A 16 year old male patient was admitted to our hospital with weakness, rapid exhaustion and bloody sputum since six months ago. He was on iron supplement therapy due to anemia. Parents were close relatives and healthy and family history was negative for similar symptoms. His weight was 58.5 kg (25 - 50 percentile) and his height was 174 cm (50 - 75 percentile). His systemic examination was unremarkable. Laboratory data were: Hb 5.8 g/dL, RBC 3,420.000/mm3, MCV 63, Hct 21.5%, hypochromic microcytic anemia was detected. Sedimentation rate was 27 mm/hour, C-reactive protein 0.33 mg/dL. Serum iron 12 µg/dL, total iron-binding capacity (TIBC) 443 µg/dL, ferritin 8.57 ng/mL. Peripheral blood smear and bone marrow biopsy were compatible with iron deficiency anemia. No evidence of bleeding diathesis was found, kidney and liver function tests were unremarkable. Increased density was observed in chest X-rays in base of both lungs. In thoracic CT scan there were densities with ground glass appearance in both lungs which were more distinct in posterobasal levels (). In the fiberoptic bronchoscopy, endobronchial lesion and bleeding focus were not detected. In the BLF, many hemosiderin laden macrophages were seen. Serum ANA (ELISA), C-ANCA, P-ANCA, Anti-dsDNA were found negative. C3, C4, IgG, IgA, IgM, IgE, inhaler specific IgE and FX5 nourishment panel values were normal. No atopy was established in skin tests. Cardiac evaluation was normal. Spirometric assessment was as follows: FVC 81%, FEV1 84%, FEV1/FVC 100%, PEF 106%. Though there were no GIS symptoms, Anti Gliadin IgA and IgG and Anti Endomysium antibodies were determined as positive. In endoscopy duodenal pili finding was compatible with celiac disease and in duodenal biopsy total villous atrophy was observed (). Gluten free diet was initiated and hemoglobin level returned to normal after sixteen months.


A 9 year-old male patient was admitted to our clinic with complaints of paleness, weakness and hemoptysis since 3 - 4 days ago. His body weight was 26 kg (10 percentile) and height was 130 cm (25 - 50 percentile). Apart from 1/6 systolic murmur in cardiac examination, no specific sign was determined. The peripheral blood smear was compatible with severe hypochromic microcytic anemia. Bone marrow biopsy revealed active erythropoeisis. Laboratory data are as follow: serum iron 18 µg/dL, TIBC 404 µg/dL, ferritin 12 ng/mL. The thoracic CT scan revealed areas of higher density with ground glass appearance characterized by extensive alveolar involvement in both lungs. Fiberoptic bronchoscopy was performed and many hemosiderin laden macrophages were found in BAL fluid. Diagnosed with IPH parenteral steroid treatment with a dose of 2 mg/kg/day was initiated and erythrocyte transfusion support provided. Since the Anti Gliadin IgA and IgG and Anti Endomysium antibodies were found to be positive, GIS endoscopy was performed and the duodenal biopsy revealed MARSH 3B histological findings compatible with celiac disease (). No remarkable finding was established in other examinations. Gluten-free diet was commenced for celiac disease. In the follow-up, steroid treatment was tapered gradually and discontinued, gluten-free diet was continued and hemoglobin level returned to normal in nine months.


A 55-year-old woman presented with dull aching pain on the right side of her abdomen. Abdominal examination revealed an ill-defined lump in the right lumbar area extending to the hypogastrium and iliac fossa. Ultrasound revealed a right-sided renal mass with an empty left renal fossa with an ectopic kidney at the L4 level. Dedicated triphasic CECT of the abdomen was performed for preoperative surgical planning. The CT revealed crossed fused renal ectopia on the right side (). The right renal moiety was lying opposite the L1-L4 vertebrae. The left moiety was seen lying horizontally opposite the L4-L5 vertebrae with its pelvis lying anteriorly and forming an L-shaped crossed fused ectopia. A 15-cm lobulated, minimally enhancing mass lesion was noticed to arise from the anteromedial aspect of the orthotopic kidney in the lower and interpolar region. The mass lesion was infiltrating the renal sinus fat and the upper pole region of the left moiety with ill-defined fat planes with the second part of the duodenum and liver.
The arterial phase of the CECT revealed three renal arteries arising from the abdominal aorta. The proximal renal artery was seen arising at the L1 level at the 9 o'clock position and was supplying the right renal moiety along with the mass lesion. The mid renal artery was arising at the upper border of the L3 level at the 10 o'clock position and was supplying the mass lesion along with the ectopic moiety. The distal renal artery originated at the mid L3 level and was supplying the ectopic moiety. Two renal veins were at the L1-L2 level draining the orthotopic moiety along with the mass lesion. Another renal vein at the lower border of the L3 level was draining the mass lesion and the left renal moiety into the inferior vena cava. The left moiety was also drained by another renal vein into the common iliac vein at the L4 level. Both renal moieties showed normal contrast excretion. The right ureter was seen coursing along the medial margin of the mass lesion, creating a plane between the mass and the left renal moiety. The left ureter was crossing the midline and was draining into the left vesicoureteric junction. No significant regional lymphadenopathy was present. The patient's serum creatinine was 1.01 mg/dL.
After the preanesthetic checkup, the patient underwent robot-assisted radical heminephrectomy on the right side under general anesthesia (). The patient was placed in the left lateral decubitus position and was well secured with adequate pressure padding. Pneumoperitoneum was created by using a Veress needle through an umbilical incision. A 12-mm trocar was inserted at the umbilicus and a 30-degree scope was introduced. Two 8-mm robotic working ports were placed at the lateral border of the rectus, one between the xiphoid process and the umbilicus and the other between the umbilicus and the pubic symphysis. Another 12-mm assistant port was placed in a midline supraumbilical location. Docking of the robot was done. The right colon was mobilized medially. By use of blunt and sharp dissection, the renal mass was mobilized at the superior pole followed by mobilization at the inferior pole with identification of the right ureter between the renal mass and the ectopic kidney where it was clipped and divided. On the basis of the preoperative cross-sectional imaging, tumor-feeding vessels were clipped and divided. The lower limit of the tumor was meticulously dissected off from the ectopic moiety with preservation of its vasculature. The parenchyma at the isthmus was quite thin, and bleeding was controlled by electrocautery. The collecting system was not opened. Thus, no formal repair of the thin raw area was needed. In an attempt to avoid iatrogenic injury to the mesenteric vessels and blood vessels supplying the healthy ectopic moiety, dissection was kept close to the tumor. The large size of the tumor was impairing vision and light focusing. While dissecting superiorly and posteriorly, the plane of dissection went through the upper polar normal parenchyma of the orthotopic kidney, which was supplied by a separate vascular twig, which kept on oozing until the kidney was completely mobilized. Identification, clipping, and division of this vascular pedicle achieved hemostasis. The large tumor size hindered its retrieval with an indigenous specimen delivery bag. For specimen delivery and hemostasis, an anterior subcoastal incision was made. A 22-Fr abdominal drain was placed. Wounds were sutured and the patient was shifted to recovery after extubation.
The total operating time was 120 minutes (16 minutes for port placement and 2 minutes for docking). Blood loss was 600 mL. Gross examination of the specimen revealed an 18 cm×12 cm mass arising from the right kidney with areas of hemorrhage and necrosis. The patient was ambulatory by the second postoperative day. Final histopathology revealed chromophobe renal cell carcinoma with negative surgical resection margins.


A 78-year-old woman visited the pain clinic for management of low back pain and sciatica. The patient did not have any underlying disease except for hypertension. The patient recently underwent a caudal epidural block and a transforaminal epidural block 6 times in a year by using an ionic contrast medium (ioxitalamate, Telebrix®). She underwent a caudal epidural block 4 times, and had no history of allergic reactions to contrast media or other substances. All procedures were performed without complications.
Magnetic resonance imaging revealed central stenosis at the L 2-3 and L 3-4 levels and spondylolisthesis at the L5-S1 level. Full informed consent was obtained from the patient prior to performing the procedure. The patient was placed in the prone position, and the sacral hiatus was typically identified between the sacral cornua. The sacral hiatus was punctured with a 22 G epidural needle through the sacrococcygeal membrane. The epidural space was confirmed by fluoroscopy with a C-arm. After the needle was advanced 2-3 cm, 1 ml of nonionic contrast media (iohexol, Omnipaque®, GE Healthcare co., Uhan, China) was injected for confirming that there was no intravascular injection or abnormal flow. Nonionic contrast media (300 mg/ml) was used as undiluted state. After the first dye injection, we detected intravascular injection of the dye (). We displaced the needle and injected an additional 1 ml of the dye, and again detected the intravascular injection. We then withdrew and repositioned the needle and injected the dye. This time, the intravascular and intrathecal injection of the dye remained undetected. We initially planned to perform a caudal block, with a mixture of 12 ml of lidocaine hydrochloride (0.5%, preservative free) and 5 mg of dexamethasone prior to the procedure. However, we decided to administer 5 mg of dexamethasone and 9 ml of normal saline instead through the caudal epidural space. Five minutes after the dye was injected, the patient began to experience dizziness but no other symptoms and was transferred to the recovery room for management of vital signs.
At the recovery room, the patient's blood pressure dropped to 60/40 mmHg, heart rate was 100 bpm, peripheral oxygen saturation (SpO2) was 98%, and the electrocardiography showed normal sinus rhythm without ischemic changes. Moreover, the patient exhibited a mild drowsy mental state without any rash or edema. Immediately 10 L/min O2 was administered to the patient through a facial mask. Then, 500 ml of normal saline solution was rapidly loaded and 0.5 mg of atropine and 10 mg of ephedrine was injected intravenously. However, the blood pressure did not improve and the patient continued to remain in a drowsy state. We subcutaneously injected 0.2 mg epinephrine and closely monitored the patient. About 30 minutes later, the blood pressure increased to 90/60 mmHg and the patient was awake. Around 1 hour later, the dizziness resolved and the patient successfully carried out an order. The vital signs became more stable (blood pressure, 100/70 mmHg; heart rate, 80 bpm; SpO2, 98%). The patient recovered without any sequela. The patient refused any additional examination (intradermal skin test, IgE) to identify the cause of the allergic reaction.


A 12-year-old boy presented to surgical casualty with intermittent discharge from the left ear for the last 12 years and decreased hearing. Recently, he had developed high grade fever for a week. On examination, the patient was conscious, oriented to time and place but had a toxic appearance. Fundoscopy showed grade one papilledema and patient had bilateral sixth nerve palsies. There were no sensorimotor or cerebellar deficits. Contrast computed tomography (CT) scan revealed a hypodense extra-axial collection, located inferior to tentorium, and spread symmetrically across the midline [Figure –]. As the patient was being prepared for posterior fossa craniectomy, he became unconscious and deteriorated to decerebrating posture. Both pupils became fixed in size and nonreactive to direct light reflex. The patient was intubated and started on mechanical ventilation. Frontal horn of lateral ventricle was tapped as a last salvage measure, but proved of no benefit.


A previously healthy 8-year-old girl was admitted to the emergency department with a sudden loss of consciousness, vomiting, and bradycardia. She was unresponsive on initial evaluation. She showed evidence of decerebrate posturing to deep painful stimulation, and her Glasgow Coma Score (GCS) was 4 points. The patient was emergently intubated and ventilated.
A noncontrast CT scan of her head revealed a 5 cm × 5 cm hyperdense cerebellar lesion with obliteration of the fourth ventricle and resultant obstructive hydrocephalus []. Magnetic resonance imaging (MRI) was not performed because of the patient's poor clinical condition. A right frontal external ventricular drain was urgently placed to relieve her high intracranial pressure. The patient was taken to the operating room, where she underwent a sub-occipital craniectomy. The intracerebellar hemorrhage was removed via standard microsurgical technique. Postoperatively, the patient was transferred to the Neurosurgical Intensive Care Unit. A postoperative CT scan showed the expected postoperative changes in addition to a small amount of blood around the fourth ventricle. No residual tumor mass was detected by CT []. No significant improvement in the neurological status of the patient was observed during the early postoperative period. Unfortunately, the patient died 12 h after surgery.
Histopathological examination of the hemorrhagic specimen identified it as a tumor mass composed of neoplastic round cells arranged in sheets and nodules, along with blood vessels and large hemorrhagic fields. The neoplastic cells demonstrated high mitotic activity, and the percentage of Ki-67 positive cells was 45–50%. The cell nuclei were round to oval in shape and had open chromatin and evidence of atypical mitosis and necrosis. Immunohistochemical analysis indicated that most of the tumor cells were strongly positive for synaptophysin and p53 and focal positive for glial fibrillary acidic protein and neuron-specific enolase. These findings were compatible with the diagnosis of medulloblastoma, Grade IV, according to the World Health Organization (WHO) 2007 classification criteria [].


We present a case of a 21-year-old female who, in the month prior to admission to our institution, had been treated multiple times in emergency departments at various hospitals referring epigastric abdominal pain and constipation. The treatment she received was based on the resolution of constipation, antacids and dietary recommendations. The patient was admitted to our emergency department after 1-month of upper quad-rant abdominal pain radiating to the left upper quad-rant, additionally she cited a weight loss of 5 kg in the last month. Her symptoms had become more aggravated two days prior to admission with unquantified fever, chills and night sweats. She had no history of previous peptic ulcer disease or surgical procedures. A review of the family history revealed no significant disease. A physical examination revealed vital sings with a heart rate of 102 beats per minute, respiratory rate 16 breaths per minute, temperature of 37°C, blood pressure of 110/56mmHg, the abdomen was distended, the percussion was tympanic, the bowel sounds were de-creased. Additionally we found a painful, not well limited, mass adhered to deep planes in the abdominal palpation without peritoneal irritation or other alterations. A work-up started with blood chemistry, CBC, and we requested a CT of the abdomen due to clinical examination findings. The preclinical showed no elevation of acute phase reactants and no electrolyte disturbance, the CT scan evidenced an irregular, small collection in the gastric antrum and behind the left rectus muscle of approximately 30x11x16mm, which was associated with increased density of the surrounding fat. Inside this area, the end of a tubular, hypodense structure (compatible with foreign body) was visible coming out from the gastric lumen through the wall, which was perforated ( and ). The findings on CT were dis-cussed with the patient who was questioned again for further information to determine the origin of the foreign body. The patient agreed to tell the truth. She ad-mitted having a major depressive episode 6 months ago and attempted of suicide. She had ingested a plastic stick from a candy (chocmelo ®) ().
She was referred to general surgery service who decided to take the patient immediately to the surgery room and performed an exploratory laparotomy. During the procedure, they found a perforation in the anterior wall of the stomach between the gastric body and the antrum, it was associated with a great inflammatory plas-tron generating a gastrocolic ligament edema. They therefore decided to perform a subtotal gastrectomy removing 50% of the stomach and then Roux-Y reconstruction. Histopathological examination revealed severe inflammation, with abscess formation and severe submucosal edema.


A 57-year-old male patient was admitted to our center because of a cystic mass in the right upper lung field that was discovered incidentally by chest X-ray during a routine health checkup. He was a current smoker with more than 30 pack years of cigarette exposure. He had been diagnosed with chronic obstructive pulmonary disease (COPD) 20 years previously and had been using an inhaled corticosteroid and bronchodilator. The patient has been working at the convenience store, and had no history of trauma or use of any anticoagulants. He had no chest pain, fever, cough, or sputum. There were no other episodes of hemoptysis. His physical examination showed decreased lung sounds in both lung fields without wheezes or crackles. There was no palpable lymph node enlargement. Routine laboratory studies including a platelet count and coagulation profiles yielded normal results, except a slightly increased C-reactive protein (CRP) level (7.13 mg/dL). Pulmonary function tests showed a severe obstructive pattern, the forced expiratory volume in 1 second (FEV1) was 1.38 L (36% of predicted volume); the forced vital capacity (FVC) was 4.08 L (85% of predicted capacity); and the ratio of FEV1 to FVC was 34%. The diffusing capacity was 15.7 mL/mm Hg/min (61% of predictive capacity). Several sputum analyses were negative for malignancy, bacterial infection, and tuberculosis. There was no evidence of human immunodeficiency virus infection. Chest X-ray showed a clearly defined homogeneous round opacity without calcification in the right lower lung field (). Computed tomography (CT) scanning of the chest revealed a huge round cystic mass across the upper and lower lobes of the right lung, which measured 9×7.9 cm at its maximum diameter ().
Single port video-assisted thoracoscopic surgery approach using 5-mm scope through a 3.0 cm skin incision was performed under general anesthesia and one lung intubation. After dissection of the pleural adhesions present, a thick yellowish cystic mass with a well-defined margin of 9×8×8 cm in size was found along the major fissure between the right upper and lower lobes (). Fine needle aspiration collected a dark brownish colored viscous fluid. The mass was resected completely. Pathological examination revealed a large amount of dense fibrous tissue with blood clots, compatible with pulmonary hematoma (), with no evidence of malignant cell infiltration. After postoperative care, the patient was discharged without any complications. A follow-up chest X-ray after 2 months showed no recurrence, and there was no evidence of recurrence 1 year after the follow-up period.


An 18-year-old male patient presented with pneumothorax on postoperative day four after the minimally invasive repair of pectus carinatum. The pectus carinatum repair was performed using the sandwich technique, which involves a 33.02-cm press-molded internal bar and a 30.48-cm press- molded external bar (). Instead of a chest tube, a small- bore central venous access catheter was inserted to relieve the pneumothorax in a less invasive manner. A chest computed tomography scan indicated the presence of multiple bullae at the apex of the upper lobe of the right lung. On postoperative day seven after the pectus repair, three days after the development of pneumothorax, we decided to remove the bullae through video-assisted thoracoscopic surgery (VATS) because the lung collapse was persistent.
Under general anesthesia, using double-lumen endotracheal intubation with the patient in the left lateral decubitus position, a 10-mm thoracoscopic port was placed at the eighth intercostal space of the middle axillary line, below the pectus bar insertion level in order to avoid bar interruption. A 2-cm working incision was made at the fourth intercostal space of the anterior axillary line and a 5-mm working port incision was made at the subscapular tip area of the posterior axillary line for a three-port VATS approach. VATS exploration using a 30° thoracoscope (Karl Storz endoscope; Karl Storz, Tuttlingen, Germany) revealed minimal hemothorax and multiple apical multiple bullae as indicated by the preoperative computed tomography scan. A finding that we did not anticipate was that the middle lobe of the right lung was entrapped between the chest wall and the pectus bar. Adhesion was present around the pectus bar and the entrapped lung, but we did not observe air leakage at that moment ().
The entrapped lung was separated from the adhesion and carefully pulled out of the pectus bar. However, a portion was injured, and it had to be resected with endostaplers (TriStapler; Covidien, Norwalk, CT, USA). The apical bullae lesion of the upper lobe was also wedge resected. An air leak test confirmed that both resected areas of the apex and the entrapped middle lobe were airtight. Bio-absorbable felt (Neoveil; Gunze, Osaka, Japan) was used to cover the lesions, followed by glue injection on the resected lesions. The patient recovered uneventfully and was discharged four days after VATS. He underwent nine months of follow-up with no recurrence of the pneumothorax.


A 32-year-old woman presented with syncope. Working as a seamstress, she felt dizzy, with blurred vision and had loss of consciousness for a few seconds. She was not anxious and had been working all day.
There was a history of several episodes of complete and transient loss of consciousness, with spontaneous recovery after <2 min, without sequelae. She had dizziness preceding syncope, but no other symptoms. Syncopes were related to emotional stress. She denied association with exercise, fear, pain or the orthostatic position as well as coughing/sneezing, swallowing, micturition/defecation and post-prandial/post-exercise periods. Syncopes occurred at least yearly from 14 to 21 years old and ceased at 32 years. There was no family history of syncope or SCD.
Physical examination was unremarkable. Electrocardiogram (ECG) showed sinus rhythm, with polymorphic ventricular premature beats (VPBs) and normal QTc (Fig. ). Echocardiogram was normal. She started bisoprolol (2.5 mg/day) and was referred to Cardiology consultation.
Syncope did not recur thereafter. Cardiac magnetic resonance was normal. Exercise testing on treadmill showed more frequent polymorphic VPBs and episodes of non-sustained VT with an increase during exercise and a decrease in the recovery phase (Fig. ). Holter monitoring was performed, revealing very frequent VPBs during daytime (mean 710 VPBs/h) and less frequent during sleep (mean 116 VPBs/h). VPBs were more frequent by the time she woke up and prepared herself to go to work and decreased during lunch and dinner time. Episodes of non-sustained VT were more frequent during daytime and decreased during sleep. No mutations in ryanodine receptor gene (RYR2) or in the gene-encoding calsequestrine (CASQ2) were found.
At 1-year follow-up, exercise testing was repeated. Compared with the first exercise testing, non-sustained VT episodes were shorter and less frequent during exercise and disappeared in the recovery phase (Fig. ). Holter monitoring was also repeated, revealing a higher frequency of VPBs during daytime (mean 670 VPBs/h) compared with the sleeping time (mean 260 VPBs/h; Fig. ). There were irregular, polymorphic, large complex tachycardia episodes, ranging from 3 to 15 complexes, with a maximum rate of 142 bpm (Fig. ). Bidirectional tachycardia was recorded (Fig. ).
Owing to intolerance, the patient was asked to switch from bisoprolol to atenolol (25 mg/day). Symptomatic hypotension (dizziness) stopped up-titration of beta-blocker and addition of flecainide. Since she did not have recurrence of syncope and the second treadmill test showed a reduction in the frequency and complexity of ventricular arrhythmias, no further treatment was initiated.
Patient's 11-year-old daughter was referred to clinical evaluation and exercise testing.


A 72-year-old man presented to the emergency department with a 3-day history of increasing low back pain (LBP). He was receiving medication for DM and hypertension for 2 years. He had no recent history of febrile illness and had not received any spinal procedure or intervention. On examination, he was afebrile, had no pain in the legs, and no neurological deficit. Magnetic resonance imaging (MRI) of the lumbar spine in the emergency department showed abnormal signal intensity in the L4-L5 intervertebral disc and in the L4 and L5 vertebral bodies. Gas was evident in the lumbar spinal canal. Thecal sac compression from a posterior epidural lesion was demonstrated from L4 to S1 level (). Under the suspicion of lumbar SEA, he was admitted to the neurosurgical department. On admission, blood lab and blood culture were done. The laboratory findings showed a white blood cell (WBC) count of 10,890 cells/mm3 (normal: 4,000-10,000 cells/mm3), an erythrocyte sedimentation rate (ESR) of 129mm/h (normal: 0-9mm/h), and a C-reactive protein (CRP) level of 15.79mg/dL (normal: <0.5mg/dL). Hemoglobin A1c (HbA1c) was 8.1%(normal: 4.0-5.6%).
He was febrile from the night of the day of admission. LBP worsened and numbness in the legs developed. Gadolinium-enhanced MRI performed the next day revealed markedly increased extent of the epidural abscess from lower L2, increased amount of gas, and anteriorly displaced cauda equina (). Gas was clearly demonstrated in non-enhanced computed tomography (CT) scan of the lumbar spine ().
Under the impression of lumbar SEA, he was brought to the operating room for an emergent operation. Just before starting to the operating room, he complained of residual urine sensation after voiding. He underwent multilevel laminectomy from L3 to S1 and evacuation of the abscess. Frank pus was identified in the epidural space. Cultures from the epidural abscess and the L4-L5 disc grew E. faecalis. Blood cultures performed on the day of admission also grew E. faecalis. The pathogen was sensitive to ampicillin and antibiotic treatment with intravenous ampicillin was begun. Intravenous ampicillin was administered for 6 weeks and discontinued without additional oral antibiotic treatment. On discharge, his pain and clinical condition improved greatly and the WBC count, ESR, and CRP levels were within normal limits.


A 58-year-old woman from Mongolia presented with a palpable mass at the right posterior neck, which has been growing gradually over two years. She complained intermittent mild pain around the mass. Physical examination indicated that the mass had a diameter of approximately 5 cm and was soft and fixed to the surrounding tissues and accompanied by mild tenderness. Moreover, the mass showed a diurnal variation in size - it became larger in the morning and smaller in the afternoon. Simple neck radiograph didn't show any abnormal finding. Ultrasonography indicated the presence of an isoechoic multiloculated mass in the right semispinalis capitis muscle, whereas magnetic resonance imaging (MRI) showed a welldefined-lobulated and heterogeneous mass with strong contrast enhancement (). On angiography, a vascular staining was noted during the late arterial phase without any definitive feeding artery or draining vein.
Tumor removal was performed through a vertical posterior neck incision in the right posterior region of the neck. During the surgery, there was an episode of sudden profuse bleeding while dissecting the muscles surrounding the tumor. The bleeding was controlled easily with electrocautery, but the mass shrank in size. Consequently, the tumor boundary became unclear making the tumor dissection difficult. However, a total resection of the tumor was possible by careful dissection of the fibrotic plane around the tumor. The excised mass was approximately 3.5×3.0 cm and dark brown with small cystic components. The mass was diagnosed as a cavernous type IMH according to a histopathological examination ().


Our patient, a 64-year-old female, presented acutely with large bowel obstruction. The only past medical history was of gallstone disease treated with laparoscopic cholecystectomy in previous 5 years.
Computed tomography (CT) confirmed obstruction at the level of the proximal sigmoid colon. Although sigmoid diverticular disease was present, the radiological features were more suggestive of malignant aetiology.
Subsequent laparotomy revealed an obstructing sigmoid mass densely adherent to pelvic wall and bladder. The proximal bowel was grossly dilated but viable with no evidence of ischaemia. Hartmann's procedure was performed with en bloc partial cystectomy. The procedure was uncomplicated with minimal blood loss. The dilated proximal colon was decompressed prior to closure, and a tube drain was left in the pelvis.
Post-operatively, she was observed in the high dependency unit (HDU) for 24 h and required no cardiovascular or respiratory support. After step down to the ward, her recovery continued to be uncomplicated. By the end of Day 4, the stoma was working, oral intake was increasing, pain was well controlled with oral analgesia, the pelvic drain had been removed and mobility was improving.
On the fifth post-operative day, her white cell count (WCC) increased to 19.2 (from 12.9 the previous day). On examination, she was borderline tachycardic (heart rate (HR) 90–100, sinus rhythm) with all other observations within normal range, including temperature. There was a superficial wound infection, but her abdomen was soft and non-tender. The wound was opened, washed out and packed on the ward. A full septic screen was requested.
The following day, there was a further increase in the WCC to 21.5, accompanied by an increased CRP to 203 (from 94 the previous day). The patient reported some nausea but no increase in abdominal pain. On examination, the abdomen was slightly distended, but there was no increased tenderness. With no obvious alternative source, a CT scan was requested to exclude intra-abdominal sepsis.
Figure shows a remarkable amount of air in the hepatic portal venous system. Figure demonstrates how the portal vein, splenic vein, superior mesenteric vein and its branches were all outlined with air. Figure shows air within the wall of both small and large bowels. Overall, the radiological findings were suggestive of extensive bowel ischaemia.
On clinical review following the CT, the patient appeared stable. She complained of nausea and had vomited ∼500 ml of bilious fluid. There was, however, no reported increase in abdominal pain, and, despite the worrying radiological features, observations and blood gas analysis were surprisingly normal: blood pressure 130/80, HR 97, apyrexial, pH 7.427 and base excess −2.4.
The patient was resuscitated with high flow oxygen, intravenous fluids and broad-spectrum antibiotics. The appropriateness of emergency re-laparotomy was debated. Given the relatively normal haemodynamic and metabolic parameters, it was felt that re-laparotomy for diagnosis and potential treatment was indicated and should be performed as early as possible, prior to physiological deterioration.
Findings at re-laparotomy were unexpected; no evidence of gastrointestinal ischaemia, no intra-abdominal contamination and no other abnormality detected. The patient remained stable throughout the procedure and was extubated post-operatively and taken back to HDU for observation.
Over the following 5 days, she made steady progress without further incident. Her bloods normalized following a course of antibiotics for urinary tract infection. A normal cystogram was performed prior to removal of urinary catheter, and she was discharged with district nurse input for wound dressing. Histological analysis revealed the sigmoid mass to be benign, and she has since made a complete recovery.


A 37-year-old right-hand-dominant male tripped over a curb and landed on his outstretched right upper extremity. He presented to the emergency department with pain and deformity over his right thumb MCP joint. X-rays obtained showed a volar dislocation of the thumb MCP joint. () A digital block was performed and closed reduction was attempted by hyperflexing the thumb MCP joint with a dorsally directed force applied over the volar base of the thumb metacarpal base. Closed reduction attempts were initially unsuccessful and the decision was made to take the patient to the operating room to perform a closed versus open reduction under anesthesia.
Once the patient was induced under general anesthesia, closed reduction of the thumb MCP joint was successful utilizing the same reduction maneuver. On further examination, the thumb had notable radial deviation at the MCP joint with stress testing. Valgus stress was applied to the thumb in neutral position as well as at 30° of flexion. This was confirmed under fluoroscopy with >30° of instability compared with the uninjured contralateral thumb, indicating a complete rupture of the UCL. An open approach was then performed where we were able to identify a complete mid-substance rupture of the UCL as well as disruption of the dorsal capsule and adductor aponeurosis. There was no transposition of tissue noted within the MCP joint. The UCL was primarily repaired with nonabsorbable sutures in a modified Kessler technique.
The patient was maintained in a thumb spica splint postoperatively for 2 weeks () after which flexion–extension exercises were begun. The patient was encouraged to perform aggressive ROM exercises five times daily. He was cautioned against forceful pinch or resisted motion of the thumb for an additional 3 weeks. He was maintained in a removable splint for an additional 4 weeks. At 6 months follow up, patient was noted to have stable and congruent MCP joint with fixed flexion deformity of 10° and 70° of flexion with no complaints of pain. At 1 year follow up, the patient continues to be pain-free and reports no limitations of activities. His Disabilities of the Arm, Shoulder, and Hand (DASH) score was 9.2.


A 41-year-old woman presented with OPLL. The patient had previously undergone posterior decompression for thoracic vertebral lesions. During the study period, cervical laminoplasty was performed using two spacers. Placement of a spacer in the lower cervical vertebra was facile, as an anchor was used that did interfer with the rod ().


A 65 year-old woman with metastatic leiomyosarcoma had progressive disease after receiving systemic therapy with doxorubicin and then pazopanib. She had no medical comorbidities, regular medication or known drug allergy. Third-line combination gemcitabine and docetaxel was initiated. Five days after the third cycle was given, she presented with acute respiratory distress. Congestive cardiac failure and septic causes were excluded. Blood tests revealed stable liver and renal function tests. Computed tomography pulmonary angiography (CTPA) excluded pulmonary emboli but demonstrated bilateral pulmonary infiltrates consistent with drug-induced pneumonitis. On treatment with corticosteroid, her condition improved.
Subsequently, she underwent skin prick testing with gemcitabine and docetaxel at the concentration of 0.2 mg/mL and 0.4 mg/mL, respectively, equivalent to the concentration at which the drugs were infused. Histamine was used as positive control and saline was used as negative control. As neither drugs elicited a positive reaction, intradermal testing was performed at a dilution of 0.02 mg/mL and 0.04 mg/mL for gemcitabine and docetaxel respectively. Readings taken thirty minutes after the injection was positive for gemcitabine, with a 5-mm increase in the diameter of the original bleb and a surrounding flare response, implicating gemcitabine as the culprit agent for the pneumonitis. A reading 24 hours later found no delayed response. Docetaxel was recommenced and led to clinically apparent and ongoing meaningful disease control.


A 59-year-old woman was found to have recurrent hormone receptor positive and HER2 positive breast cancer with malignant pleural effusion and bony metastases. She proceeded with combination trastuzumab and docetaxel, and completed five cycles uneventfully with a good clinical and tumour marker response. Six days prior to the sixth cycle, she developed acute respiratory distress. Chest x-ray revealed a stable pleural effusion and a new reticular density throughout the lung fields. CTPA excluded pulmonary emboli but confirmed widespread bilateral ground-glass opacities and interstitial septal thickening consistent with acute pneumonitis. Treatment with prednisolone was commenced with improvement in her symptoms. Septic screening detected Escherichia coli bacteriuria but no other sources of infection. A gated heart pool scan revealed a normal left ventricular ejection fraction.
She underwent similar skin testing with a delayed reading at 48 hours; intradermal testing was performed with an incremental increase in the docetaxel concentrations. Saline, as negative control, and 0.02-mg/mL docetaxel did not induce a wheal or a flare response. Docetaxel at 0.2-mg/mL and 2-mg/mL concentration did not induce a wheal but at 48-hour reading induced a wheal and flare response. Skin prick and intradermal testing was negative for trastuzumab. She thereafter continued on treatment with trastuzumab, with the addition of pertuzumab with radiological and clinical improvement of her pneumonitis one month later.


A 39-year-old man with a history of cirrhosis caused by HCV, who underwent liver transplantation 2 months ago, presented with abdominal pain and fever. Diagnostic paracentesis was performed based on clinically overt ascites. The patient was treated with antibiotics as spontaneous bacterial peritonitis (SBP) was confirmed. Because he did not respond to medical therapy, diagnostic laparoscopy and appendectomy was done for him in the next step. His symptoms did not improve and he had alternating fever. Blood and urine culture was also negative on several exams and there were no sign of pneumonia on his chest images. We decided to repeat paracentesis to confirm the control of SBP.
Paracentesis was done carefully on the site marked by ultrasound with a 16-gauge needle and semi-clear fluid was aspirated. After about 30 minutes, the patient complained of a sudden acute severe pain in his right lower quadrant (RLQ) that was triggered by coughing. In his physical examination, there was a small bulge in the RLQ, which was tender, and no thrill or bruit was detected. The patient’s hemodynamic status was stable so he was observed. Few hours later, the bulging expanded following coughs, so an abdominal ultrasound was requested to focus on the RLQ area. An abdominal wall hematoma posterior to rectus muscles was reported with no sign of herniation or arterial flow. The patient’s coagulation profile was normal except for INR of 1.5. The bulging did not expand during the next hours, he was hemodynamically stable, and the coagulation tests were normal; therefore, we only corrected the already low hemoglobin level by transfusing packed red blood cells (RBC) and the patient was observed.
Two days later, there was another episode of sudden pain and expanding of the abdominal wall bulging. Urgent abdominal wall Doppler ultrasound reported a massive hematoma posterior to rectus muscles and an IEA pseudoaneurysm (). Doppler studies showed a 3 cm × 2 cm × 2 cm oval anechoic mass through the posterior part of the right rectus abdominis muscle. Moreover, IEA pseudoaneurysm was confirmed which was 3 cm × 2.5 cm × 3 cm in diameter, and consisted of neck (4 cm) and tract (9 cm). Also, Doppler studies showed turbulent flow (to and fro sign) within this structure (). IEA pseudoaneurysm was confirmed which was 3 cm × 2.5 cm × 3 cm in diameter, and consisted of neck (4 cm) and tract (9 cm).
As the patient had a serum creatinine of 4.4 mg/dL with a blood urea of 53 mg/dL that was caused by previously known renal failure, other modalities such as abdominal-pelvic CT scan or MR angiography could not be performed in order to confirm the suggested diagnosis by ultrasound study. Furthermore, therapeutic percutaneous vascular intervention was not possible due to the risk of contrast nephropathy. So, the best diagnostic and therapeutic intervention was operative exploration.
We performed the operation with an oblique incision on the marked site of the false aneurysm by ultrasound and the hematoma was evacuated. IEA false aneurysm was exposed and bleeding from one muscular branch was observed. The hematoma was behind the rectus muscle and it was completely around the anatomic locationof IEA. During operation, for appropriate management of the pseudoaneurysm, we evacuated the hematoma completely, but the IEA bleeding did not stop. Finally, the artery was ligated and sutured. The patient`s pain and bulging was resolved following surgery and he was discharged after completion of his antibiotic treatment.
It is noteworthy that by specialist consultations and proper exams, other reasons of extra-abdominal infections were ruled out. Moreover, the patient’s abdominal pain was reduced and diagnostic laparoscopy was done to evaluate whether operable reasons exist or not. Also, the patient was immune-suppressed so the sign and symptoms of appendicitis were not reliable. Additionally, the patient did not show the typical manifestation of appendicitis, so there was no indication for appendectomy procedure. While we performed diagnostic laparoscopy, we observed an abnormal appendices and appendectomy was also carried out. We documented it as the patient’s past medical history.


A 53-year-old woman presented with a diffuse anterior neck swelling of one-month duration. The patient had not undergone any previous surgery. Physical examination revealed no evidence of palpable cervical lymphadenopathy. Ultrasonography (US) showed diffuse goiter with multiple thyroid nodules. A homogeneous and hypoechoic solid mass, adjacent to the upper margin of the right submandibular gland with focal flow signals on color Doppler sonography within the mass was detected (). A computed tomography (CT) scan revealed a circumscribed mass, hypodense to the masseter muscle and hyperdense to the parotid gland in the right parapharyngeal space (). After intravenous contrast administration, the mass, 1.7 × 1.7 × 1.6 cm in size, demonstrated homogeneous enhancement without infiltration to the adjacent muscle. At that time, radiological differential diagnoses included salivary gland origin tumor or paraganglioma or neurogenic tumors. Enlargement of the bilateral thyroid lobes with multiple non-enhancing hypodense and calcified thyroid nodules was also noted. Under general anesthesia, this mass was excised surgically. The histological diagnosis was an angiofibroma without evidence of malignancy (). After surgery, the patient revealed an uneventful postoperative course. At the three-year follow-up examination, the patient remained free of any recurrence.


A 67-year-old male patient with a right middle lobe (RML) mass was referred to the pulmonary department (Fig ). Chest computed tomography (CT) showed multiple small nodules in both lower lung fields (Fig ) and a right adrenal gland mass, suggesting metastasis (Fig ). Bronchoscopic biopsy showed squamous cell carcinoma expressing p63 (Fig –). A positron emission tomography (PET)-CT scan also showed lung to lung and adrenal gland metastases, but the standardized uptake value (SUV) of the RML mass was about 2.2 (Fig ). The patient was finally diagnosed as stage IV (T4N0M1b) lung squamous cell carcinoma and began first line platinum-based combination chemotherapy using gemcitabine. The tumor size decreased after chemotherapy (Fig ) and progression-free survival (PFS) was 23 months. Second-line treatment commenced with gefitinib and PFS was seven months. The lung lesion progressed again and the patient underwent third-line chemotherapy with weekly docetexel. After nine cycles of docetaxel monotherapy, the tumor progressed and he was treated with weekly vinorelbine as fourth-line chemotherapy. For five months, the status of the NSCLC was stable (Fig ). After five months the tumor progressed once more and we considered close observation and supportive care, but the patient was willing to undergo treatment with chemotherapy if possible. We decided to retreat him with platinum-based gemcitabine combination therapy because this combination effectively controlled the tumor for 23 months during the first-line chemotherapy. Unfortunately, the chemotherapy was ineffective and a follow-up chest CT after two cycles of chemotherapy showed disease progression (Fig ). He finally decided to discontinue treatment and was followed-up regularly in our outpatient department.
Four months after the cessation of chemotherapy, the patient’s chest X-ray unexpectedly showed that the main mass had decreased in size. Chest CT also revealed that the mass size had decreased from 7.1 × 5.0 cm to 6.5 × 5.0 cm (Fig ). After seven and 10 months of follow-up, chest CT revealed that the mass had continued to significantly decrease in size. Three months later, a PET-CT scan showed no gross interval change in the size of the RML mass (Fig ).


A 37-year-old, primigravid woman at 21 weeks gestational age presented to a local hospital complaining of fever, cough and progressive shortness of breath. She was initially treated for suspected pneumonia but decompensated rapidly requiring emergent intubation for profound hypoxemia. Given the complexity of her illness, she was transferred to our tertiary care facility.
Upon admission, the patient's chest x-ray (CXR) was notable for bilateral interstitial infiltrates, and she was therefore started on empiric broad-spectrum antibiotics and oseltamivir. She was ventilated with lung-protective settings and paralyzed to alleviate ventilator dyssynchrony. Bronchoscopy revealed DAH and bronchioalveolar lavage cultures yielded Influenza A infection. She was started on high-dose methylprednisolone for her DAH, and inhaled nitric oxide (iNO) was added to optimize oxygenation. After a transient period of improvement, new infiltrates were appreciated on CXR, prompting computed tomography (CT) of her chest. This revealed multiple cysts throughout the lung parenchyma, suspicious for the diagnosis of LAM (Fig. ).
The patient's hypoxemia and DAH worsened, and she ultimately required venovenous ECMO support on Hospital Day 15. Though oxygenation improved, DAH remained refractory to steroid therapy. Six days into her ECMO course, recombinant activated factor VII (FVIIa) was endobronchially instilled. Serial bronchoscopies demonstrated interval improvement in the hemorrhagic burden after three treatments of FVIIa.
Ten days after commencing ECMO and at 24 weeks gestational age, the patient developed preeclampsia and HELLP syndrome. The maternal fetal medicine team performed an urgent cesarean section, and a viable female neonate was delivered. Simultaneously, a right-sided wedge biopsy of the lung was performed, and based on histologic findings, the diagnosis of LAM was confirmed (Fig. a–d). On ECMO Day 14 and Post-operative Day 3 from cesarean delivery, the patient was successfully decannulated from the ECMO circuit. She was extubated to high-flow nasal cannula (HFNC) 2 days later. Over the course of 2 weeks, she was successfully weaned to room air. The neonate required significant ventilatory and nutritional support but was eventually discharged home without neurologic disability.
Since discharge from our institution, the patient remains independent of oxygen supplementation. Due to a severe perturbation in her diffusing capacity of the lung for carbon monoxide (DLCO), she was started on sirolimus, a treatment for LAM. Her most recent pulmonary function testing (PFT) revealed a DLCO of 41% predicted and a 6-min walk culminated in desaturation from baseline pulse oximetry of 98–80%. A representative section from her most recent chest CT, performed 8 months after discharge, is shown in Fig. .


A 42-year-old man was admitted to the emergency department because of inability to remove an adult product from his rectum. The patient described the incidence as his first event, and he had no specific history. The patient denied homosexual identity. No abdominal pain, nausea, or vomiting was observed. The patient's blood pressure was 128/82 mm Hg; pulse rate, 92/min; respiration rate, 18/min; and body temperature, 36.6℃. Abdominal examination revealed a soft and flat abdomen with normal bowel sounds. Digital rectal examination revealed the hard plastic bottom of the object abutting the upper anal canal and normal anal sphincter tone. His laboratory data were as follows: hemoglobin level, 12.7 g/dL; white blood cell count, 8,940/mm3; and CRP level, 6.33 mg/L. The results of evaluations for hepatitis B surface antigen, hepatitis C antibody, and human immunodeficiency virus (HIV) antibody were all negative. Radiography revealed a vibrator in the rectum, without evidence of peritoneal or perirectal free air ().
Several attempts to remove the vibrator by endoscopic snare, alligator forceps, grasping forceps, and u-turn technique with a transparent hood were made to no avail. As the endoscopic maneuvers failed to remove the foreign body, surgical removal under spinal anesthesia was planned. However, the patient refused to receive spinal anesthesia. We attempted to remove the foreign body by blindly using tenaculum forceps but could not grasp it tightly and failed (). Finally, we decided to use the forceps under endoscopic assistance. After the endoscope was inserted in the anal canal, the tenaculum forceps was inserted and proceeded along the vision obtained by the endoscope until the distal ends reached the foreign body. Under direct endoscopic guidance, the tenaculum forceps was opened and used to grasp the end of the foreign body (). Finally, the object was removed successfully. The removed object was relatively large and heavy (length, 25 cm; diameter, 5 cm; weight, 650 g). Mucosal injury was observed during endoscopic examination immediately after the removal. However, the patient did not complain of abdominal pain and therefore was discharged.


A 59-year-old man was admitted to the emergency department with a carrot in the rectum and mild lower abdominal discomfort. He had no specific history and denied homosexual identity. The patient's blood pressure was 132/78 mm Hg; pulse rate, 88/min; respiration rate, 18/min; and body temperature, 36.5℃. Abdominal examination revealed a soft and flat abdomen with normal bowel sounds. Digital rectal examination revealed the hard bottom of the carrot near the rectal angle and normal anal sphincter tone. His laboratory data were as follows: hemoglobin level, 14.7 g/dL; white blood cell count, 17,270/mm3; and CRP level, 6.55 mg/L. The results of evaluations for hepatitis B surface antigen, hepatitis C antibody, and HIV antibody were all negative. The foreign body was not observed on abdominal radiography, and no evidence of peritoneal or perirectal free air was observed ().
The carrot observed during endoscopy was deemed to be too large and heavy for removal using endoscopic devices. Hence, we decided to use tenaculum forceps from the start. By using the same techniques described previously, we were able to remove the carrot successfully (). The patient's abdominal discomfort subsided immediately, and he was discharged from the hospital.


A 48-year-old male patient presented with chronic neck pain with cervical post laminectomy syndrome following two cervical spine surgeries with no significant medical problems. The pain was not responsive to conservative medical management including oral opioid therapy. The patient underwent a successful intrathecal opioid trial followed by Intrathecal drug delivery system (IDDS) implantation (Medtronic Synchromed II 40 ml pump) in August 2007. The patient had a history of PDPH following the intrathecal opioid trial before permanent placement and was treated with epidural blood patch to control the headache after failed conservative management. He was followed by his pain physician for intrathecal pump refills and management without problems with good pain control. In December 2013, the elective replacement indicator (ERI) showed 4 months remaining, and non-critical alarm (single tone) started in January 2014. The patient was scheduled for removal of native pump and replacement with new intrathecal pump. In February 2014, the old intrathecal pump was surgically replaced with a new one and it was placed in the same place over the left side of his abdominal wall. Strict aseptic precautions were followed throughout the procedure. He was discharged home the following day without any immediate postoperative complications. The patient followed up with his pain physician weekly during the subsequent 2 weeks. The wound healing was uneventful, and the pump analyses were normal during the follow-up visits. Despite his pain physician’s request, the patient did not follow up with his pain physician for the subsequent four weeks because of bad weather and lack of symptoms.
Six weeks following the IDDS replacement, the patient woke up in the morning complaining of headache, photophobia, and nausea. He also observed redness and warmth over the left lower abdominal incision site. He denied any drainage or fever. The patient presented to the pain clinic later that day. On examination, patient had localized erythema over the left abdominal wall over the surgical area. There were no signs of tracking of redness over flank or paraspinal area (). Intravenous antibiotics were started, and, under general anesthesia, the intrathecal pump and the catheter system were explanted through the left lower abdominal and left paraspinal incisions respectively with placement of purse string suture around the paraspinal catheter removal site. The system was withdrawn through the abdominal incision in order to prevent tracking of the infection towards the back. Considering the patient’s symptoms (photophobia, nausea, and headache) and the risk of infection spread from abdominal wound to CNS, the surgical wounds were left open without primary closure under wet and dry dressings. The patient was discharged home the next day with a PICC line on intravenous antibiotics and oral opioid medication. Wound cultures shown methicillin sensitive staphylococcus aureus (MSSA) sensitive to Nafcillin.
The patient presented 10 days after explantation of the intrathecal pump to the emergency room with persistent headache worsened with sitting and standing positions. He also had wet dressing over the paraspinal wound. On examination, clear fluid (cerebrospinal fluid-CSF) was noticed leaking from the paraspinal wound (). Initially, the patient was managed conservatively with bed rest, oral analgesics, hydration and caffeine for 24 hours (-). His symptoms did not resolve and he was referred to neurosurgery for surgical management for persistent and significant CSF leak with severe headache and an open paraspinal surgical wound. He underwent bilateral laminectomies at L2 and L3 with exploration of lumbar wound and dura matter. Immediately after removing the inferior portion of the L2 lamina, the surgeon encountered a brisk CSF leak from a pinhole opening surrounded by ligament and scar tissue. Dural repair of the CSF leak was performed with a tiny piece of muscle using a stitch with 4-0 nylon suture. All the leakage immediately stopped at that point, and there was no extrusion of any rootlets or nerve material (). The postoperative period was uneventful with complete relief of the headache.


The patient was a 38-year-old female, housewife, who was admitted on discovery of a splenic mass during a routine physical examination. She had no complaints of abdominal bloating, abdominal pain, cough, expectoration, weight loss, incompetent, etc. She had no family history of tuberculosis (TB) or contact with patients with TB. She had no history of steroid intake. An abdominal ultrasound showed several hypoechoic masses in the patient’s spleen. Magnetic resonance imaging (MRI) indicated splenomegaly and multiple irregular intrasplenic masses without clear boundaries. Inhomogeneity was shown inside the masses, where T2-weighted images showed mainly high intensity signal, and low intensity signal was seen in the periphery around some of the masses. T1-weighted images showed mainly equal intensity, and slight hyperintensity was seen inside and around some of the masses. With a contrast-enhanced scan, no enhancement of the masses was seen, whereas the boundaries became clearer rendering a honeycomb appearance (). Other significant laboratory tests included white blood cells of 4.8×109/L, erythrocyte sedimentation rate of 30 mm/h, C-reactive protein of 8 mg/L, human immunodeficiency virus test was negative, normal chest X-ray, and a normal electrocardiogram. A decision was made to remove the spleen. During the surgery, the spleen was found to be enlarged with tense adhesions to the surrounding tissues and a significant amount of small tubercles on the surface of the left diaphragm, upper-left abdominal peritoneum, stomach, gastrosplenic ligament, splenic fossa, and the nearby greater omentum. A large amount of suppuration and curdled material was seen when the spleen was open. Since TB was not on our list of differential diagnoses initially, only intravenous levofloxacin was given for 1 week after surgery and the patient was discharged. Postoperative pathology showed intrasplenic granulation accompanied by necrosis, and negative acid-fast staining (). Twenty days after the surgery, the intraoperative pus culture demonstrated positive bacillus growth. The patient had not received any anti-TB medications at this point.
The patient developed a fever 2 months after surgery. Physical examination showed a temperature of 38°C, headache, no obvious nausea or vomiting, no loss of consciousness, and no myoclonus. MRI indicates a 4.0×3.3 cm mass in the right frontal lobe. The right ventricle was deformed with a left midline shift. No changes were observed in the other ventricles and cisterna. The diagnosis from the MRI was intracranial abscess (). Lung computed tomography (CT) suggested multiple pulmonary nodular lesion and pulmonary cavitation (). A complete blood count showed a white blood cell count of 10.6×109/L, platelet count of 792×109/L, and C-reactive protein of 11.0 mg/L. Cerebrospinal fluid analysis showed chloride of 128 mmol/L, glucose of 3.3 mmol/L, and proteins of 1.13 g/L. The diagnosis of a TB intracranial abscess and pulmonary TB after splenectomy for a TB abscess was made, and the HRZE (isoniazid 300 mg qd, rifampin 450 mg qd, pyrazinamide 500 mg tid, and ethambutol 750 mg qd) regimen was started immediately. Twenty days later, chest CT indicated a significant shrinkage of the pulmonary loci, and the patient’s head MRI showed a slight decrease in the size of the intracranial abscess. Anti-TB regimen was discontinued 1.5 years later. Regular follow-up showed a complete resolution.
This case report was approved by the ethics committee of The First Affiliated Hospital, School of Medicine, Zhejiang University, and the patient provided their agreement and written consent to this report being published.


A 36-year-old woman came to the neurosurgery clinic with a one-year history of neck pain and semi-lateral radicular pain in her right hand. Her past medical history was unremarkable. On ultrasound examination, there was a hypo-echoic oval mass-like lesion located on the right side of the C3 and C4 vertebrae and adjacent subcutaneous soft tissue, measuring 1.2 × 3.6 × 1.6 cm. The ultrasound possible differential diagnosis was right paravertebral muscle soft tissue lesion due to inflammatory or neoplastic origins. A lateral plain x-ray of the neck revealed an ill-defined hypoattenuated area within the deep soft tissue of the posterior aspect of the C3 and C4 vertebrae just posterior to the related spinous process without bony erosion, demineralization, foreign body, or soft-tissue calcification. Irregularity and possible erosion in the spinous process of C5 of the cervical vertebrae was seen ().
On Doppler ultrasound, there was no blood flow detected and the mass was reported as a hypo-vascular lesion. On magnetic resonance imaging (MRI), a well-defined encapsulated 2.6 × 2 × 1.8 cm mass lesion emanating from the soft tissue of the paravertebral neck was detected that abutted the spinous process and lamina of the posterior neural arc of the C3 and C4 vertebrae and appeared to be low signal intensity on the T1 weighted imaging (T1W1) (). The lesion was seen as a target shaped lesion with a centrally hypo-intense and peripherally mild hyper-intense thick rim and surrounding edema on T2WI (). On post-contrast T1WI, considerable enhancement of the peripheral thick rim and adjacent posterior soft tissues of C3 and C4 vertebrae were presented (). The patient underwent surgical resection, and a frozen section study was requested. The specimen received for frozen section consisted of one piece of cream colored tissue measuring 3 × 2 cm. Histopathological examination revealed a lobulated tumoral lesion composed of fibromyxoid connective tissue admixed with small islands of cartilaginous tissue and areas of calcification, so the frozen section suggested a benign lesion. The received specimen for permanent diagnosis consisted of multiple pieces of brownish colored tissues altogether measuring 4 × 3 cm. Histopathological examination revealed a tumoral lesion composed of proliferated chondrocytes, admixed with fibromyxoid connective tissues, and scattered osteoclast-like multinucleated giant cells (, ). Mature bone trabeculae rimmed by osteoblasts with areas of calcification were also detected. The final diagnosis was CMF of the posterior elements of the cervical bones with extension to the adjacent soft tissue. The patient received no other treatment and after two years of surgery, she has not suffered from any problem related to the lesion in her neck area and no recurrence was reported.


A 17-year-old male reported with gradual, progressive, painless diminution of vision in both eyes since 3 months. Family history was unremarkable. The best corrected visual acuity was the perception of light+ in right eye and 20/400 in the left eye. The anterior segment showed dense cataract in the right and posterior chamber intraocular lens in the left eye []. Intraocular pressure was 4 mmHg in the right and 16 mmHg in the left eye. Left eye fundus revealed multiple radial perivascular lattices, vitreous condensation, tessellations, and posterior staphyloma [], and an axial length of 26.3 mm. The left eye was amblyopic. Ultrasound B-scan of the right eye revealed closed funnel retinal detachment (RD) and reduced axial length (21.2 mm) []. Electroretinogram showed normal responses in the left and expected nonrecordable responses in the right eye []. Systemic examination revealed speech abnormality (nasal twang), large cleft palate [], and mild hearing defect.


A 55-year-old female came with complaints of on and off right lower quadrant abdominal pain for 1-year. The patient also had urinary complaints such as intermittency, burning, and frequency. She denied any episodes of fever, chills, gross hematuria, or dysuria. Her past medical and surgical history were insignificant. The per abdominal examination was normal, but on bimanual pelvic examination a mass on the right side near the bladder neck area was palpable.
Ultrasonography (USG) suggested a well-circumscribed polypoidal soft tissue lesion projecting in urinary bladder lumen and attached to the posterior wall and base of the bladder with no internal vascularity []. Intravenous pyelography demonstrated a large filling defect in the bladder and normal functioning kidneys []. To know the detailed anatomy, magnetic resonance imaging (MRI) was done, which showed a large, well-defined rounded, soft tissue lesion of size 67.6 mm ×51 mm at posteroinferior aspect of urinary bladder, close to anterior surface of the cervix and vagina. The mass was isointense to the skeletal muscles on T1 and T2 images. It also showed small focal irregular cystic areas of necrosis []. The finding was suggestive of a benign lesion, probably leiomyoma. The urine cytology smear showed large numbers of squamous cells; few degenerated cells and bacteria, but atypical cells were not seen.
On cystoscopy, a large smooth sessile growth arising from the right posterolateral wall was noted []. The right ureteric orifice was not visualized. Transurethral resection (TUR) of the lesion was performed, and resected specimens were sent for histopathological examination. At the completion of the resection, the previously palpable pelvic mass could no longer be appreciated by bimanual examination.
On postoperative day 1, the patient's urine was clear, the Foley catheter was removed, and the patient was discharged on oral antibiotics. The histopathological examination showed spindle cells in sheets and fascicles oriented in different planes. There was no epithelial lining seen. There was no atypia, mitotic activity or other indices of malignancy. The impression of leiomyoma was made []. On follow-up at 3 months, the patient was asymptomatic, and USG was normal.


A 32-year-old male patient presented to the trauma bay following MVC, complaining of abdominal pain. Physical examination and subsequent imaging revealed a 12.9 cm × 16.9 cm × 16.6 cm abdominal mass and an empty scrotal sac. The right hemiscrotum was atrophic on physical examination, and ultrasonography revealed the left testicle to be in the inguinal canal. The patient denied any symptoms prior to the MVC, including pain, hematuria, weight loss, fatigue, etc., He and his wife had been trying unsuccessfully to achieve pregnancy for 2 years. He had no significant past medical, surgical, or family history, smoked 1 pack of cigarettes/month, and worked mainly as a laborer.
A biopsy of the mass showed malignant germ cells, consistent with seminoma. Staining showed the mass to be positive for octamer-binding transcription factor-4, CD117, cytoskeletal (CK7), and CK818. Three courses of bleomycin, etoposide, and cisplatin (BEP) were given at 21-day intervals, which were well tolerated, and the regimen decreased the size of the mass to 6.1 cm × 9.9 cm × 9.2 cm []. Immediately prior to BEP therapy, beta-human chorionic gonadotropin (beta-hCG) was 29 (normal: 0-5 mIU/mL) and alpha fetoprotein (AFP) 5.4 (normal: 0.6-6.0 ng/mL). Postchemo markers included a beta-hCG < 1 and AFP 4.9. Lactate dehydrogenase (LDH) was within normal range pre- and post-chemo. The patient was counseled about sperm banking prior to chemotherapy.
In January 2014, the patient underwent exploratory laparotomy for resection of the mass, with bilateral-template postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) and left orchidopexy. The patient was first placed in dorsal lithotomy position for cystoscopy and bilateral insertion of ureteral catheters to help identify and protect the ureters. A midline incision was made and upon entering the abdomen, the right lower quadrant mass was immediately appreciated []. Because of its size and location, a surgical oncologist was present to help mobilize the omentum and excise the mass off the right iliac vessels. There was no hydronephrosis or right ureteral involvement. The appearance of the tumor was consistent with an intra-abdominal testicle. The spermatic cord structures entering the mass were dissected caudal to cephalad, until the gonadal vein was seen inserting into the vena cava []. At the insertion point, the gonadal vein was ligated and transected, and the mass was passed off the field.
After mobilizing the colon, the split and roll technique was utilized to carefully remove lymphatic tissue from the vena cava within the margins of the bilateral-template.[] Lumbar vessels were secured with silk ligatures and clips. Paracaval, precaval, interaortocaval, preaortic, and para-aortic lymph nodes were sent for pathology. Attention was then turned to the left orchiopexy, which proceeded without complications.
Final pathology of the mass and lymph nodes did not show any viable residual tumor or metastatic disease. The patient was discharged home on postoperative day 5 without any postoperative complications. Four months following his surgery, the patient's scrotal ultrasound, repeat serum tumor markers, and chest X-ray are all within normal limits.


A 39-year-old Japanese man with frontal lobe symptoms, including stereotyped and socially inappropriate behaviors, disinhibition, and euphoria, was admitted to our university hospital in November 2011. Over the previous 2 years, he had shown slight impairment in recent memory and abnormal behaviors, such as reading comics during a parent-teacher association meeting and pilfering. In the hospital, the patient was secured in a unit within the psychiatric ward because he entered other rooms without permission. Subsequently, he repeatedly touched female nurses in an inappropriate manner.
The patient’s Mini-Mental State Examination score was 23/30 and his Frontal Assessment Battery score was 12/18. His deep tendon reflexes in the extremities were brisk and the Babinski sign was positive bilaterally, but he did not have any extrapyramidal symptoms. A blood examination revealed no abnormalities other than subtle liver dysfunction, with an aspartate transaminase level of 77 IU/L (normal range 9–37 IU/L), alanine transaminase of 176 IU/L (normal range 3–49 IU/L), iron deficiency (106 μg/dl; normal range 120–140 μg/dl) and an elevated ferritin (656 ng/ml; normal range 27–211 ng/ml). Brain fluid-attenuated inversion recovery magnetic resonance imaging revealed diffuse high-intensity white matter areas and slightly diffuse atrophy in the cerebral cortices without the “eye of the tiger” sign (). No abnormalities were detected in the cerebrospinal fluid or on electroencephalography.
Although he had no family history of NHD, a genetic analysis was performed for several inherited neurological disorders, including autosomal dominant familial Alzheimer’s disease (amyloid precursor protein, presenilin 1, microtubule-associated protein tau, and progranulin) genes known to cause neurodegeneration in the brain due to iron accumulation (PANK2, C19orf12, and FTL), and leukoencephalopathy (CSF1R); all were found to be negative. Subsequently, exome sequencing conducted in the patient and his parents identified a mutation in the TYROBP (DAP12) gene, located on chromosome 19q13.1. The mutation was a homozygous single-base deletion of 141G in exon 3 that was observed in the patient’s genomic DNA. His parents were each heterozygous for the mutation. As a result, the patient was diagnosed with NHD. After making a definitive diagnosis, a retrospective orthopedic analysis of computed tomography of the patient’s hand (obtained when his left wrist was twisted before the neuropsychiatric symptoms appeared) showed bone cysts. To date, he has not suffered any bone fractures ().
To address his frontal lobe symptoms, the patient was first given risperidone, increasing the dose slowly from 1 to 3 mg/day over 4 months. However, the risperidone dose was reduced because it had little effect, but caused drug-induced parkinsonian behaviors, such as sialorrhea and postural instability. Subsequently, he was given 400 mg of sodium valproate (serum valproic acid concentration 49.46 μg/ml) together with risperidone 1 mg/day. Beginning approximately 2 weeks after starting the sodium valproate therapy, the patient’s socially inappropriate behaviors improved gradually, he was allowed to roam the psychiatric unit freely, and there were no obvious side effects. Presently, the patient has been hospitalized for 3 years and his cognitive impairment has progressed rapidly. We can no longer communicate with him.


A 37-year-old male presented with progressive swelling of feet and facial puffiness for 6 months. On physical examination, he had mild pallor, moderate pedal edema and cloudy cornea with a peripheral arcus in both eyes [].
Laboratory investigations revealed hemoglobin of 8 g/dL with “target” erythrocytes in peripheral blood film examination; serum haptoglobin of 64 mg/dl (normal range: 70–200 mg/dl), total cholesterol 215 mg/dl, high-density lipoprotein cholesterol (HDL-C) 10 mg/dl, and triglycerides 385 mg/dl. Renal biopsy showed glomerulomegaly with mild mesangial expansion and foam cell infiltration in mesangium and glomerular basement membrane (GBM) []. Tubules also showed foamy changes with focal tubular atrophy, and interstitium showed the presence of foam cells.
In view of the clinical profile, characteristic dyslipidemia (high triglyceride, very low HDL) and histological changes, serum LCAT deficiency were suspected. Plasma LCAT activity was determined at Pacific Biomarkers, Seattle, USA. The cholesterol esterification rate was undetectable indicating complete lack of LCAT in plasma. Clinical evaluation of family members revealed corneal opacities and dyslipidemia in patient's mother and his younger sister. However, there was no renal, hematological or other systemic involvement in both of them. Genetic testing of the proband and serum LCAT activity of the other affected members could not be done due to financial constraints. Based on the clinical manifestations, the proband was diagnosed to have classic FLD while his mother and sister were diagnosed to have FED.


The patient was a 47-year-old man who had bilateral proliferative diabetic retinopathy, neovascular glaucoma, and tear dysfunction. Schirmer I test revealed tear secretion levels of 5 and 3 mm in the right and left eyes, respectively. Tear breakup times were 7 and 8 seconds for the right and left eye, respectively. The ocular surface staining with fluorescein dye was scored as Grade 1 in both eyes. Accordingly, retinal photocoagulation was performed to treat the proliferative diabetic retinopathy and rubeosis iridis; the latter resolved completely with treatment.
However, despite the administration of the maximum tolerated doses of topical antiglaucoma medications, intraocular pressure (IOP) continued to remain high, with the level in the left eye exceeding more than 25 mmHg. Therefore, trabeculectomy with MMC using limbal-based conjunctival flap was performed; during surgery, 0.04% MMC was applied for 5 minutes. Tenon’s capsule was not excised, and the conjunctival flap and the underlying Tenon’s capsule were closed tightly with shoelace 10–0 nylon sutures. Three hours after the operation, a large and diffuse filtering bleb was detected; however, no leakage of the conjunctival scar was noticed. However, leakage was detected on the first postoperative day, and the IOP was 7 mmHg with noncontact tonometer. Resuturing the conjunctiva at the point of leakage stopped the leakage transiently, but it resumed the next day even though the subject was treated with a compression bandage after resuturing. On examination, severe keratoconjunctival epithelial failure () was detected, and the patient was treated with 0.1% sodium hyaluronate eye drops (Hyalein; Santen Pharmaceutical Co Ltd, Osaka, Japan) administered six times daily with the patient lying supine to allow the drops to spread onto the upper blebs. With this treatment, improvement in the epithelial failure was seen at some sites, which showed the presence of many microcysts on the bleb surface; the leakage resolved completely 2 days after starting the sodium hyaluronate eye drops without using compression bandage (). One month after starting this treatment, the microcysts disappeared; the bleb surface was smooth; and the IOP was 10 mmHg (). However, subsequently, 18 months after starting the application of sodium hyaluronate eye drops, the bleb was found to be flat and IOP was poorly controlled despite administration of maximum tolerated doses of topical anti-glaucoma medications and exceeded 22 mmHg in the left eye. Therefore, trabeculotomy was performed, and thereafter, IOP has remained in control, at less than 15 mmHg, over a period of 5 years.


A 27-year-old male with no significant past medical history presented to his primary care physician with a three- week history of intermittent left anterior shin pain. He played soccer regularly three times a week, and stated that he had been recently kicked several times in his lower legs. He denied edema, erythema, paresthesias, or difficulty walking. The patient did admit to awareness of a painless lump at the lateral aspect of his knee for several years. On physical examination he had full range of motion and strength of his left lower extremity. A firm, non-tender palpable mass was present on palpation of the fibular head. Radiographs revealed a large tibial osteochondroma at the knee which was associated with a large fibular erosion (Fig. , ). The patient was referred to orthopaedics and magnetic resonance imaging (MRI) was obtained to further characterize the abnormality (Fig. ). Besides the erosion, no other feature worrisome for malignant transformation was present. The cartilage cap of the osteochondroma showed no abnormal thickening. The absence of edema in the fibula also signaled that the erosion was chronic in nature, and that an active erosive process was not present. Since his pain was most attributable to a recent soccer injury and not to malignant transformation, the patient was not offered further intervention or surgical management. Following a trial of conservative management, the patient returned to his normal activity level with a resolution of pain. He has remained asymptomatic after 3 years of follow up.


A 21-year-old male with a history of HME and acute lymphoblastic leukemia presented to the oncology clinic with a two-day history of fever and polyarthralgia. He complained of pain, redness, swelling and stiffness in his wrists, hands and hips initially, which quickly progressed to involve his shoulders, elbows, knees and ankles. He had a past history of prior excision of symptomatic osteochondromas in childhood, but did not report any recent tumor-related complications as an adult.
On physical exam, the patient had a temperature of 39.2oC and shaking chills. His elbows, wrists, knees and ankles were edematous, erythematous, warm and tender to palpation. He had decreased range of motion secondary to pain in his elbows, wrists, hands, hips and ankles. The patient received a dose of vancomycin and meropenem at the oncology clinic and was admitted to the hospital. Radiographs of his upper and lower limbs revealed multiple osteochondromas consistent with HME. Radiographs of the right ankle showed a tibial osteochondroma adjacent to a chronic-appearing pressure erosion with smooth margins at the distal fibula (Fig. , ). The osteochondroma otherwise lacked the aggressive features of associated soft tissue component calcifications or internal bony ill-defined areas of radiolucency or mineralization. Radiographs of the left knee also showed other atypical bone-related complications presenting in this patient (Fig. ). During the hospital admission, orthopaedic and infectious disease consultations were performed. The osteochondromas were found to be non- contributory to the patient’s symptoms. The patient received antibiotics for one week during his inpatient stay, during which time his fever, global joint pain and stiffness resolved. At the time of discharge he was without joint complaints. The osteochondroma-related bony pressure erosion was considered an incidental finding of a chronic nature and treatment was conservative. The patient remains without complaints or physical limitations at the right lower leg after 9 months of follow up.


A 41-year-old male with a history of HME presented to his neurosurgeon with new-onset of left buttock pain, following recent craniotomy and surgical excision of a right cerebellar pontine angle schwannoma. He had a past surgical history of prior removal of symptomatic osteochondromas from both lower limbs as a child. He had neither left hip, pelvic or buttock pain, nor limited physical activity as an adult prior to his recent brain surgery. He had been aware of a bony prominence at his left buttock for many years, and this mass was otherwise without symptoms for as long as he could remember. His pain began following the craniotomy, during which time he had been placed in the left lateral decubitus position for the procedure. The patient was referred to orthopaedics for further evaluation of his buttock pain. On physical examination, he had a large firm left buttock palpable mass, which was tender to gentle percussion. The mass also moved in concert with the left femur, with limited left hip internal and external rotation. A radiograph of the pelvis showed a large mineralized mass associated with the left femur, and also the incidental finding of a small osteochondroma and pressure erosion at the left pubic body (Fig. ). Follow up MRI (Fig. , ) and computed tomography (CT) (Fig. ) characterized further the extent of the osteochondromas. The MRI and CT showed no aggressive features of the pubic osteochondroma. The cartilage cap was only a few millimeters thick, and the margin of the erosion was smooth with an absence of bone marrow edema in the left pubic body. The symptomatic left femur osteochondroma was resected. The right pubic body osteochondroma, however, was treated conservatively, and the patient has remained asymptomatic at the symphysis pubis after 6 years of follow up.


A 29-year-old male with a history of HME presented for tumor surveillance of his upper and lower limbs two years after the removal of a symptomatic osteochondroma. He had a past surgical history of multiple osteochondromas removed from his right lower leg, left ankle and right wrist. He had no known symptoms on the day of imaging. CT showed multiple osteochondromas in his upper and lower limbs, with an intra-articular left ilium osteochondroma extending across the left sacroiliac joint and causing a left sacral wing pressure erosion (Fig. ). The erosion was well-defined, with no other signs worrisome for malignant transformation. The bony impingement of the osteochondroma at the left sacral wing was diagnosed as a chronic incidental finding, and management was conservative. The patient has remained asymptomatic after 5 years of follow up.


A 75-year-old man suffering from opioid refractory pain (recorded as 9 according to visual analog scale (VAS)) due to an advanced stage IV histologically-proven pancreatic adenocarcinoma with liver metastases and celiac trunk infiltration not suitable for surgery, was referred to our center. EUS confirmed the nodular hypoechoic lesion of 40 × 38 × 33 mm in the pancreas []. Ca 19-9 level was 987.07 U/mL. As the tumor stage was beyond any possibility of surgical radical care and in order to relieve patient's symptoms, after informed consent was obtained, EUS-guided CPN combined to EUS-guided tumor ablation was arranged. Under sedation with propofol, EUS was conducted with a Pentax FG-36UA ultrasound endoscope (Pentax Europe Ltd, Hamburg, Germany) using a curved-array transducer. A 22 G needle (Cook Medical Inc, Bloomington, Indiana, USA) was introduced though the endoscope's working channel to inject 10 mL 2.0% lidocaine and 20 mL of ethylic alcohol 95% into the base of the celiac trunk at its origin from the aorta [central approach, ]. After performing CPN, 40 mL 75% of lesion volume of ethanol (concentration 95%) were directly injected into the tumor [].
No major complications were recorded during the procedure. In the days following the procedure, mild (grade 2) diarrhea and fever were the only minor complications experienced by the patient. Complete tumor devascularization was assessed by means of computed tomography (CT) 48 h after the procedure []. Ca 19-9 dropped down to 56.84 U/mL at 2 weeks after EUS.
Complete pain relief, namely VAS 0,[] was achieved 3 days after the endoscopic ablation. The patient remained pain-free without need of opioid, and was treated only with paracetamol for 20 weeks and afterwards experienced pain relief, (defined as pain within 30% of baseline)[] until death occurred 30 weeks after the procedure.


The patient was a 56-year-old woman with an incidentally noted, 1.1 cm right thyroid nodule. The nodule had microcalcifications, and there was a suspicious central neck lymph node. Fine needle aspiration biopsy revealed papillary thyroid carcinoma. The patient elected to proceed with total thyroidectomy and central neck dissection. The Dragonfly neuromonitoring system was used. This system employs surface electrodes on the endotracheal tube that detect and record electromyographic activity from the thyroarytenoid muscles. In addition, stimulation-evoked muscle action potential was recorded including latency, amplitude and waveform morphology. During dissection of the right superior pole, the external branch of the superior laryngeal nerve (EBSLN) was identified. A nerve branch was noted originating from the EBSLN anterior to the cricothyroid muscle and coursing across the superior pole of the thyroid gland. This nerve then joined the main branch of the RLN prior to its laryngeal entry at the cricothyroid joint (Fig. ) consistent with an extralaryngeal variant of the HCN. Stimulation of the EBSLN, but not the HCN, produced a strong twitch of the cricothyroid muscle. Stimulation of the HCN (set 100) at a current intensity of 0.5 mA produced a triggered compound muscle action potential with a peak latency and a peak-to-peak amplitude of 5.0 ms and 887.3 µV, respectively (Fig. A). Stimulation of the RLN at a current intensity of 0.5 mA produced a triggered compound muscle action potential with a peak latency and a peak-to-peak amplitude of 4.8 ms and 989.5 µV, respectively (Fig. B). Stimulation of the EBSLN at a current intensity of 0.4 mA produced a triggered compound muscle action potential with a peak latency and a peak-to-peak amplitude of 5.4 ms and 35.6 µV, respectively (Fig. C).


A 16-year-old male without a past medical history presented to our hospital due to headache and diplopia. An initial brain magnetic resonance image (MRI) revealed a well-enhanced 3.8 × 2.7 cm sized multicystic mass in the pineal gland with hydrocephalus (fig. ). Laboratory findings revealed that serum β-human chorionic gonadotropin (HCG) was increased to 19,920 mIU/ml, and the α-fetoprotein level was 3.6 ng/ml. Craniotomy was performed for tumor removal, as well as external ventricular drainage. However, on the operation field, a hypervascular tumor was recognized. Given the risk of bleeding, a minimal tissue biopsy with ventricular drainage was performed. The pathologic result of the biopsy was choriocarcinoma. Cytologic examination of the drained cerebrospinal fluid did not find any malignant cells. A whole-body positron emission tomography/computed tomography (PET-CT) scan did not reveal any lesions, including the mediastinum and gonad. Concerning hemorrhagic complication, systemic chemotherapy was chosen as initial treatment rather than radiation therapy. Ifosfamide (900 mg/m2 on days 1–5), cisplatin (20 mg/m2 on days 1–5) and etoposide (50 mg/m2 on days 1–5) combination chemotherapy was administered. After 2 cycles of chemotherapy, complete regression of the intracranial mass was identified without complication (fig. ). The serum β-HCG level was normalized to 0.27 mIU/ml. After an additional 2 cycles of chemotherapy, radiation therapy covering the entire ventricular system and the spine was performed for consolidation purpose. He tolerated the entire treatment without specific complications.


A 17-year-old male without a previous medical history presented with headache, vomiting, polydipsia and polyuria. Initial brain MRI revealed two well-enhanced T1 and T2 isointense masses in the suprasellar region and pineal gland (fig. ). Laboratory findings showed serum α-fetoprotein (1.1 ng/ml) and β-HCG (1.56 mIU/ml) levels within the normal range. Despite increased serum osmolality, urine was diluted and polyuria was not corrected after water deprivation. The prolactin level was increased up to 77.65 ng/ml (range 1.1–13.0). During navigation-guided craniotomy with tumor biopsy, which was performed on the suprasellar mass, germinoma was confirmed. Sequential spine MRI and spinal tapping did not reveal any concomitant lesions on the entire spine. To reduce the radiation dose and field, upfront chemotherapy was decided on. Ifosfamide (1,800 mg/m2 on days 1–5) and etoposide (100 mg/m2 on days 1–3) combination chemotherapy was administered alternatively with etoposide (100 mg/m2 on days 1–3) and carboplatin (600 mg/m2 on day 1). He completed 4 cycles of neoadjuvant chemotherapy without specific treatment-related complications; however, grade 4 hematologic toxicity was identified. After 4 cycles of chemotherapy, complete regression of all masses on both lesions was identified (fig. ). Consolidative radiation therapy was performed on the whole ventricular system (24 Gy), and a boost dose of 16 Gy was irradiated to the tumor bed.


A 14-year-old boy presented with a diffuse swelling over the dorsum of the nose which was gradually increasing in size over the past 5 months. There was no history of pain, nasal block, nasal discharge or bleeding. He was operated for a similar swelling in the same site 7 months back and the same was diagnosed as neurofibroma. The swelling recurred after 2 months and was progressively increasing in size. On examination, there was a diffuse swelling over the dorsum of the nose, nasal supratip and right lateral nasal wall, measuring about 4 × 3 × 2 cm. The swelling was soft, mobile and not fixed to the underlying nasal septal cartilage or nasal bones, but adherent to the overlying skin of the nose. The skin over the swelling was normal with no sinuses or dilated veins. A healed surgical scar of about 2 cm in length was seen over the columella and right nasal rim []. He also had multiple café-au-lait spots over the anterior and posterior aspects of the trunk [Figures and ]. A slit-lamp examination of the eye showed multiple Lisch nodules in the iris [].
Ultrasound of the nasal region showed a superficial ill-defined hyperechoic lesion in the right side of the nasal bridge without any evidence of vascularity, altered echogenecity or inflammation. Remaining investigations were normal. A provisional diagnosis of recurrent neurofibroma was then made.
He was then subjected to open rhinoplasty with a bilateral infracartilaginous incision with a stair step columella incision. The lesion was carefully dissected from the adherent nasal skin and the surrounding structures and was completely excised.
The specimen received for histopathological examination consisted of two gray white soft tissue fragments measuring 3 × 2 × 0.5 cm in aggregate. The cut surface was solid gray white with gelatinous areas.
Microscopic examination revealed a diffuse neoplasm encompassing the entire tissue and composed of spindle-shaped cells with wavy, buckled nuclei and some with oval nuclei arranged in a haphazard pattern with entrapment of lobules of mature adipocytes and skeletal muscle fibers [Figures –]. Scattered ectatic blood vessels were also seen interspersed between the tumor cells. Few foci showed differentiation toward Meissner's type of tactile corpuscles [].
The tumor cells showed diffuse positivity for S100 immunomarker confirming the diagnosis of diffuse neurofibroma [].


A 60-year-old woman with a diagnosis of left renal calculus was scheduled for left percutaneous nephrolithotomy. The preanesthetic evaluation revealed the history of poor effort tolerance. She had a past history of ischemic heart disease with hypertension since 6 months and was on regular treatment. On examination, pulse rate was irregularly irregular with a range of 56–60/min and blood pressure was 130/70 mm Hg. Clinical examination of the cardiovascular system and the respiratory system was normal. Laboratory investigations were within normal limits. Electrocardiogram (ECG) showed an irregular rate with intermittent sinus pause. Chest X-ray was normal. In view of the irregularly irregular pulse and abnormal ECG in an elderly, a cardiology opinion was sought. The cardiologist ascertained a diagnosis of an asymptomatic sinus node dysfunction, which was resistant to atropine. Echocardiography was normal. Anticipating the autonomic disturbances that could occur in prone position under anesthesia, which may have significant hemodynamic implications when superimposed on the sick sinus syndrome, the cardiologist was again referred to for temporary pacing, and a temporary pacemaker at RVOT septum was inserted prior to surgery [].
The anesthetic technique planned was balanced general anesthesia with endotracheal intubation. Once the patient was taken into the operation theater, five-lead ECG, noninvasive blood pressure, pulse oximetry, were connected. After giving glycopyrrolate 0.2 mg, midazolam 0.05 mg/kg, and morphine 0.1 mg/kg intravenously, patient was induced with propofol 2 mg/kg and vecuronium 0.1 mg/kg intravenously. Airway was secured under direct laryngoscopy with size 7.0 endotracheal tube. Maintenance was done with oxygen: Nitrous oxide 50:50 with sevoflurane 2% on low flows with circle system. Intraoperatively there were repeated episodes of continuous pacing by the temporary pacemake [] followed by a resumption of normal sinus rhythm. Other vital parameters were stable in the intraoperative period. The surgery lasted for 2 h. Neuromuscular blockade was reversed with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg. Patient was shifted to the post anesthesia care unit with stable vitals. Postoperative analgesia was provided with intravenous paracetamol infusion and intravenous injection tramadol. Postoperative period remained uneventful with no evidence of pacing. Temporary pacemaker was removed on the 2nd postoperative day after consultation with the cardiologist. There were no further episodes of bradycardia in the postoperative period, and the patient was discharged on the 5th postoperative day.


A 22-year-old female with body mass index 20.2 kg/m2 presented with chief complaints of right flank pain and hematuria for 8 weeks. Her general and systemic examination was unremarkable. The patient had RCC in the lower mid pole of the right kidney with invasion into right renal vein, IVC and extended up to cavo-atrial junction. Transthoracic echocardiography revealed normal biventricular contractility and a thrombus in the right pulmonary artery (RPA).
The surgical procedure involved radical right nephrectomy, followed by IVC thrombus and RPA embolectomy under cardiopulmonary bypass (CPB). General anesthesia was planned. Monitoring including oxygen saturation, electrocardiogram, invasive blood pressure, end-tidal carbon dioxide (EtCO2), temperature, central venous pressure (CVP), and TEE were applied. An 11 Fr. sheath was also introduced in the right internal jugular vein along with CVP catheter. Initial TEE examination showed a thrombotic mass extending from the right renal vein up to the IVC-right atrium (RA) junction [] and an isolated organized thrombus in the RPA. Cardiac chambers were free from any thrombus []. A mid-line thoracoabdominal incision was given and during the ligation of renal vein there was a sudden fall in blood pressure, rise in CVP, increase in airway pressure, and a fall in EtCO2. TEE examination showed sudden appearance of thrombus in the RA, extending across the tricuspid valve (TV) into the right ventricle (RV) during the diastolic phase, and almost completely obstructing the flow across the TV. The patient was immediately put in a head down position and fraction of inspired oxygen was increased to 100%. Intravenous fluids and intermittent boluses of injection phenylephrine (50 mcg) was administered to support hemodynamics. Meanwhile, emergency CPB was instituted after systemic heparinization and achieving activated clotting time of >480 s. The patient was cooled to a temperature of 18°C. Fogarty catheter, introduced via a longitudinal incision near the main pulmonary artery bifurcation, into the left pulmonary artery and the fresh thrombus was removed. The RPA was opened near the superior vena cava and both fresh and organized thrombus was retrieved. Thrombus from RA was removed directly. The IVC was almost clear of thrombus except in one portion of intrahepatic IVC, revealed by intra-operative TEE []. The remnant IVC thrombus was approached from the RA end and was extracted by removing it from below the hepatic IVC. Thrombus was removed during intermittent low flow state of 10 min duration. Weaning from CPB was initiated after gradual re-warming. Intra-operative TEE confirmed that there was no residual thrombus. After weaning from CPB, TEE showed mild tricuspid regurgitation with severe pulmonary artery hypertension (with peak RV systolic pressure of 68 mmHg). Injection milrinone was added to the on-going infusion of injection nitroglycerine, injection adrenaline, and injection dobutamine. Patient was shifted to Intensive Care Unit. Trachea was extubated the next morning and patient was shifted toward after weaning from vasoactive infusions on postoperative day 2.