc with IVC thrombus. There were no enlarged lymph nodes. The post-operative course was uneventful.
Gross examination revealed a tumor measuring 9 × 8 × 7 cm with a firm white surface on cut section, displacing the entire kidney and abutting the renal pelvis. A 2 cm fleshy mass with cut surface similar to the tumor was seen to extend out of the renal vein without infiltrating it (IVC thrombus). Light microscopy findings are described in . The stromal cells were negative for HMB45 [], SMA, CD34, Melan A, S-100 [], EMA [] and desmin on immunohistochemistry. Slides were reviewed by a second expert pathologist and the diagnosis of arteriovenous malformation of right kidney was confirmed.
She remained asymptomatic on follow-up for 2 years and there was no local recurrence on abdominal sonography. She has since married and has one child.


A 10-month-old female child, born of a third degree consanguineous marriage, presented with an inability to make eye contact and follow objects since birth. There was no significant history regarding the antenatal, natal and post-natal period. Developmental milestones had been reached normally.
General examination revealed platycephaly of the skull. Neurological and other systemic examinations were within normal limits. On ophthalmic examination, an absence of fixation with up-rolling of each eye was noted. The child did not follow any light or visual target and the pupillary reflexes were absent in both eyes. Ocular movements as tested by Doll's eye maneuver were normal. The ocular adnexa were also normal.
Anterior segment examination revealed bilateral anterior embryotoxon with bilateral microcorneas.
The right eye had an inferiorly placed pupil (corectopia) while the left eye had partial aniridia associated with a lens coloboma in the inferotemporal quadrant. There were no abnormalities seen on gonioscopy and intraocular pressures were within normal limits. Axial lengths were also within normal limits.
Ophthalmoscopy revealed the absence of both optic discs, which were represented by whitish, undefined round structures. Both, the disc area and the retina were devoid of retinal blood vessels. There was marked choroidal tessellation with multiple areas of chorioretinal atrophy seen bilaterally [Figures and ].
The ONs could not be seen on B-scan ultrasonography. Magnetic resonance imaging of the brain showed the presence of markedly thinned out ONs []. The optic chiasma and optic tracts were hypoplastic. Flash visually evoked potential (VEP) was unrecordable. There were no other CNS abnormalities detected.


A 32-year-old pregnant woman presented to our hospital at 12 weeks and 5 days of gestation for evaluation following detection of increased fetal nuchal translucency (NT). Her delivery history was G0P0A0. She and her 34-year-old husband had no family histories of congenital disorders or malformations. Prenatal maternal serum screening was normal, and prenatal fluorescence in situ hybridization, using probes of X, Y, and CEP 8 (Abbott Laboratories, North Chicago, IL, USA) according to the manufacturer's instructions, was unremarkable. Conventional G-banding karyotyping was performed on metaphase mitotic cells obtained from amniotic fluid, according to standard procedures. The results indicated a karyotype of 46,XX,del(7)(q21q22) (). Karyotyping results from both parents were normal. To delineate the precise breakpoint, genome-wide high-resolution microarray (Affymetrix Cytoscan 750K array, Affymetrix Inc., Santa Clara, CA, USA) was performed. A hemizygous deletion on 7q21.13q22.1, covering 90,625,014-103,430,901 bp region (), was detected. The final karyotype was concluded as 46,XX,del(7)(q21.13q22.1).
Fetal magnetic resonance imaging and ultrasonography (USG) were performed at 27 weeks and 3 days of gestation. No phenotypic abnormalities were detected except for increased NT to 4.5 mm. Mild polyhydroamnios was observed.
At 36 weeks and 5 days of gestation, the female fetus was delivered by caesarean section due to fetal distress. At birth, she exhibited poor-to-moderate crying and activity, and her 1- and 5-minute Apgar scores were 6 and 6, respectively. The neonate weighed 1,730 g (<3rd percentile), was 38 cm long (<3rd percentile), and had a head circumference of 30 cm (<3rd percentile). Laboratory tests including blood cell count, liver function test and arterial blood gas analysis were unremarkable. The following abnormalities were observed upon physical examination: low-set ears, ear malformation, palatine cleft, upslanted and wide palpebral fissure, micrognathia, microcephaly, short fingers on both hands, polydactyly between the second and third toes, cutaneous syndactyly of the first and second toes, and deformities of the first and fifth toes of the left foot ().
Serial head USG indicated asymmetric lateral ventriculomegaly, and transthoracic echocardiogram revealed a 2.5 cm patent ductus arteriosus (PDA) and a 2.4 cm atrial septal defect (ASD). Computed tomography scans of the neck and chest revealed subglottic tracheal stenosis and persistent left-sided superior vena cava (LSVC). Abdominal USG was unremarkable. Visual and audiologic examinations were not conducted due to the infant's young age, but auditory brainstem response testing indicated probable hearing loss. Repeat karyotyping using the infant's peripheral blood indicated a karyotype of 46,XX,del(7)(q21.13q22.1), identical to the results obtained from prenatal amniotic fluid sampling.
At manuscript submission, the infant had undergone PDA ligation surgery and was being treated in the intensive care unit of our hospital with oxygen supplementation, blood transfusion, and antibiotics due to repeated respiratory failure and infections.


A 65-year-old man, non-smoker, presented to a regional hospital with nonspecific chest pain and exertional shortness of breath for one week duration. He has history of long-standing hypertension and atrial fibrillation on oral warfarin therapy. He gave history of generalized fatigue, weight loss, over two-month period. He was diagnosed to have heart failure and treated.
He underwent a transthoracic echocardiogram, which revealed a multi-lobulated mass measuring 5.1 × 2.5 cm freely mobile in the right atrium (RA) [Figure and ], arrowheads, ]. In addition, there was another mass measuring 1.4 × 2.8 cm in the right ventricle [], arrowheads, ]. This was interpreted as either thrombus or cardiac tumor. His international normalized ratio (INR) was 2.6. He was referred to our center for transesophageal echocardiogram. Clinically he was afebrile, looking sick, emaciated with palpable hard right supraclavicular lymph node. Chest and cardiac examinations were unremarkable. There was no evidence of deep vein thrombosis. His chest X-ray showed cardiomegaly with mild bilateral pleural effusions. Electrocardiograph (ECG) demonstrated atrial fibrillation with controlled ventricular rate. On enquiry, he gave history of generalized fatigue, weight loss, over 2 month's period.
Repeat echocardiogram confirmed the previous echocardiogram findings Biventricular function was good and valves were normal. There was minimal posterior pericardial effusion.
Computed tomography (CT) of the neck, chest and abdomen/pelvis showed bilateral supraventricular lymph node enlargement with large superior and anterior mediastinal lymphadenopathy [, arrowhead], right upper lobe pulmonary artery intraluminal filling defects [, arrowheads], and multiple hypodense liver lesions in left lobe.
He was suspected to have metastatic carcinoma of unknown primary origin (CUP). Blood investigation revealed normal full blood count, urea, electrolytes, creatinine, negative blood and urine cultures, lactate dehydrogenase was 321 IU/L (n = 95-190), alkaline phosphatase 149 IU/L (n = 30-110), albumin 22 gm/L (n = 35-50), C-reactive protein (CRP) 174 mg/L (n < 5), and erythrocyte sedimentation rate (ESR) 34 mm/Hr (n = 0-20). Tumor markers like prostate-specific antigen, cancer antigen 125/19-9, alpha-fetoprotein, carcinoembryonic antigen and Beta-2 microglobulin were all within normal limits. Bone scan did not reveal any bone metastasis. Pleural fluid aspiration was negative for malignant cells. However, supraclavicular lymph node fine-needle aspiration cytology showed metastatic carcinoma suggestive of squamous cell carcinoma. He was seen by multidisciplinary team and found to be in advanced stage of cancer and ineligible for any specific treatment. He died after 2 weeks of admission.


A 9 year old female child presented to our hospital with difficulty in performing tasks like writing or holding an object. However, she had no significant difficulty in her daily activities.
There was absence of flexion movement at interphalangeal (IP) joints of bilateral thumbs. The child did not give any history of trauma. Family history of any birth defect was also absent.
Local examination revealed minor hypoplasia of the thumbs and absence of dorsal wrinkles [] and flexion creases [] at the IP joints of both the thumbs. Thenar eminence atrophy was present []. Active flexion at the IP joints of bilateral thumbs was absent. Thumb opposition was also weak. Functional limitation in holding a pen was documented []. Movements of all other joints of the hand were normal.
Radiograph of hands showed mild skeletal and soft tissue hypoplasia of bilateral thumbs [].
Magnetic resonance imaging (MRI) of hands showed absence of bilateral FPL muscles. In addition, there was absence of flexor pollicis brevis (FPB) and abductor pollicis brevis (AbPB) muscles and hypoplasia/atrophy of bilateral opponens pollicis (OP) muscles. Bilateral adductor pollicis brevis (AdPB) muscles appeared normal in morphology [].
After pre-anesthetic checkup, the patient was planned for FPL reconstruction in bilateral thumbs. Two-staged surgery was planned; in the first stage, flexor pulley was reconstructed, and 2 months later, FPL reconstruction was done using flexor digitorum superficialis (FDS) tendon to the ring finger. Postoperative physiotherapy was done to increase the range of motion (ROM) of the IP joints of both thumbs. At this moment, the patient has achieved ~20° of flexion at the IP joints bilaterally.


A 78-year-old male smoker patient diagnosed to have non-small cell lung cancer (NSCLC), stage IV (adrenal and liver metastasis) was subjected to whole body bone scan to detect skeletal metastases, if any. The patient had received local palliative radiotherapy 20 Gy/5# for 1 week and was on chemotherapy with gefitinib since 12 days. There was no history of bone pain or skeletal trauma. Bone scintigraphy was performed 3 h after intravenous injection of Tc99m-methylene diphosphonate. Increase in tracer uptake was noticed in the lower cervical vertebrae, right first rib, and medial cortical margin of the lower third of shaft of left femur [Figure and ]. Hybrid single photon emission computed tomography/computed tomography (CT) localized the cervical uptake to left articular process of C6 and left transverse process of C7 vertebrae with dense sclerotic changes likely degeneration due to altered weight distribution.
CT scan of the lower third of the left femur showed lysis of the anteromedial cortical margin with no soft tissue component [Figure and ]. On the basis of bone scan and pattern of cortical bone destruction, the diagnosis of a skeletal metastasis from a bronchogenic carcinoma was suggested.


A 60-year-old man from southern British Columbia presented ambulatory, in the spring of 2011, to a Vancouver area ED for further evaluation of intermittent headaches, generalized weakness, fatigue, hyponatremia, weight loss, and a recent hearing deficit. The headache and malaise symptoms had been present for two months and started when the patient and his wife vacationed in southern California. While golfing there, he experienced a thunderclap headache associated with fever, nausea and vomiting. The patient sought care at an urgent care facility and was immediately referred to the ED of a nearby academic hospital where he had a CT scan of the head, was diagnosed with sinusitis, and discharged with a prescription for clarithromycin. When his symptoms failed to improve, he returned home to British Columbia, was evaluated at another ED, and given an oxycodone prescription for symptomatic relief. The patient was then followed up with his primary care clinician who ordered an outpatient CT scan of the head which showed sinusitis. Despite completing a second course of antibiotics- moxifloxacin, the patient continued to experience headache, malaise and fatigue. A finding of hyponatremia and worsening symptoms prompted a referral to the ED by his family physician.
The patient, a retired communications technician with no significant past medical history and whose only medications included oxycodone and acetaminophen, denied alcohol abuse, illicit drugs use, any known sick contacts, or other recent travel. He gave no history of trauma, change in vision, chest pain, cough, shortness of breath, abdominal pain, night sweats, focal weakness, paresthesias, incontinence, rash, or joint pain but admitted to a recent 10 pound weight loss, debilitating fatigue, intermittent low grade fever and, of most concern to him, gradual hearing loss which he attributed to wax build-up.
His triage vital signs were temperature 37oC (98.6oF), heart rate 127 beats/min, respiratory rate 17 breaths/min, blood pressure 118/57 mmHg, and room air oxygen saturation 98%. The patient was well-developed but appeared fatigued. The external auditory canals were full of cerumen with bilateral decreased hearing which did not improve after wax removal. His neck was supple without lymphadenopathy. The oral cavity and pharynx showed normal mucosa and good dental hygiene. Cardiovascular examination revealed tachycardia without a murmur. Respirations were unlabored and both lungs were clear to auscultation. The abdomen was soft and non-tender with no hepatosplenomegaly. The skin was warm, dry, and without a rash. Aside from subtle hearing loss and lethargy, neurological examination revealed intact cranial nerves, motor function (normal tone coordination and muscle strength against resistance), and symmetrical deep tendon reflexes.
Laboratory examination revealed that the patient had WBC of 13 800/L with a neutrophil predominance and a hemoglobin level of 12.4 gm/dL. A chemistry panel was significant for adescreased sodium of 127 mmol/L, potassium 3.3 mmol/L, and chloride 91 mmol/L. Urinalysis, TSH and liver functions tests were normal. HIV antibody was negative. Chest X-ray and head CT angiogram were unremarkable. A lumbar puncture revealed an elevated opening pressure of 27 cmH2O with colorless cerebral spinal fluid (CSF) containing 59 WBC (38% neutrophils, 42% lymphocytes, 20% monocytes), 6 RBC, a low glucose of 40 mg/dL, and elevated protein level of 2.9 g/L. A cryptococcal antigen titer was strongly positive (> 1:1 024).
The patient was immediately given amphotericin B and flucytosine in doses for the immunocompetent host and admitted to the hospital. Several days later, Cryptococcal species were identified as C. gattii. Upon further questioning, the patient recalled that he had visited Vancouver Island seven months earlier. After two months of hospitalization, the patient was eventually discharged neurologically intact except for a continued mild bilateral hearing deficit.


A 63-year-old man visited our clinic for treatment of gastric HGD. The patient was referred to our clinic after a biopsy revealed a 1-cm active ulcerative lesion, identified as a microfocal tubular adenoma with HGD, after 2 months of proton pump inhibitor use and 1 week of Helicobacter pylori eradication treatment (). Upon physical examination, the patient exhibited no specific symptoms or abnormalities. The patient had no history of alcohol use or smoking, and no history of specifically diagnosed medical conditions. Blood tests showed that the white blood cell count was 5,340×103/µL; hemoglobin, 13.9 g/dL; and platelet count, 245×103/µL. All other laboratory findings were within normal limits. No specific gastric wall abnormalities or lymph node enlargements were noted on an abdominal computed tomography scan. The patient underwent a repeated upper endoscopy in our clinic for a more exact evaluation of the previously proven gastric dysplasia. A 7-mm, discolored, nodular lesion (previously found to be HGD) was noted at the lesser curvature side of the low body (); therefore, we obtained two biopsy samples. A second elevated and nodular lesion was noted at the entire angle, and two biopsy samples were obtained from the more prominent nodular lesion located at the anterior wall of the angle (). Both lesions revealed HGD; therefore, we planned to perform ESD for HGD treatment.
ESD was performed under conscious sedation, using midazolam and propofol, in the hospital on day 1. No complications such as bleeding or perforation were observed after the procedure. The first lesion (located at the lesser curvature side of the low body) measured 0.7×0.5×0.5 cm in size, and was found to be low-grade dysplasia. The second lesion, at the center of the angle, measured 1.2×0.7×0.5 cm in size, and was found to be HGD. However, lateral margin involvement was observed at both lesions. Postoperative diet was started at day 3, and the patient was discharged the same day. After 6 months, follow-up upper endoscopic biopsy was performed, and HGD was again detected. We attempted ESD a second time, but were not successful because of diffuse edema and uncertain margins.
If the results of the follow-up endoscopic biopsy had been EGC, we might have chosen a gastrectomy with regional lymph node dissection. However, since the biopsy result was HGD, we wanted to preserve as much of the stomach as possible. After detailed consultation, we undertook laparoscopy-assisted EFTR to treat the gastric dysplasia.
Surgery was performed with the patient under general anesthesia, and lasted 2 hours and 20 minutes. The patient received an antibiotic injection; then, a 12-mm initial access site was established at the periumbilicus. After a forward-viewing laparoscope was introduced through the periumbilical trocar, a pneumoperitoneum was created with carbon dioxide, and two additional trocars were placed. An upper endoscope with a transparent cap was also used. We marked the normal mucosa surrounding the lesion with APC (), then injected fluid into the affected submucosa. An initial cut (precut) was made with a needle knife outside the sealed area; then, an insulation-tipped knife was inserted into the precut incision, and used to create a circumferential submucosal incision (). A small puncture was made on one side of the lesion (), and full-thickness resection was performed with an IT-2 knife around three-quarters of the circumference (). A harmonic scalpel was used to liberate the remaining quarter of the circumference under laparoscopic supervision. The defective gastric wall was closed manually after a mini-incision, and a leakage test using endoscopic air inflation was carried out after the closure.
The postoperative diet was started at day 5, and patient was discharged at day 10 without complications. The excised portion of the lesion was measured at 4.2×3.0×1.2 cm. The final pathological report revealed HGD with a focal intramucosal carcinoma of 0.8×0.7 cm (). No lymphovascular invasion or resection margin involvement was detected. Therefore, we conclude that the lesion was completely resected.


A 70-year-old man with an unremarkable medical history was hospitalized with a complaint of epigastric pain. Physical examination revealed epigastric tenderness; however, other examination findings were normal. No abnormal findings were detected on laboratory and radiologic examinations. Serum total cholesterol, triglyceride, high density lipoprotein cholesterol, and low density lipoprotein cholesterol levels were 151, 215, 33, and 102 mg/dL, respectively. Endoscopic examination was performed to find the cause of the epigastric pain. Multiple shallow gastric ulcers and a duodenal ulcer were detected and suspected to be the cause of the pain. Aspirin medication was the suspected cause of the multiple ulcers. Besides the ulcers, in the upper esophagus 20 cm from the incisors, a 3-mm yellowish granular elevated mucosal lesion was found and a biopsy was performed (). Microscopically, large round cells were aggregated in the lamina propria immediately beneath the squamous epithelium. The cells had small nuclei that were centrally or eccentrically located. The cytoplasm was sparse and contained vacuoles (). The lesion was diagnosed histologically as xanthoma of the esophagus.


This was a case of a 47-year-old female patient who presented to the surgical gastroenterology division of our institute with epigastric pain, decreased appetite and vomiting for the preceding 2 months. She also had six to seven episodes of hematemesis and melena. She was hemodynamically stable at the time of presentation. Laboratory tests revealed hemoglobin of 10.1 g/dl with normal renal and liver function tests. Upper gastrointestinal endoscopy showed a narrowing at the gastro-esophageal (GE) junction and edematous, friable mucosa with multiple hemorrhagic erosions and ulcerations throughout the stomach, suggestive of malignancy. However, the initial biopsy was non-contributory. The patient was subsequently put on a feeding jejunostomy. A contrast enhanced computed tomography showed asymmetric circumferential mural thickening, from the cardia to the pylorus in a less-distended stomach and extensive fat stranding in the adjacent omentum; free fluid was also noted in the perihepatic and perisplenic locations and a sclerotic focus was detected in the L4 lumbar vertebra. The patient then underwent FDG PET [–] is to rule out any distant metastases. Intense diffuse FDG uptake (maximum standardized uptake value 12.1) was seen in asymmetric circumferential mural thickening involving the GE junction and the entire wall of the stomach. FDG uptake was also noted in the perigastric fat stranding. A few faintly FDG avid supradiaphragmatic lymph nodes were also seen. The vertebral lesion did not show any FDG uptake. Subsequent biopsy from the antro-pyloric region was suggestive of a poorly differentiated adenocarcinoma of signet ring type. Faint FDG avid ascites was also noted in the pelvis, which was positive for malignancy by cytology. Thus, metastatic disease was confirmed and the patient was managed with palliative treatment, avoiding surgery.


A 78-year-old woman presented for a routine ophthalmological consultation reporting an uncomplicated bilateral cataract surgery in a private clinic 3 years before. A hydrophobic acrylic IOL (AcrySof®; Alcon Laboratories, Inc., Fort Worth, TX, USA) was implanted in the capsular bag bilaterally. There was no known history of glaucoma or OHT. Best-corrected visual acuity (BCVA) was 8/10 oculi uterque (OU) and intraocular pressure (IOP) was 18 mmHg in both eyes. Anterior segment biomicroscopy revealed XFM in the pupillary border and on the anterior surface of the IOL in the right eye (). Posterior segment examination was unremarkable.


A 68-year-old man was evaluated in a routine ophthalmological examination. He had been submitted to uncomplicated bilateral cataract surgery 2 years before, with implantation of a hydrophilic acrylic IOL (Akreos® Adapt; Bausch & Lomb Incorporated, Bridgewater, NJ, USA) in the capsular bag. There was no history of glaucoma or OHT, and the patient had no eye complaints. His BCVA was 10/10 OU and IOP was 16 mmHg in both eyes. Slit lamp examination of the left eye showed XFM in the pupillary border and on the anterior surface of the IOL (). Fundoscopy was unremarkable.