A 4-month-old-male infant presented with eroded, erythemato-squamous eruption characterized by dry, scaly and crusted skin lesions, almost symmetrically distributed in perioral, acral and perineal areas (a–d). The fingers and the toes were also involved areas, except for the nails. The patient was born prematurely at 28 weeks (weight at birth: 1200 g) to healthy and unrelated parents in a chorioamnionitis context. Parallel to enteral breast milk feeding, parenteral nutrition was instituted since birth and continued to the 20th day of life. Oligo-elements supplementation, including zinc, was continued until the 34th week of corrected postnatal age (6th week of life) since he was exclusively breast-fed. Statural and weight growths were normal for his corrected age (weight at age of 4 months: 4450 g). At admission, at the age of about 4 months, when the rash first appeared, irritability, diarrhea, and alopecia were associated symptoms.
Impetiginized dermatitis, candidiasis and contact dermatitis were other possible causes. The skin lesions were not typical of candidiasis, fungal infections being excluded by microbiological samples as well. Moreover, the patient’s age and the localization of skin eruptions were not in favor of a contact dermatitis. The impetiginized dermatitis was disproved by the topography of the rash, additional microbiological assessments, and the favorable evolution without antibiotics.
Laboratory and biochemical studies showed decreased zinc levels in the infant’s serum (20 mcg/dL, normal range 67–118 mcg/dL), and maternal serum (68 mcg/dL, normal range 73–137 mcg/dL), as well as in the breast milk (29 mcg/dL compared to the value of 300 mcg/dL of the maternal milk’s control sample). The albumin and alkaline phosphatase (ALP) values in the infant’s serum were normal. The child had methicillin-resistant Sthaphylococcus Aureus (MRSA) and extended spectrum beta-lactamase (ESBL) bacterial colonization of skin lesions. A MRSA decolonization was realized. No other micro-organism was found. Sequencing of the SLC39A4 gene showed no mutation, excluding classical acrodermatitis enteropathica.
Zinc supplementation was instituted orally at 5 mg/kg/day. The skin lesions improved significantly within three days and resolved completely after 15 days (e–h). Long term evolution was favorable after weaning.


This case report highlights a 57-year-old woman who received five months of chemotherapy for breast cancer completed in 2016. The participant’s Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity (FACT/GOG-Ntx) score was 133/152. She specifically reported tightness and discomfort in her hands, lower extremity joint pain, muscle cramps, and generalized weakness. She reported no comorbidities associated with polyneuropathy.
Force plates are the gold standard measurement for assessing postural balance []. The BTrackS is a low-cost, portable force plate that is accurate and reliable. The BTrackS mCTSIB protocol quantifies balance by tracking the center of pressure (CoP) during various sensory manipulating conditions. The measured path length represents the total horizontal distance (front to back and side to side) travelled by the CoP. Large values of path length indicate more movements, suggesting less control of the maintenance of balance. The mCTSIB protocol measures standard, proprioception, vision, and vestibular contributions toward balance []. The protocol consists of four 20-second trials with breaks between each trial (< 10s), standing as still as possible with their hands on their hips and feet shoulder-width apart. In the first trial, the participant stood with their eyes open measuring the ‘standard’ condition, or uncompromised condition. In the second trial, the participant stood with their eyes closed measuring the ‘proprioception’ condition. For the third trial, the participant stood on a foam pad with their eyes open measuring the ‘vision’ condition. In the fourth and final trial, the participant stood on a foam pad with their eyes closed measuring the ‘vestibular’ condition. To better understand the balance measures of the case participant, we compared the results to normative data of a healthy sample of similarly aged women [].
The TUG is a reliable and valid measurement for dynamic balance and may be useful to identify clinical changes over time []. The participant was instructed to start seated in a standard height chair, stand up, walk 3m, turn around, and sit back down. Time started when the researcher said “go,” and ended when the participant’s glutes touched the seat of the chair. Time was measured using a stopwatch to the nearest 0.1s [].
Outcomes
The participant demonstrated poor balance control in all conditions. She had a path length (cm) in standard (eyes open/firm) of 43, proprioception (eyes closed/firm) 110, vision (eyes open/foam) 81, and vestibular (eyes closed/foam) 133. In comparison to normative data for 50- to 59-year-old women (Figure ) [], the participant’s path length was between the 1st and 10th percentile in the vestibular condition, and below the 1st percentile in standard and vision conditions. Moreover, the results indicate the proprioception contribution toward balance control was severely compromised, with the participant’s path length in this condition more than double the largest values of the normal range. The participant also had an 8.28s TUG time.


Patient 2 is a 32-year-old female HA patient (FVIII 3%; heterozygous for F8 intron 22 inversion) with no family history of HA. Her HA phenotype results from a sporadic mutation on her paternal X chromosome, combined with skewed inactivation of her maternal X chromosome. X chromosome-targeted WES analysis identified a missense mutation in the synaptotagmin-like protein 4 (SYTL4) gene (NM_001129896; c.1655A > C; p.K552T) encoding the SYTL4 protein, which is involved in intracellular membrane trafficking via interaction with Rab GTPases. Based on segregation studies, patient 2 (A) inherited the mutant SYTL4 gene from her mother (C), who also demonstrates skewed XCI (). Both her sisters and her brother received the X chromosome bearing a normal copy of the SYTL4 gene (D–F). Both sisters demonstrate normal random patterns of XCI ().
Patient 2 chose spontaneous pregnancy with neither PGD nor prenatal diagnosis, eventually giving birth to a boy with severe HA.


A 78-year-old non-smoking Caucasian man came to our attention for the first time after undergoing coronary computed tomography angiography documenting multivessel coronary artery disease. He had consistently high levels of low-density lipoprotein cholesterol (LDL-C) and lipoprotein(a) (Lp(a)) and a family history of early-onset CVD in first-degree relatives. Comorbidities were chronic myeloid leukemia (CML), recurrent prostate cancer, hypertension with left ventricular hypertrophy (LVH), recurrent deep-vein thrombosis (DVT), non-alcoholic fatty liver disease (NAFLD; FibroScan fibrosis score F0 to F1) and Type 2 diabetes. For these reasons, by the time the patient was on pharmacological treatment with 500 mg metformin twice a day; triptorelin, 75 mg acetylsalicylic acid, 40 mg pantoprazole, cholecalciferol, 5 mg amlodipine, 16 mg candesartan, 2.5 mg indapamide and 2.5 mg bisoprolol twice a day; and ezetimibe. He was treated with an intermittent imatinib schedule (alternate months on and off imatinib). He had a personal history of intolerance to statins even at the lowest doses because of disabling muscle cramps and increased creatine kinase (CK) serum levels judged to be clinically relevant. These symptoms disappeared after withdrawal of statins and recurred after rechallenge with statins, supporting a causal effect.
He was started on treatment with the PCSK9 inhibitor evolocumab, 140 mg subcutaneously (SC) every 2 weeks (QW2). Treatment-emergent changes in lipids and lipoproteins were long-lasting () and consistent with our previous observations [], and the medication was well-tolerated by the patient in the long term and correctly assumed over time. Unexpectedly, after 2 years of continuous treatment with evolocumab, serum lipids increased (), apparently without any reasonable explanation.
The possibility that the patient may have developed an acute condition potentially reducing the effect of evolocumab had to be investigated. The most plausible explanation for the increase in serum lipids was that the patient had thyroiditis. We planned additional laboratory tests, but his hormonal thyroid test was normal (thyroid stimulating hormone = 2.30 μU/mL) and thyroid antibodies were negative.
We then speculated that the patient missed the drug injection, even though he was firmly claiming that he had regularly taken the drug. After discussing with the hospital pharmacy service director who was responsible for the drug utilization review (DUR), we were able to ascertain that the patient had not received fewer injections than prescribed. Moreover, the patient’s wife confirmed that her husband was very careful to administer the drug in the right time window (i.e., once every 14 days). However, even though the patient was supposed to have been administered evolocumab the day before the visit, on physical examination, he did not have any puncture marks into the appropriate injection sites (i.e., abdomen, thighs or upper arms), suggesting no recent administration of the drug in those areas. On the contrary, an injection mark was clearly distinguishable on the patient’s right thumb.
By repeating the drug administration procedure with a sham injection during the follow-up visit, the patient was found to have habitually injected evolocumab into his right thumb after turning the injector upside down ().
After retraining the patient on proper care, the levels of plasma lipids fell back again (total cholesterol = 106 mg/dL; LDL-C = 25 mg/dL; Lp(a) = 49.7 mg/dL) and our hypothesis was definitely confirmed.


A 69-year-old Japanese man presented with pain and a polypoid mass on the lower left gingiva for which he consulted in our hospital. He had received chemoradiotherapy for SCC of the buccal mucosa 15 years prior to this consultation at the age of 54 years. At that time, he had an ulcerative lesion with a reddish and rough surface in the buccal mucosa including the corner of the mouth (Fig. A). The patient was a plasterer, and asbestos exposure was not apparent. He had no relevant medical history, including no history of smoking and alcohol consumption. The lesion was diagnosed as moderately differentiated SCC following a biopsy (Fig. B, C). Radiological examinations suggested a cancer metastasis in the left submandibular lymph node, and he received chemotherapy with cisplatin (total 110 mg) and 5-fluorouracil (total 2925 mg) via peripheral venous route and concomitant radiotherapy: the primary tumor and neck were irradiated at the dose of 70 Gy, performed in the hospital for 4 months. The treatment resulted in a complete clinical remission of the primary tumor (Fig. D) and a complete remission of the neck lesion, which was pathologically confirmed as metastasis composed of nonviable SCC cells (data not shown). No recurrence was detected in subsequent years; however, he developed mandibular osteonecrosis 6 years after chemoradiotherapy and was treated with oral roxithromycin.
On examination at the age of 69 years, his vital signs were within normal ranges. He developed Parkinson’s disease a year before this consultation, and the disease was well controlled with oral levodopa (300 mg/day) and benserazide hydrochloride (85.5 mg/day). He showed trismus; however, he had no other abnormal physical and neurological findings. On intraoral inspection, a polypoid mass measuring 10 mm in diameter was found in the left molar region of the lower gingiva (Fig. A). Its surface was rough and covered by a whitish pseudomembrane. Panoramic radiography showed bone resorption, exhibiting a moth-eaten appearance that involved the base of the mandible (Fig. B). Contrast-enhanced computed tomography revealed a soft-tissue mass lesion accompanied by extensive bone resorption of the mandible (Fig. C, D).
A malignant tumor was suspected, and a biopsy specimen from the polypoid lesion was obtained. The polypoid mass was composed mainly of loose granulation tissue (Fig. A), where atypical spindle or pleomorphic cells were scattered in the fibrin-rich edematous or pale stroma together with neutrophils, lymphocytes, and capillary endothelial cells (Fig. B). The surface of the lesion was mostly ulcerated but partially covered by squamous epithelium with no obvious atypia; only slight nuclear enlargement and disordered basal cell polarity were noted (Fig. C). In the subepithelial tissue, atypical spindle cells were arranged haphazardly and exhibited large, basophilic cytoplasm and bizarre nuclei (Fig. B, C). Some of them exhibited mitotic figures, some of which were atypical (Fig. D, E). Neutrophils were frequently incorporated within their cytoplasm (Fig. E–G), some of which appeared to be degraded with missing nuclei (Fig. E, G, arrows).
Immunohistochemistry revealed that atypical spindle cells were positive for vimentin (Fig. A) and α-smooth muscle actin (Fig. B), but not for pan-cytokeratin (Fig. C). No epithelial markers other than p63 were detected (Table ). The spindle cells were partially positive for p63 (Fig. D), and most were positive for p53 (Fig. E). Ki-67 staining was observed in approximately half of the cells (data not shown). Furthermore, granular CD68 staining was observed in the cytoplasm (Fig. F). These findings were highly suggestive of a malignancy, and SCSCC and post-irradiation sarcoma were considered in the differential diagnosis, given that the patient had a history of chemoradiotherapy for treating SCC of the buccal mucosa 15 years before.
Although the final diagnosis had not been determined, the patient was admitted to our hospital for surgery. On admission, his height and body weight were 145 cm and 45.7 kg, respectively, and vital signs were within normal range (blood pressure 127/79 mmHg, pulse 68 beats/minute, and body temperature 36.0 °C). Complete blood count showed mild anemia (red blood cells 4.07 × 1012/L, hemoglobin 128 g/L, hematocrit 36.0%, mean corpuscular volume 90.4 fL, mean corpuscular hemoglobin 31.4 pg, mean corpuscular hemoglobin concentration 348 g/L, white blood cells 5.49 × 109/L, and platelets 130 × 109/L). The biochemical test results of blood and urine were within normal ranges with the exception of a mild elevation in C-reactive protein (8.7 mg/L), which was presumably caused by the gingival tumor. He underwent hemimandibulectomy pursuant to a clinical diagnosis of a malignant tumor. The postoperative course was uneventful.
The hemimandibulectomy specimen had a protruding tumor that exhibited an ulcerated surface and that measured 23 × 15 mm from the gingiva to buccal mucosa (Fig. A). The location of this tumor was not the same site of the previous tumor. On the cut surface, there was a whitish and solid lesion invading the mandibular bone (Fig. B, left). Histologically, most of the lesion was composed of conventional SCC, measured 45 × 25 × 15 mm in size, and invaded the mandibular bone extensively (Fig. B, right and Fig. C). The spindle cells were distributed near the SCC foci, mostly in the remaining polypoid segment (Fig. D). Because the atypical spindle cells were concomitant with the conventional SCC component, we finally diagnosed the lesion as SCSCC. The tumorous spindle cells frequently contained neutrophils within the cytoplasmic vacuoles (Fig. E, F), forming cell-in-cell figures. Such figures were much rarer in the conventional SCC cells. Intense staining for lysosomal-associated membrane protein 1 (LAMP-1) and cathepsin B, which are both lysosomal markers, were observed around the vacuoles containing the neutrophils (Fig. G, H). This suggested that such cell-in-cell figures may result from the phagocytosis of neutrophils rather than from emperipolesis. The patient has had no evidence of recurrence 5 years after the surgery.


A five-month-old pre-term male neonate was born by cesarean section at 35 gestational weeks due to a macrocephaly. The birth weight was 2.8 kg. He was transferred to the neonatal intensive unit (NICU) for approximately one month and intubated for two weeks and then moved to the nursery for observation for two months without the involvement of Otorhinolaryngology. The patient had a history of paramedian facial cleft, craniofacial anomalies (occipital scalp defect, midface hypoplasia, absence of the right nasal ala, incomplete cleft lip, and right medial epicanthal fold defect), kyphoscoliosis, central hypotonia, congenital heart disease, and recurrent history of upper respiratory tract infections. He underwent ventriculoperitoneal shunting for the treatment of hydrocephalus.
The patient presented at the emergency department of King Abdulaziz Medical City with two episodes of apnea in two days, with cyanosis around the mouth for less than one minute (both episodes resolved spontaneously), dyspnea, poor feeding, decreased activity, fever, and increased nasal secretions. He was admitted to the pediatric intensive care unit (PICU) as a case of bronchiolitis to rule out sepsis. He was then referred to the otorhinolaryngology clinic for difficulty breathing and continuous mucoid nasal discharge.
The examination revealed a febrile (39 ºC), pre-term male neonate, in evident respiratory distress, with a respiratory rate of 60 cycles per minute, noisy breathing, chest retraction, and Sp02 of 70% in ambient air, maintained at 92% with the use of an 8-liter non-rebreather face mask. Examination of the eyes showed hypertelorism, downward deviation and slanting of the right eye, proptosis, and difficulty closing the eyes. Nasal examination showed a retracted right ala and a large volume of nasal secretion (Figure ). Attempts to pass an 8-Fr suction catheter tube met resistance 4 cm into the nasal cavity, and fiberoptic endoscopic examination showed bilateral CA. Oral examination showed that the patient was a mouth breather, with a retracted upper lip and a high arched palate.
Ear examination showed no preauricular skin lesions (tags or pits) or deformity in the pinna or tympanic membrane. However, the ear retained its normal shape, but the left ear appearing larger than the right ear. Computed tomography (CT) of the paranasal sinuses revealed bilateral mixed type CA (Figure ). Additionally, an MRI of the brain was performed on the same hospital admission. The findings were consistent with holoprosencephaly and schizencephaly (Figure ).
The patient underwent surgery to repair the CA at a weight of 3.2 kg. He was laid in a supine position, pre-oxygenated, and intubated. The throat was then packed with wet gauze. Shoulder support was placed, and the head stabilized on a head-ring. Head dressing was applied, and the rest of the body was covered with a sterile drape.
The nasal cavities were prepared using drops of 0.5% xylometazoline for decongestion. The bilateral CA was approached via the endoscopic transnasal route. The bilateral atresia was gently punctured with a sickle knife, and an incision was performed in the medio-inferior part of the posterior choana. The flap was elevated successfully, the vomer removed, and the bony boundaries (pterygoid) were widened laterally using a curette. Adequate bilateral choanal openings were created (Figures , ).
The patient had an uneventful recovery postoperatively and was discharged after a few days. At the three-week follow-up, he gained weight (4.6 kg), and his symptoms improved. Six weeks after surgery, he demonstrated adequate choanal openings bilaterally, no further episodes of nasal obstruction, no difficulties in breathing or feeding, and further weight gain (5.5 kg).


A 27-year-old man was referred to our hospital for lung transplantation evaluation. His history included acute myeloid leukemia at age 20 years, for which he underwent bone marrow transplantation (BMTx) 1 year after the diagnosis with fully matched human leukocyte antigen typing. Three years later, he reported dyspnea on exertion and was diagnosed with bronchiolitis obliterans caused by chronic graft-versus-host disease (Fig. a). He suffered from invasive pulmonary aspergillosis during his treatment with high-dose inhaled steroids, bronchodilators, and antimicrobial drugs. Home oxygen therapy was initiated because of type II respiratory failure. Four years after BMTx, his condition worsened, requiring mechanical ventilation. He was eventually discharged home with a tracheostomy and mechanical ventilation. At the time of referral back to our hospital, his condition was relatively stable, and he could undertake moderate activities of daily living. He was fully committed to his rehabilitation. A multidisciplinary transplantation selection committee at our hospital deemed him suitable for lung transplantation. After obtaining his consent, we enrolled him on Japan’s national lung-transplantation list.
After about a year at home, he developed a right pneumothorax that eventually required thoracotomy. Four months later, he developed a left pneumothorax, which exacerbated carbon dioxide retention. Although the pneumothorax was managed with chest drainage and pleurodesis, the carbon dioxide retention and resulting acidosis were barely manageable with conventional mechanical ventilation, which ultimately necessitated VV-ECMO. ECMO was established via the right internal jugular vein (using a 23-Fr cannula) and the left femoral vein (with a 21-Fr cannula) (Fig. ), after which he was transferred to an ECMO center at Nippon Medical School Hospital to await lung transplantation.
About 2 weeks later, he developed another left hemopneumothorax. Chest tube drainage resulted in a massive hemothorax, necessitating open thoracotomy for hematoma removal and hemostasis. He attained relative stability despite a few septic episodes caused by Bacillus cereus.
On day 111 of ECMO, however, he developed hemoptysis. Computed tomography revealed intrapulmonary bleeding in the right lung (Fig. ), requiring catheter embolization of the right bronchial artery. On day 129 of ECMO, there were signs of acute inflammation, including an elevated C-reactive protein level (25 mg/dL). Although blood cultures remained negative, the ECMO cannulas were moved to the left jugular vein (19-Fr cannula) and right femoral vein (23-Fr cannula) (Fig. b). On day 136 on ECMO, with his general condition continuing to deteriorate, a suitable donor was identified, and the patient was readmitted to our hospital. During the pre-transplant waiting time on VV-ECMO, he had been treated with continuous unfractionated heparin. His activated partial thromboplastin time (APTT) was maintained at around 40–60 s. When bleeding occurred, the APTT was controlled at around 35–40 s. His activated clotting time was also monitored and maintained within the range of 160–200 s. After stabilization, he could eat and drink to some extent but still required mechanical ventilation (Fig. a). His rehabilitation was limited because a double-lumen cannula for VV-ECMO was not available in Japan.
At admission, enhanced computed tomography had revealed limited access to the patient’s major veins because of previous cannulation. We therefore consulted with a cardiologist, who inserted a Swan–Ganz catheter through the left subclavian vein (chosen because it appeared to be the only accessible major vein) preoperatively.
Bilateral lung transplantation began with continuous VV-ECMO. Severe adhesions in both thoraces made the procedure challenging. In addition to his history of bilateral thoracotomy, his right lung was inflamed and hard, making it impossible to collapse and difficult to mobilize. After dissecting as much of the intrathoracic adhesions as possible, we switched to veno-arterial ECMO by cannulating the ascending aorta, using two already existing venous cannulas for drainage. Standard pneumonectomy and graft anastomosis were performed with a reasonable ischemia time (left lung: total ischemia 8 h 21 min, warm ischemia 42 min; right lung: total ischemia 11 h 50 min, warm ischemia 52 min). Total blood loss was 34,930 mL.
After reperfusion of the bilateral lungs, we planned to maintain central veno-arterial ECMO because of the massive bleeding and transfusion, the long-term ECMO, and the patient’s unstable preoperative condition. However, the diffuse intrathoracic bleeding was so difficult to control that a half-dose of protamine was administered. Although it resulted in reasonable hemostasis, the membranous oxygenator clotted, with suddenly decreased ECMO flow. Fortunately, the patient’s vital signs, including oxygenation, remained stable despite the diminishing ECMO support.
His postoperative course was uneventful, and 94 days after transplantation he was transferred elsewhere for rehabilitation. He has remained in good condition for 2 years 8 months since the lung transplantation without significant complications (Figs. c, b). The long-term non-ambulatory VV-ECMO therapy, however, seems to have interfered with his left leg movement, although it is slowly improving.


A 46-year-old male presented to the Emergency Department with a history of fever and intractable pain in the right groin. The patient was a known IV drug user without any other underlying medical condition. He had multiple past hospital admissions for various reasons. The inflammatory markers including C-reactive protein and white cell count were elevated.
He was referred to the Radiology Department for CT angiography of the lower limb arteries to exclude pseudoaneurysm because of frequent needle usage for drug administration. On CT, multiple air locules were noted within the proximal femur (Figures , b), the surrounding joint space and soft tissue including the muscles and the intermuscular planes (Figure ).
The femoral vessels were intact. Linear metallic foreign objects were noted in the soft tissue of the groin on both sides, consistent with embedded needles (Figure ).
An X-ray pelvis was performed on the same day as a baseline for future follow-ups, which showed multiple radiolucent areas in the soft tissue around the right hip (Figure ). A preliminary diagnosis of emphysematous osteomyelitis was made based on CT findings. MRI was deemed unsuitable for this patient due to the risk of injury from embedded needles close to the femoral vessels.
The patient was subsequently transferred to a tertiary care hospital for surgical debridement. The culture of the debrided tissue grew anaerobic organisms, namely Finegoldia magna, a Gram-positive coccus and Actinomyces europaeus, a Gram-positive bacillus on enriched medium. He was treated with a long course of Clindamycin.
On follow-up after eight weeks, the patient was afebrile and the inflammatory markers were within normal limits. On X-ray, the intraosseous gas had resolved, though subtle cortical changes from osteomyelitis were evident (Figure ).


A 37-year-old man was admitted to our maxillo facial surgery department with a two-week history of dental pain on treatment with antibiotic therapy at home. During this time, after extraction of the right lower third molar, there was progressive swelling of the submandibular and latero-cervical region showing tense and painful skin and progressive involvement of the right upper thoracic region. The patient did not report any pathologies in his past medical history. On admission, he was conscious and cooperating, and his body temperature was 37.5°C, blood pressure 110/60 mmHg, heart rate 94 bpm, and oxygen saturation on room air 98% with no signs of respiratory exertion. Physical examination revealed swelling of the latero-cervical region with involvement of the right pectoral region where the skin appeared tense, burning, and painful on palpation (Figure ). The examination of the oral cavity revealed poor oral hygiene with inflammation of the gingival mucosa and leak of purulent material in the gingival fornix. A computed tomography (CT) scan of the head, neck and thorax with contrast was performed and revealed locules of gas and ill-defined low attenuation in the cervical area and in the thigh chest muscle, highly suspicious for a gas-forming infection (Figures and ).
Routine laboratory reports as follow: white blood cell count 15.230 mm3, Hb 14.5 gr/dL, CPK 414 U/L, CRP 150 mg/L, PCT 0.94 ng/mL, sodium 139 mEq/L, and potassium 4.1 mEq/L. The day after his hospital admission, the pain and swelling increased and he developed dysesthesia on the right upper thoracic zone. A compartment syndrome secondary to infection was diagnosed; thus, the patient underwent urgent extensive surgical debridement of the right pectoral area. The operating field showed interstitial “dishwater-like” fluid and discolored poor contractile muscles with pockets of necrosis and pus. The tissues were irrigated with 10 L of saline and empiric antibiotic therapy was started with IV piperacilline-tazobactam 4.5 gr ev/4 per day and IV daptomycin 8 mg/kg per day. The antibiotic therapy was continued for 10 days at the same dose. It was decided to quickly ensure broad antibacterial coverage for gram-positive, gram-negative, aerobic, and anaerobic microorganisms. The choice of these drugs was also driven by our experience in a previous study concerning SSTIs. Blood cultures were performed pre-operatively with a sterile peripheral vein technique, and during surgery, cultures were taken from the surgical site. After surgery, the patient was extubated, and the next day, he started HBOT as adjunctive therapy. HBOT treatment consisted of two dives with 100% oxygen in a pressure chamber 2.8 atmospheres absolute (283.71 kPa) within the first two days, and then daily for a total of 16 sessions. The total time in 100% oxygen via mask for each treatment was 60 min, with three phases in room air, each lasting 5 min. The day after surgery, an increase in CPK values (660 U/L) was observed. Subsequently, a progressive reduction in CPK values was noted, which returned to values of less than 100 U/L on day eight. Similarly, we observed a progressive reduction in CRP, white blood cell, and PCT values (<20 U/L, 10,000 mm3 and 0.10 ng/mL, respectively). The Hb value remained substantially stable during all phases of treatment, and no blood transfusion was needed.
Clinical improvement was observed three days after HBOT, and three weeks after admission, the patient was discharged home in good health (Figure ). A check up three months after hospital discharge showed a complete recovery of the health status with restitutio ad integrum of the involved anatomical areas (Figure ).


A 32-year-old lady presented to the Emergency Surgery Department, Lok Nayak Hospital, New Delhi with complaints of generalized abdominal pain, distension, vomiting, and constipation for five days and fever for two days. There was no history of any similar complaint in the past. There was no history of the passage of any mucoid material in the vomitus or the stools. There was no history of any prior hospital admission for any surgical procedure. She did not suffer from diabetes mellitus, hypertension, or tuberculosis. The patient was a non-smoker, non-alcoholic and did not chew tobacco. She had normal menstrual cycles. The family history was non-contributory.
On examination, she was dehydrated, and her vitals were stable. The abdomen was distended and bowel sounds were sluggish. However, there were no signs of peritonitis.
The full blood count (FBC) of the patient showed a white blood cell (WBC) count of 12,000 with neutrophilia (75%), eosinophilia (15%), hemoglobin of 8.6 gm/dL, and normal platelet counts. The renal and liver function tests were normal. The coagulation profile was normal. Enzyme-linked immunosorbent assay (ELISA) for anti-Echinococcus antibodies was positive. X-ray abdomen (erect) (Figure ) showed a large air-fluid level in the upper abdomen.
Requisition for a contrast-enhanced computed tomography (CECT) abdomen was sent to the Radiology Department and the patient was scheduled for the scan after one week. However, on day 5 of admission, the patient developed tachycardia and severe abdominal pain. The abdomen showed signs of localized peritonitis in the right hypochondrium, epigastrium, right lumbar and umbilical segments. After discussing the case with the radiologist, the patient was shifted for an urgent CECT abdomen. The scan showed a large cystic lesion with air-fluid level arising from the liver with probable rupture of cyst into the colon. Multiple hydatid cysts in the liver, omentum, and pelvis were noted (Figures -).
The patient underwent an exploratory laparotomy. Intraoperatively, a cystic lesion of 12×7×9 cm was seen in the right lobe of the liver, filled with daughter cysts. The cyst was isolated with sponges soaked in the povidone-iodine solution. The cyst densely adhered to the hepatic flexure of the colon with minimal fecal content within the cyst cavity. However, it was extremely difficult to delineate and dissect out the fistulous tract due to dense inter-bowel and hepato-colic adhesions. The entire contents of the liver cyst cavity were evacuated, and thorough lavage was performed. A drain was placed within the cavity thereafter. Keeping in mind the high likelihood of occurrence of iatrogenic injuries and hemodynamic instability of the patient, it was decided not to proceed further with adhesiolysis. The remaining hepatic, omental and pelvic hydatid cysts (Figures , ) were excised completely and a temporary diversion ileostomy was made, with a plan to evaluate and assess the colon anatomy at a later date.
The post-operative period was uneventful, and the cyst cavity drain was removed on the 13th post-operative day when the output was reduced to nil. Histopathology report confirmed the diagnosis of hydatid disease in the liver, omentum, and pelvis (Figure ).
The patient was discharged thereafter; with a plan to close the diversion ileostomy after a contrast distal loopogram study for confirming the absence of any fistulous communication between the colon and liver or peritoneal cavity. She was discharged on the 14th postoperative day after fully tolerating an oral diet. She was prescribed tablet albendazole 400 mg BID on discharge and was advised to follow up on a regular basis. Distal loopogram after six weeks did not reveal any fistulous communication of colon to the liver or peritoneal cavity. The patient underwent ileostomy closure after three months of the index operation. She made an uneventful recovery and was doing well at the end of three months follow-up.


A 37-year-old Asian American woman with a past medical history significant for the polycystic ovarian syndrome (PCOS), human papilloma virus (HPV), herpes simplex virus-1 (HSV-1), iron deficiency, and vitamin B12 deficiency-related anemia presented in February to the emergency department (ED) with body aches, fever, fatigue, cough, and recurrent upper respiratory infections for the past three months.
Two weeks later, the patient presented to the hematology clinic for a general follow-up regarding her long-term iron malabsorption/deficiency, vitamin B12 deficiency-related anemia, and increasing joint pain in her elbows, knees, and wrists which worsened over the course of the day. Coronavirus disease 2019 (COVID-19) was suspected but the serology test returned negative. Elevations in C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and +antinuclear antibody (ANA) warranted a CT scan of the chest, abdomen, and pelvis in April. The scan showed an incidental finding of a 65.7 mm porta hepatis mass on the posterior of the left portal vein, posterior to the right and common hepatic arteries, and the associated retroportal lymph nodes (Figure ). Her lactate dehydrogenase (LDH), vitamin B12, and white blood cell (WBC) counts were within limits. She denied any fever, alcohol use, or illicit drug use. More specific tests including hepatitis B, hepatitis C, parietal cell antibodies, and intrinsic factor antibodies were negative. To rule out neoplastic etiologies, the carcinoembryonic antigen (CEA) and cancer antigen (CA) 19-9 were measured and were found to be within normal ranges. Infectious etiologies were also considered but ultimately excluded due to negative blood and urine labs. Biopsy results of the hepatic mass were inconclusive but suggested several differential diagnoses of a lymphoproliferative disorder, a ganglioneuroma, or a schwannoma such as lymphoid or autonomic neural origin.
Surgery was performed in August without complications. The hepatic artery lymph node, the lymph node at the right crus diaphragm, and the retroportal lymph node and tumor were excised, all of which were HHV-8 negative. Microscopy studies showed lymph nodes with varying degrees of florid follicular hyperplasia and progressive transformation of germinal centers. Rare atretic follicles, as well as follicles with multiple germinal centers, were also observed. The interfollicular areas were expanded by increased plasma cells without atypia as well as several foci of vascular proliferation. While no vesicular hyalinization was observed, these findings were used to diagnose MCD.
Post diagnosis, the patient was managed with symptomatic observation along with continued monitoring of ESR and immunoglobulin G (IgG). Repeat abdominal CT was done every six months to track remission and to determine candidacy for siltuximab therapy in the event of symptom exacerbation. Hemoglobin and ESR normalized after surgical resection. To date, the patient continues to recover well after her surgery and has plans to resume activities of daily living.


A 44-year-old man presented to his primary care provider for a right proximal clavicular mass and enlarging neck for six months that he attributed to an injury from Jujitsu. The patient endorsed mild pain in the area but denied dysphagia, dysphonia, choking, or shortness of breath. The patient reported 20 lbs of weight loss. He denied hypoesthesia or motor deficits. On physical examination, a firm 8 cm mass was fixed to his right clavicle. There was palpable thyromegaly, the right lobe more prominent than the left, but there was no cervical lymphadenopathy and no significant motor or sensory deficits. Initial workup with an X-ray of his right clavicle revealed a large soft tissue density mass extended to the midline of the right proximal clavicle. A subsequent soft tissue neck ultrasound confirmed a 5.4 × 3.6 cm mass extending from the thyroid with features of increased vascularity and calcification extending from the thyroid (). CT of the neck showed extension of the mass into the adjacent sternoclavicular junction with osteolysis of the middle third of the clavicle and the superior aspect of the sternum body (). Due to suspicion of thyroid malignancy versus osteosarcoma, fine-needle aspiration of the mass was completed that showed a cohesive nest of neoplastic cells, and the nuclei were enlarged with pleomorphism. Focal calcification was noted, but there was no evidence of colloid or macrophages on multiple passes. Immunohistochemical stains were performed on the cell block, and the neoplastic cells were immunoreactive for TTF-1, PAX8, CK7, and thyroglobulin, and they were negative for CK20, calcitonin, synaptophysin, or chromogranin (). The overall findings supported the diagnosis of papillary thyroid carcinoma. To assess the extent of the mass for total thyroidectomy, a chest CT scan with contrast confirmed marked enlargement of the right thyroid gland, measuring 5.3 × 7 × 4.9 cm, with invasion into the right proximal clavicle, adjacent strap muscles, and first rib as well as tracheal deviation and extension into the mediastinum.
The oral and maxillofacial surgery team performed a composite resection of the tumor, including a segmental osteotomy of approximately two-thirds of the medial clavicle. In continuity with the suprasternal and clavicular portion of the mass, the cardiothoracic surgery team performed a sternotomy to access and resect the substernal component, dissecting it off the first rib and manubrium without a segmental osteotomy. The great vessels were dissected and preserved with dissection of the mass off the superior mediastinum and thoracic inlet. The maxillofacial surgery team continued cephalad to perform a total thyroidectomy. Left levels 2–4, right levels 2–5, and bilateral central compartment selective neck dissections were completed. The mass was then delivered en bloc. The right sternocleidomastoid and strap muscles were sacrificed due to tumor involvement, but all other structures were dissected and preserved, including bilateral recurrent laryngeal nerves and the brachial plexus ().
Postsurgically, the patient's serum calcium was low 7.9 mg/dL with simultaneously low PTH 9 pg/mL and low 25-hydroxyvitamin D 16.8 ng/mL. Thyroglobulin was markedly high at 15655.0 ng/mL (confirmed on dilution), and thyroglobulin antibody <1.0 IU/mL. Pathological examination of the right thyroid and clavicle showed PTC with extrathyroidal extension and clavicle involvement (staged pT4a pN0) with margins and lymph nodes negative for carcinoma (). The tumor showed a predominantly solid pattern with areas of the follicular pattern, but there were no cribriform areas identified. Immunohistochemical stain for beta-catenin showed no evidence of nuclear staining, which is not compatible with the morular pattern of papillary thyroid carcinoma. Next-generation sequencing revealed KRAS Q61 R mutation, and the following mutations were not detected: BRAF, HRAS, TP53, PTEN, TERT, RET, NTRK, and PPARg. The left thyroid showed benign pathology. Due to the perceived need for treatment with radioiodine therapy, the patient was not discharged home on levothyroxine, but was given supplemental calcium and vitamin D with subsequent follow-up with endocrinology.
Postoperatively, the patient's course was complicated by a large expanding left neck hematoma that developed after a fall at home. The patient was readmitted and underwent an emergent hematoma evacuation without further incidence. He was able to follow up with endocrinology with laboratory studies at that time showing serum calcium was 8.6 mg/dL, TSH > 150.00 mIU/L, and free T4 0.2 ng/dL. He was started on calcitriol 0.5 mcg daily), vitamin D 50,000 units weekly, and calcium 1000 mg 4 times daily. Levothyroxine was held at this time with a plan for radioactive iodine treatment. On follow-up, an iodine-123 whole-body scan noted increased uptake over the lower lumbar spine that was suspicious for skeletal metastasis. A positron emission tomography (PET) scan confirmed a high fluorodeoxyglucose (FDG) avid lytic lesion along the posterior element of S2 with a maximum standardized uptake value (SUV) of 13.32. Magnetic resonance imaging (MRI) also revealed an enhancing sacral mass measuring 3.4 cm × 3.3 cm × 2.7 cm at the level of posterior elements of S1 extending to the sacral canal, causing severe sacral canal stenosis. There was a mass effect upon the traversing bilateral S2 nerve roots. These findings were consistent with metastatic disease.


A 76-year-old man noticed melena and had a medical examination. He was found to have renal dysfunction 6 years earlier, and further evaluations showed serum albumin, 2.2 g/dL; urinary protein, 4+; urinary Bence Jones protein- (BJP-) λ-type M protein positivity; decreased serum IgG, IgA, and IgM levels; and an increased serum IgD (516 mg/dL) level. In addition, bone marrow aspiration showed clonal proliferation of plasma cells, so he was diagnosed with MM (IgD-λ type, BJP-λ type, International Staging System III). He was treated with 7 courses of bortezomib dexamethasone (BD) therapy, but due to recurrence, his therapy was changed to lenalidomide dexamethasone (Ld), and he was undergoing his 36th course. On upper gastrointestinal endoscopy, a type 1 tumor with a diameter of 30 mm was seen at the posterior wall of the corpus of the stomach, and the histopathological diagnosis of the tumor was tubular adenocarcinoma (Figures –). And, the HER2 status of gastric cancer was negative, and MSI status of that was not examined. In addition, computed tomography (CT) showed liver metastasis of gastric cancer, so the gastric cancer was diagnosed as clinical stage IV (T3N2M1). Furthermore, CT showed a pulmonary nodule with a diameter of 20 mm in the upper lobe of the left lung, and the diagnosis of the nodule was primary lung cancer clinical stage IA2 (T1bN0M0) based on the imaging findings (). Transbronchial lung biopsy could not be performed because the lesion of the lung cancer was a very difficult place for the examination, and the gastric cancer had advanced and a poor prognosis. So, immediate chemotherapy was needed. In conclusion, this patient was diagnosed as having primary gastric cancer and lung cancer that developed during the treatment of MM. The laboratory data at the time of diagnosis are shown in .
For this case of multiple primary cancers, the treatment plan was considered by the cancer board of our institute, and the treatment of the gastric cancer, which had the worst prognosis, was prioritized. First, one course of tegafur, gimeracil, oteracil potassium (TS-1), and oxaliplatin (SOX) was administered, but it was discontinued due to gastrointestinal symptoms and changed to docetaxel (DOC). He had a history of unstable angina and paroxysmal atrial fibrillation and had been treated for percutaneous coronary intervention two years ago. To avoid the onset of thrombosis, he was treated with monotherapy of docetaxel for second line. Since the serum IgD level also tended to increase gradually during the previous treatment, the treatment plan was re-examined, and the treatment for MM was resumed after the administration of a second course of DOC. Then, DOC and Ld treatment were administered alternately. However, due to progression of the lung cancer, the treatment was changed from DOC to nivolumab the following year. After the start of nivolumab, the lung cancer showed partial response, and the gastric cancer showed stable disease, but the MM gradually worsened. Although the serum IgD level decreased due to the addition of daratumumab, lenalidomide, and dexamethasone (DLd), the patient was unable to continue chemotherapy because of loss of appetite, which was thought to be an exacerbation of gastric cancer. The serum IgD level and carcinoembryonic antigen (CEA) level were increased. The patient died 17 months after the multiple primary cancers were diagnosed ().


The patient is a 68-year-old male with chronic kidney disease on peritoneal dialysis for 3 years. He presented with recurrent exertional chest pain at a local facility where he underwent coronary angiography showing complex 3-vessel disease with severe diffuse calcification of all coronary arteries. The proximal left anterior descending (LAD) and left circumflex (LCX) arteries showed 99% stenosis, and the right coronary artery (RCA) was totally occluded (). A broken coronary guide wire was left in situ following a failed attempt at RCA revascularization.
The patient was referred to the Guangdong Cardiovascular Institute for angioplasty. The RCA was engaged with a 7-French Amplatz left 0.75 guiding catheter and the left coronary artery (LCA) with 7-French XB 3.5 catheter. Antegrade crossing of the RCA chronic total occlusion (CTO) lesion with various guide wires including Pilot 150 and 200, UB3, and Conquest Pro failed necessitating a switchover to the retrograde strategy. The LAD lesion was prepared with rotational atherectomy, and the proximal segment was stented with a 3.0∗24 mm drug-eluting stent (DES). The RCA was approached retrogradely through the first septal collateral using SION blue guide wire through a 150 cm Corsair microcatheter (Asahi Intecc, Nagoya, Japan) and advanced to the distal cap of the CTO lesion. A Pilot 150, Pilot 200, UB3, and Conquest Pro guide wires failed to cross to the proximal true lumen. Through the antegrade guide and with the help of stiffer guide wires (Pilot 200, Conquest Pro), the proximal cap of the CTO lesion was punctured and modified. This eventually facilitated the placement of a RotaWire (Boston Scientific, Marlborough, MA, USA) through the architecture of the occluded vessel followed by rotational atherectomy with a small-sized (1.25 mm) burr. Repeated cycles of proximal cap modification with further advancement of the RotaWire and rotational atherectomy through the vessel architecture facilitated passage of the antegrade gear (microcatheter and guide extension catheter) through the long CTO segment ().
Reverse controlled antegrade and retrograde subintimal tracking (reverse CART) facilitated passage of the retrograde guide wire into the antegrade guide extension (Guidezilla, Boston Scientific) and guiding catheter. A successful “rendezvous” between the retrograde microcatheter and an antegrade RotaWire (Boston Scientific, Marlborough, MA) was achieved, followed by further rotational atherectomy into the distal true lumen. The procedure was completed using standard techniques after exchanging for a workhorse guide wire. Three DES were implanted into the RCA with satisfactory final results (). The whole procedure lasted 03:04 hours of which 02:11 hours were spent on the RCA lesion. About 260 milliliters of contrast agent was used.


A 26-year-old Chinese man who was previously healthy and had no significant medical or family history of any significant disease incidentally found right hepatic masses on ultrasonography (without detail and images) at the local hospital in March 2013. Among these masses, the largest one was 75 × 61 mm in size. At that time, the patient did not have any discomfort, such as abdominal distension or abdominal pain, and his laboratory values and serum tumor markers were all within normal limits. During the next 12 months, he did not complain of discomfort or take any medication.
In March 2014, to further diagnose the liver lesions, he visited our hospital. On admission, the patient's physical examination, laboratory indicators, including routine blood tests, routine urine tests, liver function, kidney function, coagulation function (FDP 2.34 mg/L), AFP, CEA, tumor-associated carbohydrate antigens (CA125 and CA199) and rheumatism-related indicators, were all within the normal limits. Abdominal MRI showed well-defined, smooth edges and homogeneous, solid, round-like lesions originating from the second to eighth segments of the right lobe of the liver (). The lesions displayed hypointensity on T1-weighted sequences (T1WI), hyperintensity on T2-weighted sequences (T2WI) and diffusion-weighted images (DWI), peripheral enhancement in the arterial phase and contrast retention in delayed phases. The largest mass in liver segment 7 was ~86 × 81 × 81 mm in size and was closely related to the right hepatic vein and inferior vena cava (IVC). Despite the large mass size, the hepatic vein and IVC were not compressed. He was diagnosed with giant HHs, and transarterial embolization or radiofrequency ablation was suggested. However, the patient rejected this advice for the time being. From April 2014, he started to cough and had throat pain, which was relieved after drinking a large amount of water and resting but often recurred. He thought the discomfort was related to his teaching career and did not seek medical help. In August 2014, he visited our hospital because of his HHs. However, he did not receive interventional treatment for the positive findings of urine protein and urine occult blood, as well as an increased level of serum creatinine to 314 μmol/L. He then visited another hospital and had undergone a histopathological examination of percutaneous renal biopsy. He was diagnosed with IgA nephropathy, chronic kidney disease (stage 4), secondary hypertension, chronic tonsillitis and HHs and was treated with amlodipine besylate, metoprolol, furosemide, and terazosin hydrochloride. Under the above treatments, his renal function did not improve but deteriorated progressively; thus, he started regular dialysis 3 times a week in October 2014.
In June 2015, he was hospitalized in the ICU at the local hospital because of acute heart failure. During hospitalization, ultrasound examination reported multiple hemangiomas in his liver, and the largest hemangioma located in segment 7 was 76 × 61 mm in size ().
In December 2016, he was prescribed AZM tablet 0.5 qd for 5 days and then oral 0.25 qod for the long term to treat his recurrent tonsillitis and regulate his immunity. His cough was relieved, and his tonsillitis was cured.
In May 2017, Doppler ultrasound showed that his HHs were significantly smaller than before (56 mm × 26 m vs. 76 × 61 mm), with unclear outlines and shapes, strong echo points and normal internal blood vessels inside the lesions (). In November 2017, abdominal CT before kidney transplant surgery showed that the original multiple HHs in his right liver were blurred in outline and shape, and the size of the largest HH was reduced to 44 mm × 28 m, with an obscure outline, uneven internal echo, normal internal blood vessels, and plaque-like hyperechoic shadows behind it ().
Follow-up of the patient by phone during over 3 years indicated that the patient regularly took tacrolimus, mycophenolate mofetil, methylprednisolone, amlodipine besylate, metoprolol and terazosin hydrochloride. His blood pressure was controlled at a normal level, and his liver and kidney functions were normal with no anemia, hematuria or proteinuria. Results of abdominal ultrasound examination in May 2017 () and May 2018 () reported that the original HHs in the patient's liver were unclear.


A four-year-old female child came to our hospital with chief complaints of pain and swelling over the left foot for the past five months. The intensity of pain increased on prolonged walking, running, or playing, and the foot swelling was gradually increasing in size. There was no history of fever, weight loss, or other constitutional symptoms. Also, there was no antecedent history of trauma. On clinical examination, there was localized mild tenderness and swelling over the dorsum of the left foot (Figure ); however, the ankle range of motion was full with pain on extreme dorsiflexion.
Routine hematological investigations including complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and Mantoux test were advised. The serum inflammatory markers were raised with ESR 75 mm/hour and CRP 50 mg/dl, and the Mantoux test was found positive. A plain radiograph of the left ankle joint revealed an isolated lytic lesion in the talus bone with a sclerotic rim (Figure ).
Magnetic resonance imaging of the left ankle showed a hypointense lesion in the talus on T1 weighted images with surrounding marrow edema, and also mild synovial thickening was seen in the tibiotalar joint. There was no soft tissue mass, fluid/hemorrhagic level, or any cortical breach in the talus (Figure ).
Debridement and curettage of the lesion were done both as a diagnostic and therapeutic procedure. During surgery, caseous cheesy material came out from the talus, which was sent for Gram staining, Zeihl-Neelsen staining, histopathology, and culture. The Zeihl-Neelsen staining showed acid-fast bacilli, and the histopathology revealed caseous granulation tissue. The patient’s foot and ankle were immobilized in posterior slab support for two weeks till suture removal, which was then replaced with a plaster cast. The cast was removed after three months, after which active and passive ankle range of motion exercises were started. After histological confirmation, the anti-tubercular chemotherapy was started. It consisted of initial two months of four-drug therapy (intensive phase)--isoniazid (H) (10 mg/kg), rifampicin (R) (15mg/kg), pyrazinamide (Z) (35 mg/kg), and ethambutol (E) (20 mg/kg)--followed by 12 months of two-drug therapy (HR) (continuation phase). The patient was followed every two weeks after the start of treatment, up to the end of the intensive phase, and then every two months until completion of treatment. The parameters assessed on follow-up visits included symptomatic improvement, adherence to treatment, inquiry about any adverse events, and weight measurement. Dosages of drugs were adjusted to take account of any weight gain []. She was also periodically evaluated for radiological improvement of the lesion. After completion of therapy, there was complete resolution of the lytic lesion, with the patient playing happily without any pain with a full range of ankle movement (Figure ).


A 33-year-old male with no known comorbid conditions presented with intermittent chest pain. He described the chest pain as a pressure-like sensation in the midsternal area. He denied radiation of the chest pain to other areas of the chest wall, left arm, or jaw. The patient did not report any worsening of chest pain with cough, taking a deep breath, or movement. The patient had two episodes of chest pain in the past two days and each episode lasted 10-15 minutes. The patient denied any similar episodes of chest pain in the past or any familial cardiac history. The patient denied any history of smoking or alcohol abuse. He denied using illicit drugs including intravenous drugs. He denied ever having an echocardiogram or heart catheterization. Vital signs were stable and physical examination revealed no chest wall tenderness. Electrocardiogram (ECG) showed sinus rhythm with no significant ST changes. The patient had a basic laboratory workup done that included complete blood count (CBC), comprehensive metabolic panel (CMP), and troponin level. High sensitivity troponin level was significantly elevated to 704.6 pg/mL (normal range: 3.0-58.0 pg/mL). The remainder of his basic laboratory workup was within normal limits. He was started on a weight-based heparin drip and taken to the cardiac catheterization lab. The left heart catheterization report revealed normal anatomy of the left coronary artery (LCA), originating from the left aortic sinus, bifurcating into the left anterior descending (LAD) artery, and left circumflex artery (LCX). The RCA was originating from an anomalous position, adjacent to the LCA, but slightly anterior to it. The RCA originated from the left aortic sinus (Figure ). There was an ostial dissection of the anomalous RCA (Figures , ). Cardiothoracic surgery was consulted and recommended coronary artery bypass grafting (CABG). The patient underwent CABG with the placement of a saphenous vein graft to the proximal RCA. The patient’s postoperative hospital course was uneventful with no complications. He had complete resolution of his symptoms and was discharged in stable condition.


An African American female in her early 50s was admitted to the hospital for worsening abdominal pain. She complained of intermittent generalized abdominal pain that started one month before the presentation. Her pain was not worsened with any movements, not associated with food, and mildly relieved by acetaminophen. She never had similar pain before. She denied any fever, chills, fatigue, cough, shortness of breath, hemoptysis, muscle aches, weight loss, loss of appetite, change in bowel routine, melena or hematochezia, and vomiting. She also denied any skin nodules, rashes, or joint pains. She also denied any recent travels or sick contacts. Her past medical history included mitral valve prolapse. She was a homemaker. She denied any history of smoking, alcohol, or drug abuse. She was not taking any medications at home. She had a strong family history of breast and lung cancer.
On the initial presentation, vital signs were normal. Her physical examination was within normal limits except for mild right upper quadrant tenderness without rebound, guarding, or rigidity. There were no signs of lymphadenopathy, leg edema, skin rashes, or nodules. Initial laboratory analysis was significant only for abnormal liver enzymes- aspartate aminotransferase (AST) 67 U/L (normal 13-39 U/L), alkaline phosphatase (ALP) 185 U/L (normal 50-142 U/L), low albumin 3.13 gm/dL (normal 3.5-5.7 gm/dL), and low serum lipase of 6 U/L (normal 11-82 U/L). Serum calcium was 9.5 mg/dL (normal 8.6-10.8 mg/dL). The remainder of the complete blood count and metabolic panel were also normal. Mild polyclonal gammopathy was diagnosed via serum protein electrophoresis. Chest x-ray showed patchy air opacities bilaterally, and COVID-19 polymerase chain reaction (PCR) was negative. Computed tomography (CT) abdomen showed multiple subpleural nodules along with a complicated sub-hepatic cyst/abscess, bowel wall thickening, prominent gastro-hepatic and gastroduodenal lymph nodes. Interventional radiology was consulted for CT-guided pigtail catheter placement to drain a sub-hepatic abscess. Her abdominal pain improved after the sub-hepatic drainage. Fluid analysis was unremarkable for infection or hepatic sarcoidosis. The patient also underwent esophagogastroduodenoscopy (EGD) and colonoscopy for concern of Inflammatory bowel disease based on CT findings, which were grossly normal. The histopathologic results from gastric biopsy-confirmed chronic non-caseating granulomatous gastritis (Figure ), negative for Helicobacter pylori infection, fungal or mycobacterial stains.
Subsequent CT-thorax was done, which revealed bilateral reticulonodular opacities and multiple nodules in bilateral lungs (Figure ). All the infectious workups, including human immunodeficiency virus (HIV), hepatitis A, hepatitis B, hepatitis C, and Quantiferon Gold test for tuberculosis, were negative. Influenza/RSV, group B streptococcus screen, respiratory cultures, fungal cultures, and mycobacterial cultures from sputum were negative. Blood cultures were also negative. Serum beta-D glucan test was negative as well. Tumor markers - CA 19.9 and alpha-fetoprotein were unremarkable. Pulmonology was consulted, and the patient had bronchoscopy with left upper lobe transbronchial biopsy.
Based on the laboratory data and clinical findings, a presumed diagnosis of sarcoidosis was made. Since she did not have any specific symptoms like dyspnea, nausea, vomiting, and her abdominal pain had improved after the drainage, she was not started on immunosuppressive agents. She was ready to be discharged. The risks, adverse effects, and benefits of starting Prednisone for the presumed diagnosis of sarcoidosis were discussed with the patient. She elected to wait for lung biopsy results and have a pulmonary function test (PFT) during an outpatient pulmonary clinic visit. The patient did follow up outpatient and had a mild restrictive disease on PFT. The lung biopsy results revealed poorly formed noncaseating granulomas (Figure ) and intra-alveolar hemorrhage. Stains for fungal and acid-fast organisms were negative. She did not receive any specific therapy as she remained asymptomatic. Repeat PFTs after three months showed significant improvement in the restrictive process.


An otherwise healthy 2-year-old male presented to our emergency department (ED) following an unwitnessed Dimetapp ingestion of unknown amount and formulation (common Dimetapp formulations: brompheniramine, dextromethorphan, and phenylephrine with or without acetaminophen or the nighttime formulation: diphenhydramine, phenylephrine). On exam, he was tachycardic and hypertensive with dry mucous membranes consistent with an anticholinergic crisis, requiring fluid resuscitation and benzodiazepines, thus necessitating admission to the Pediatric Intensive Care Unit (PICU). On arrival to PICU, he became hypopneic and lethargic, with a Glasgow Coma Score (GCS) of 9, and was started on high-flow nasal cannula. Electrocardiogram (EKG) showed a normal QRS and QTc interval. Laboratory evaluation showed no electrolyte abnormalities. Urine and serum drug screens were negative. Given his tenuous respiratory status, a dexmedetomidine infusion was initiated instead of using benzodiazepines to avoid potentiating further respiratory compromise with possible intubation. Dexmedetomidine was administered at 0.3 mcg/kg/hr for the first hour then decreased to 0.2 mcg/kg/hr the second hour, before being discontinued. The patient's heart rate and blood pressure appropriately decreased (). He remained hemodynamically stable while maintaining his airway and was subsequently discharged home uneventfully.


An otherwise healthy 14-year-old girl was transferred from an outside hospital after an unwitnessed intentional overdose involving over 100 diphenhydramine (25 mg) tablets with suspicion of other unknown over-the-counter medication ingestion. The patient was noted to have episodes of emesis and urinary incontinence. Labs were notable for presence of cannabinoids, mild transaminitis, acetaminophen level of 33, hypokalemia (2.9 mEq/L), and hypomagnesemia (1.6 mg/dL). EKG showed a prolonged QTc of 545 ms which later improved to 454 ms. At the outside hospital, the patient received 10 mg of lorazepam and another 6 mg in our ED due to persistent agitation, tachycardia, and hypertension before being transferred to the PICU. Her exam was notable for mydriasis, dry skin, hallucinations, agitation, and nonsensical speech despite multiple doses of lorazepam. Due to her persistent anticholinergic crisis, the decision was made to start her on dexmedetomidine. The team refrained from using physostigmine due to concerns of possible cardiotoxicity in the setting of QTc interval abnormalities and possible polypharmacy. She was started on dexmedetomidine at a dose of 0.3 mcg/kg/hr and slowly titrated to 0.7 mcg/kg/hr, which steadily improved her agitation and brought an appropriate resolution of her tachycardia and hypertension (). Anticholinergic symptoms completely resolved within 13 hours allowing the patient to be cleared for discharge to an inpatient psychiatric facility.


The dead body of 45-year-old male was brought for autopsy. The body was stiff at all the joints. The hands were clenched and the whole body smeared in blood. Post mortem lividity could not be appreciated. A rectangular contusion with muzzle imprint was noted in the front of the chest which measured 10 × 8 cm. An oval perforated lacerated wound (entry wound) having 1.8 cm diameter was present in the middle of the contusion [
]. The wound was charred, black in color with surrounding blackening of the skin. The perforated wound was 48 cm from the vertex in midline, 115 cm from the sole of the foot and 18 cm from the supra sternal notch. It was 17 cm from the right mid axillary line and 20 cm from the left mid axillary line. A linear slit-like laceration (exit wound) was present on the back in the left side which measured 0.5 × 0.2 cm and was located 25 cm from the vertex, 129 cm from the sole of the foot [
].
On opening the chest, a perforating fracture was noted in the xiphoid process [
]. The heart was pulverized [
] with exsanguination of the blood into pericardial cavity. The clotted blood in the pericardial cavity weighed about 650 gm. When a probe was directed through the heart from the defect, it was noted that the entry point was located on the right side of the anterior interventricular septum and exited through the left ventricle [
]. The direction was right to left and below upwards. The left lung was completely collapsed and there was a penetrating injury noted at the upper lobe. The rest of the findings were unremarkable.
As per the history provided by the victim’s brother, the deceased was an unmarried male. He was diagnosed with schizophrenia since adolescence for which he was on the prescription medicine Quetiapine. The medicine was not available at his rural pharmacy and due to the COVID-19 pandemic lockdown, he was unable to visit the tertiary hospital for his regular prescription. The medicine was therefore discontinued for 3 months prior to death. The victim consumed homemade arrack (a distilled alcoholic drink) regularly which they prepared at their home.
The crime scene photograph provided by the investigating officer showed a single barrel, smooth-bored firearm which was a flint lock type muzzle loader [
].


A 48-year-old man underwent laparoscopic partial liver resection of segment 8 for liver metastasis of rectal cancer. Laparoscopic lower anterior resection was performed in patients with stage T3 rectal cancer. The pathological diagnosis was adenocarcinoma with no lymph node metastasis and the surgical margins of the tumor were negative. Twenty months after surgery, computed tomography revealed a new lesion beneath the diaphragm. Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) revealed a hypointense tumor located just beneath the diaphragm at the liver segment 8 on the hepatobiliary phase (Fig. ). The surgery was performed due to growth in tumor size. The patient was placed in a left hemilateral decubitus position, and five laparoscopic ports were placed as described in Fig. . Pneumoperitoneum was established through the right lateral umbilical 12-mm camera port inserted using the open-entry method. Adhesions from the previous surgery were dissected. Tumor invasion to the diaphragm was detected while the right lobe was mobilized. The invaded area of the diaphragm was encircled using a hanging tape. Liver resection preceded diaphragmatic resection. Due to severe adhesions around the hepatoduodenal ligament and the small extent of resection volume, liver resection was performed without the Pringle maneuver. Liver resection was performed using HARMONIC ACE® (Ethicon Endo-Surgery, Cincinnati, OH, USA) and CUSA® (Clarity Ultrasonic Surgical Aspirator System, Integra LifeSciences Corporation, NR Ireland Limited) while hanging the liver tumor with tape. The inflow of CO2 into the pleural space after diaphragmatic resection created a poor surgical field due to the development of unsustainable pneumoperitoneum. The liver and diaphragm were held down using two snake retractors to secure the surgical field. The diaphragm defect was repaired with continuous or interrupted sutures placed using LAPRA-TY® (Ethicon Endo-Surgery, Cincinnati, OH, USA) clips and 3–0 Vicryl sutures. Both ends of the string were tied using a LAPRA-TY® clip without ligation. Continuous or interrupted sutures were placed based on the tension of the diaphragm while reducing the pneumoperitoneum pressure from 10 to 6 mmHg, and respiration was temporarily stopped while consulting with the anesthesiologist. The surgery was completed with a 14-French chest tube insertion. The patient had no respiratory or circulatory abnormalities during the surgery. The total operative time was 272 min with a 10-mL blood loss. The image of the surgical method is shown in Fig. . The video of the surgery is available online only (Supporting Information). The postoperative course was uneventful, the chest tube was removed after confirming no air leakage on the first postoperative day, and the patient was discharged 8 days after the surgery. The pathological diagnosis was liver metastasis of rectal cancer invading the diaphragm. The surgical margins of the tumor were negative. The tumor weighed 5 g, including the diaphragm. The excision range of the diaphragm was 34 × 44 mm (Fig. ). Eighteen months after the surgery, no abnormalities were found in the diaphragm regarding respiratory symptoms and imaging findings. Written informed consent was obtained from the patient to publish this video article and any accompanying images presented in this study, and patient anonymity was preserved.


A 66-year-old lady with diabetes mellitus (DM) and hypertension (HTN), presented with complaints of slurred speech and right-sided weakness at 0600h morning. She woke up at 0540h and was seen normal on the day of admission. Her Covid-19 polymerase chain reaction (PCR) test turned positive as she had cough. Neurological examination revealed global aphasia, right side lower facial asymmetry, partial left gaze preference, right side strength of 1/5 upper and lower extremity, right homonymous hemianopia, right side neglect with moderate to severe on National Institutes of Health Stroke Scale (NIHSS, score: 14). Initial CT stroke protocol, perfusion and angiography showed left parietal subcortical recent ischemic stroke, left side internal carotid artery (ICA) occlusion and focal severe stenosis at proximal left middle cerebral artery (MCA)-M1 segment causing left cerebral hemisphere small infarcted cores, penumbra and other areas of delayed perfusion. A large 2.2-cm floating thrombus within the proximal aortic arch was attached to the anterior wall. Aortic arch soft and calcified plaques were also seen (Figures -). At 0922h IV thrombolytic bolus alteplase dose was given, continuous infusion of alteplase was withheld because of the doubt about a potential aortic dissection. Intervention radiologist and vascular surgeon were consulted for mechanical thrombectomy or possible surgical intervention, but they recommended that she is not a candidate for intervention due to a chronic intracranial occlusion and continued conservative medical treatment. After 24 hours, repeat non-contrast CT head showed left-sided caudate, and thalamic acute ischemic stroke was noted. MRI/magnetic resonance angiography (MRA) head showed left posterior parieto-occipital, left centrum semiovale, left thalamocapsular and left peritrigonal region ischemic infarction and left side MCA-M1 segment showed moderate stenosis with mild stenosis proximal basilar artery. She was started on low molecular weight heparin (LMWH) therapeutic dosage twice after 24-hour post TPA for five days then switched to oral anticoagulant. Workup for hypercoagulable state was negative except COVID-19 PCR test which was positive (protein C&S activity, anticardiolipin antibodies, factor V Leiden, homocysteine level, activated protein C resistance). Echocardiography showed normal left ventricle (LV) function [Ejection fraction (EF)-65%] and normal valves. Ten days after the stroke, repeat aortic contrast CT angiography showed diffuse atherosclerotic changes in the aortic arch, descending thoracic aorta and abdominal aorta. These atherosclerotic changes were most severe at the distal part of the abdominal aorta which showed circumferential mural thickening and calcifications extending to both common iliac arteries causing mild luminal narrowing. There was no evidence of intraluminal filling defects or floating thrombi, and no evidence of aortic aneurysm or acute aortic dissection. After two weeks of rehabilitation, activity of daily living was dependent on wheelchair and modified Rankin Scale was 4/6 (Moderately severe disability) on discharge.


A 39-year-old gentleman with HTN, was brought by emergency medical services (EMS) after he had minor car accident at about 0510h morning. He was noticed to have right side weakness and inability to talk. He reached hospital at 0616h. Covid-19 PCR test was negative. Neurological examination revealed drowsiness, global aphasia, right side lower facial asymmetry, left gaze preference, right side strength of 0/5 upper and lower extremity, right homonymous hemianopia, right side impaired sensations with severe NIHSS (score: 23). Initial CT stroke protocol, perfusion and angiography showed acute infarct involving left frontotemporal parietal lobes and left capsule-ganglionic regions with matched perfusion defect, and right paramedian aspects of frontal and parietal lobes showed mismatched defect (Figures -). CT cerebral angiogram showed left internal carotid artery (ICA) occlusion and significant attenuation of left middle cerebral artery (MCA-M1,M2) with hypoplastic right anterior cerebral artery (ACA-A1). A large 5 x 1 cm thrombus in the arch of the aorta was attached to the left anterolateral wall. No evidence of distal embolus in the visualized thoracic, abdominal or pelvic viscera was noted. The patient had ischemic stroke and was not a candidate for IV thrombolysis and thrombectomy. Workup for hypercoagulable state showed mild positive lupus anticoagulant value of 53.8 seconds (normal 45.3 second), while antineutrophil cytoplasmic antibody (ANCA), anticardiolipin antibodies, factor V Leiden, prothrombin C (factor II), antithrombin activity, protein C & S activity, antibeta-2 glycoprotein were normal. Echocardiography showed normal LV function (EF-52%) and no evidence of thrombus in left ventricle. The patient was admitted in MICU for close monitoring for intracranial pressure (ICP) and neurosurgical intervention. Patient's Glasgow coma scale (GCS) dropped with right anisocoria and he was intubated and ventilated. Repeat CT scan head after 24 hours showed large left MCA full territory and a small right frontal parafalcine acute ischemic stroke. There was a 7-mm midline shift to the right side with mass effect. He underwent decompressive craniectomy. The patient developed diabetic insipidus and acute kidney injury (AKI). He was hemodialyzed for hyperkalemia. On 9th day of admission, he had fixed dilated pupils and absent brainstem reflexes, and he had sudden bradycardia and cardiac arrest and declared dead.


A 50-year-old male patient was admitted to our clinic. He complained of a recent increase in snoring, apnea attacks, and swallowing difficulties. There was no mass on the neck palpation. Physical examination revealed a bulging of the anterior pillar of the palatal tonsil resulting in slight obstruction of the upper airway.
The patient underwent neck MRI with gadolinium injection (). It revealed a well-defined 52 × 38 mm tumor of the right PPS, which was hypointense on T1-weighted sequences and hyperintense on T2. There was a displacement of the right oropharyngeal wall medially. It was independent of the deep lobe of the parotid. These MRI features were consistent with PA with possible focal areas of malignant degeneration in diffusion-weighted imaging (DWI) sequences.
The tumor was not extirpable through the transoral approach alone. A combined approach associating cervico-parotid and transoral incisions was therefore necessary. This approach allowed the exposure of the facial nerve avoiding its damage.
The postoperative course was uneventful apart from House's grade III facial palsy which regressed using corticosteroids.
Definitive histology was consistent with encapsulated pleomorphic adenoma.
NB: the patient has given his consent for the MRI images to be used for research and the case to be published.


A 71-year-old female presented with 8 kg weight loss over several months, appetite loss, and leg edema for several weeks. An enhanced computed tomography (CT) scan revealed a 94-mm right renal mass with a bulky tumor thrombus within the IVC to the junction of the IVC and the right atrium, maximum thrombus diameter of 37 mm, a few lung nodules, and para-aortic adenopathy (Fig. a). A transthoracic echocardiogram revealed no tumor within the right atrium. A bone scan revealed no metastasis. A core needle biopsy of the renal mass showed mostly necrotic tissue with a region of clear-cell RCC (ccRCC) (Fig. a). Immunohistochemical analysis revealed that PD-L1 was not expressed on tumor cells (Fig. b). The patient was not appropriate for radical surgery because her Karnofsky performance status (KPS) was 40. Systemic immunotherapy was administered for metastatic RCC based on International Metastatic RCC Database Consortium (IMDC) poor-risk classification including KPS < 80%, diagnosis to treatment interval < 1 year, anemia, and hyper calcemia. After 2 cycles of nivolumab and ipilimumab therapy, CT revealed that the primary tumor was stable at 94 mm in diameter and lung nodules were undetectable except for the one in the right lower lobe, but the tumor thrombus was extended within the right atrium. Nivolumab and ipilimumab therapy was changed to pazopanib monotherapy due to disease progression (Fig. b). She had marked improvement in Karnofsky performance status to 70 and resolution of leg edema and appetite loss.
Follow-up CT at 4 months after treatment revealed that the renal mass had decreased to 84 mm in diameter, and all lung nodules were undetectable. The tumor thrombus in the right atrium was also undetectable, but the tip of the thrombus remained at level 3. The diameter of the IVC at the renal vein ostium was 15.6 mm. Complete occlusion of the IVC was not observed (Figs. c, ). She underwent right nephrectomy and IVC thrombectomy after 2 cycles of nivolumab and ipilimumab therapy and pazopanib therapy for 5 months.
The surgical method is described below. A cardiac surgeon secured the right upper arm vein and the right femoral vein to prepare for extracorporeal circulation. A middle incision to the xiphoid was made in addition to chevron incision. The right kidney and IVC were exposed. The area around the kidney and the IVC had strong adhesions. The right renal artery was ligated at the aortocaval. A tumor thrombus was confirmed between the common iliac vein bifurcation and the diaphragm by echoic imaging, but no tumor thrombus was observed in the right atrium. A liver surgeon secured the hepatic triad. Furthermore, an incision was made in the epicardium and the IVC was secured above the diaphragm. Since no change in blood pressure was observed when the IVC was clamped above the diaphragm, a decision was made to perform nephrectomy without using extracorporeal circulation. The hepatic triad was clamped using a Pringle, and the IVC (above the diaphragm and on the common iliac vein bifurcation) was clamped. The vascular wall was incised at the bifurcation of the renal vein and the IVC to secure the tumor thrombus. The tumor thrombus was manually removed from the IVC wall. However, dense adhesions were revealed between the tumor thrombus and the wall of the IVC. The IVC was resectable from beneath the hepatic vein to the IVC bifurcation. Unfortunately, the tip of the thrombus could not be removed. Since the tip of the thrombus was macroscopically firm necrotic tissue, no additional excision was performed. The operative time was 9 h, and the bleeding volume was 3000 mL. No surgical complications occurred. CT and a transthoracic echocardiogram 1 week after surgery revealed no metastatic findings and only the mass within the IVC near the right atrium. Treatment for RCC after surgery was not performed because we diagnosed the mass as having no viable cells by pathological findings. 1 year after surgery, the mass has not changed and no metastatic lesions have been observed.
Finally, the pathologic diagnosis was ccRCC (7.5 cm, International Society of Urologic Pathologists [ISUP] Grade 3). Macroscopic findings showed a light yellowish-brown color in the margin area and extensive necrosis in the internal red and yellow areas (Fig. a). Histologically, tumor cells with clear cytoplasm and round nuclei were observed at the margin of the lesion. The proportion of residual tumor in the primary tumor was 10–20% (Fig. b, c). The tumor thrombus tissue was necrotic and replaced by a hemosiderin-phagocytic macrophage population. No viable cells were observed. No tumor was found in the wall of IVC. Immunohistochemical analysis revealed that PD-L1 was expressed on lymphocytes and macrophages infiltrating the tumor, but not on the tumor cells themselves (Fig. d).


A 35-year-old male with prior history of major depressive disorder, traumatic brain injury, and severe polysubstance use (alcohol, cocaine, cannabis, opiates, and benzodiazepines) presented to the emergency department via emergency medical services after attempting to cut his wrists bilaterally in the setting of polysubstance use. In the emergency department, labs were remarkable for a blood alcohol level of 421 mg/dL and mild transaminitis (aspartate aminotransferase 325 U/L, alanine transaminase 284 U/L). The urine toxicology screen was positive for cannabinoids and benzodiazepines. On initial psychiatric evaluation, the patient was cooperative, tearful, and withdrawn. He endorsed suicidal ideation with depressed mood, anhedonia, hopelessness, and difficulty sleeping. During this time, the patient was alert and oriented to time, place, and person. He denied hallucinations, delusions, or other perceptual disturbances, and no psychosis was observed. The patient was medically cleared and transferred to the inpatient psychiatric unit for further stabilization. Within 72 hours, the patient was found to have worsening transaminitis (>1,500 U/L) and subsequently transferred to the regular medical floor to manage acute hepatitis. At this time, the ammonia level was normal (9 µmol/L), and mentation was intact.
The following day, the patient remained alert and oriented. He was cooperative, friendly, and maintained fair eye contact. His mood was neutral, his thought process logical and linear, and he denied suicidal or homicidal ideation. Physical examination was remarkable for mild bilateral hand tremors. The patient described new-onset closed-eye visual hallucinations, which resolved upon opening his eyes and recurred on eye closure. He denied auditory hallucinations, delusions, or other perceptual disturbance, and none were elicited. On further interrogation, the patient stated the hallucinations were vivid, graphic, and animated. He specifically reported observing the cartoon character Daffy Duck when he closed his eyes, which subsequently disappeared when he opened his eyes.
The next morning, the patient became disoriented, agitated, and presented with new-onset illusions, mistaking the treating psychiatrist for his father and the hospital bed for his living room couch. The patient was in severe emotional distress, asking the treatment team to help him save his father, whom he believed was trapped under the couch. The patient became increasingly agitated, attempted to elope by hitting his hospital room window with an IV pole, and was imminently transferred to the intensive care unit (ICU) to treat severe delirium, primarily attributed to alcohol withdrawal in the setting of suspected polysubstance withdrawal. At this time, the ammonia level was found to be elevated at 82 µmol/L. The patient was intubated for airway protection and started on intravenous (IV) midazolam 20 mg/hour and fentanyl 2,000 µg/hour.
After 72 hours, the patient was extubated, regained alertness and orientation, and followed complex commands. At this time, the patient denied hallucinations, delusions, illusions, or other perceptual disturbances. To further explore the nature of this unique clinical presentation, we gauged the patient’s level of insight regarding the hallucinations during a follow-up evaluation. The patient precisely recalled vivid closed-eye visual hallucinations. He confirmed the absence of visual hallucinations on admission. He also confirmed that the hallucinations began the day before severe delirium, though he stated he had little to no recollection of his ICU course. The patient also confirmed that the hallucinations appeared when he closed his eyes and resolved when he opened his eyes. Each time he closed his eyes, the patient recalled watching a different scene or subject, occurring in nonsequential order, without distinct features. The patient described seeing cartoon characters such as Daffy Duck, an unfamiliar blond woman with curly hair having an ambiguous face, and a forested landscape. He described the images as vibrant, lifelike, and evocative. He denied the images were memories or personally relevant and stated he knew these visual hallucinations were not real. Although the patient admitted to a prior history of delirium tremens, alcohol-related blackouts, polysubstance use, and polysubstance withdrawal, the patient stated the closed-eye visual hallucinations occurred for the first time.


The first case described a 28-year-old lady who was first reviewed by a psychiatrist at the age of 18-year-old for suspected conversion symptoms when she presented with right-sided limb weakness following a trivial fall. She further narrated that she did not feel loved and was not treated equally among her siblings by the parents. She admitted having some depressive symptoms but does not fulfill criteria for major depressive disorder. At that point, she was diagnosed as having dysthymic disorder with conversion symptoms. Psychoeducation, reassurance, and supportive psychotherapy were given during the hour-long consultation. No oral medication was prescribed. She was given an open appointment for psychiatric evaluation at the nearest hospital due to logistic reason. The session was the only encounter with the psychiatrist.
However, since the first meeting, the patient had believed that something truly romantic had occurred between them. She had been following the psychiatrist through Facebook™ and made several picture collages of the psychiatrist, recovered from the therapist's personal social media account. She had even created multiple fake Facebook™, WeChat™, and Twitter™ accounts in the psychiatrist's name and had posted several affectionate videos to manifest the romantic love she had for the psychiatrist. She even succeeded to retrieve the psychiatrist's private phone number from the office, after impersonating as a family member. Since then, the psychiatrist had also been receiving regular missed phone calls, letters, and text messages from more than 10 different mobile numbers on a weekly basis.
Despite being advised against the stalking behavior by the psychiatrist, she continued to text the psychiatrist and mostly vents about her life struggles and how she did not feel loved and wanted. Gradually, the content became threatening as she sought for more attention, claiming that her condition was deteriorating with frequent auditory hallucinations and had self-injurious behavior, but persistently refused to attend the clinic for further evaluation and treatment. She also claimed that she has been physically abused by the parents. Therefore, the local welfare department was alerted to further investigate and perform home visit; however, they affirmed that the patient has had two accounts of making bogus calls and fabricating abuse stories to the National Urgent Response (NUR), which was the hotline number set up by the Malaysian Ministry of Women, Family and Community Development (MWFCD) to enable early intervention for victims of domestic violence. The cases were eventually dismissed after a closed session with the parents and careful medical examination. Apart from that, several psychosocial investigations were performed involving the schoolteachers and schoolmates which revealed no impairment in academic achievement or social functioning. The parents were regularly updated on the patient progress and informed of the need for psychiatric evaluation, but unfortunately, they dismissed the issue as frivolous. However, once police report was lodged by the psychiatrist of the perpetual physical harassment of the patient trailing her at work, they eventually agreed for psychiatric evaluation by a different psychiatrist.
Her mental status examination revealed a fixed and systematized delusions that the first therapist was in love with her since the first consultation and that the love was mutual. Her affect was appropriate, and her speech was relevant and coherent. She denied delusion of reference or control and denied of having sexual fantasies with the therapist. Her cognitive functions were intact except for her poor insight. No mood symptoms were elicited. Urine drugs were negative, and routine blood investigations were normal.
She was the second out of five siblings. Her parents did not notice any behavioral changes at home and denied any traumatic events and physical or sexual abuse throughout the patient's childhood. The patient denied of having past romantic relationships. The parents, however, admitted that the patient was commonly cared for by a babysitter during her early childhood as both parents were occupied with their career development.
Since then, she had been seen by three different psychiatrists, and the diagnosis remained as primary erotomania towards the first psychiatrist. She was initially prescribed with oral antipsychotics, but due to her poor insight and poor oral compliance, she was decided for monthly intramuscular depot injection. With ongoing treatment, she had ceased any form of physical contact with the first psychiatrist but remained convinced that the first psychiatrist was in love with her.


The second case described a 42-year-old lady, a divorcee diagnosed with schizophrenia at the age of 32. She came from a lower socio-economic background with poor social support. Previously, she had experienced physical and psychological abuse by her ex-husband who was an alcoholic. She had been shunned away by her own family and had to surrender the custody of her 9-year-old son following the divorce due to her mental illness.
She has had few suicidal attempts by overdosing paracetamol due to marital conflict. With regard to her psychiatric illness, she poorly complies to her oral medication and had multiple hospital readmissions due to relapse psychotic symptoms.
She developed erotomanic delusion when she first met a female therapist three years after her first diagnosis of schizophrenia. She truly believed that the therapist was in love with her following their first meeting. Apart from having delusion of control and paranoid delusion, she also experienced third-person auditory hallucination and tactile hallucination of having sexual intercourse with the therapist. She had bizarre delusion, likening her therapist to a God, and that the therapist was destined to be her soulmate. She was convinced that they will be together when the therapist is reincarnated as a male in her next life. The patient habitually sent love letters, elaborate gifts, and candies to the therapist, including lavish flower bouquets on Valentines. She also developed stalker-like behavior, peeking the therapist at work. In the attempt to persuade the patient for depot antipsychotic injections, the therapist had promised to continue to see the patient for subsequent routine consultation.
She responded well with intramuscular fluphenazine 37.5 mg monthly with improvement of psychotic symptoms, including erotomania. Unfortunately, once she was clinically well, she began to default treatment and follow-up causing relapse psychotic symptoms.


Our patient is a 64-year-old male with a past medical history including squamous cell carcinoma of the head and neck (diagnosed in 2004, status post resection and chemoradiation) and past surgical history of right TKA in 2018. He was admitted to the hospital complaining of right knee pain of seven-day duration. The patient started experiencing progressively worsening pain, swelling, and redness around his right knee for over one week. He denied any history of recent trauma, fever/chills, or other joint involvement. However, he stated undergoing routine scaling and root planing dental procedure two weeks before his symptoms started and was administered amoxicillin as a prophylaxis antibiotic. Vitals on admission showed temp: 36.5°C, blood pressure (BP): 166/77 mmHg, pulse: 74 bpm, and saturation of 95% on room air. Physical examination was significant for right knee erythema and edema. There was a considerably limited range of movement with marked tenderness on palpation and differential warmth around the right knee. Joint effusion was detected clinically. Knee arthrocentesis was performed, and the synovial fluid was sent for analysis and culture. Cardiovascular, respiratory, and abdominal examinations were normal. The white blood cell (WBC) count was 4,500/mL with a differential of 73.4% neutrophils, 16% lymphocytes, and 7.1% monocytes, ESR was 44 mm/hr, and C-reactive protein 78.2 mg/L. Synovial fluid analysis was turbid, fluid nucleated cells of 18,750/mm3, fluid neutrophils 91%, fluid lymphocytes 5%, and no fluid crystals were observed. Microbiological culture of the synovial fluid showed gram-positive cocci. Empirical treatment was initiated with vancomycin 1 g 12-hourly. Given the high probability of septic arthritis, the patient was taken to the operating room and right knee irrigation and debridement with polyethylene exchange were performed. The arthrocentesis synovial fluid culture 72 hours after collection showed alpha hemolysis on chocolate agar (Figure ) and sheep blood agar (Figure ), which was identified as G. haemolysans isolated from the subculture of thioglycolate broth.
Given the rarity of the organism, cultures were sent to Quest diagnostics in Valencia, California for sensitivity. The patient’s postoperative course was unremarkable with an improvement of knee edema and tenderness. He was making good progress towards all goals of physical therapy with an improved range of motion. He was discharged on daptomycin 6mg/kg 24-hourly for six weeks. Antibiotic susceptibility report for G. haemolysans came back after discharge and showed sensitivity for meropenem, ceftriaxone, clindamycin, penicillin, and vancomycin. Upon follow-up, he was doing well, and antibiotics were de-escalated to amoxicillin.