A 90-year-old male patient presented with dyspnea to our department. His medical history included coronary heart disease with myocardial infarction and double coronary stent implantation 4 months before as well as a negative smoking history. Further relevant comorbidities were pericarditis epistenocardica and chronic renal failure. CT scans revealed a tumor mass of 33-mm maximum size in the lower left lobe of the lung and a supposed mediastinal lymph node involvement. In a 18F-FDG-PET/CT scan, the primary lesion was present with a SUVmax of 19.7 (fig. ). Furthermore, PET/CT-positive hilar and mediastinal lymph nodes were found at positions 11L and 5. These findings resulted in a UICC stage IIIA (cT2a, cN2, cM0). The mediastinal lymph node was not reached by endobronchial workup.
A core needle biopsy was taken. At histological examination, a poorly differentiated adenocarcinoma of predominant solid subtype was found. Immunohistochemistries for cytokeratin 7 and thyroid transcription factor-1 were positive, whereas negative immunostains for p63 and CD56 ruled out squamous cell and neuroendocrine carcinoma subtypes. Molecular tests for EGFR and KRAS mutations as well as for ALK translocation and MET amplification were all negative. However, fluorescence in situ hybridization (FISH) analysis for ROS1 rearrangement showed aberrant probe signals in 81 of 100 evaluated tumor cell nuclei (fig. ). Therefore, the diagnosis of a poorly differentiated pulmonary adenocarcinoma with ROS1 translocation could be established.
Due to tumor stage, comorbidity and age the patient was not eligible for surgery or conventional chemotherapy. Stereotactic radiotherapy of the primary lesion was discussed but not favored due to the molecular finding of a ROS1 translocation. After tumor board discussion and informed consent, the patient was treated with crizotinib at a daily dose of initially twice 250 mg p.o. Lab results at day 7 showed a further increase of already previously elevated gamma-glutamyl transpeptidase (GGT) from twice to four times of the upper normal limit (UNL) and an elevation of glutamate-oxaloacetate transaminase (GOT) and aspartate-amino transferase (ASAT) from normal to twice of UNL. In the same period, serum creatinine raised from 1.6 to 2.0 mg/dl. Following 7 days of drug withdrawal, crizotinib was restarted with a reduced daily dose of 250 mg, while lab parameters had improved with persistently elevated serum creatinine at the former level. The patient reported discomfort consisting of nausea, emesis and diarrhea, starting at day 5 after reduction of the dose level. On day 15 of crizotinib 250 mg p.o. once daily, the patient suffered from thoracic pain, and he stopped medication. With a delay of 3.5 weeks, the patient restarted therapy with crizotinib 250 mg once daily again. An acute ulcerative fibrinous purulent esophagitis (month 4.5) resolved with a H2-blocking oral therapy. In summary, over a period of 11 months, adverse events caused a cumulative off-drug interval of 11.5 weeks. The first tumor evaluation was done by chest X-ray 2 and 3 months after initiation of crizotinib. Planar measures of the primary lesion decreased from 26 × 50 mm at baseline to 18 × 42 and 13 × 34 mm, respectively. CT scans after 4.5 months revealed that the primary lesion showed a partial remission from 33 to 13 mm (CT) and complete metabolic response (PET). At this time, the hilar and mediastinal lymph nodes were still present in CT and PET scans. X-ray of the chest at months 7 and 10 showed no relevant changes. After 11 months, the patient is still under treatment (crizotinib 250 mg daily, half of the recommended dose) without any limitation in daily living and a performance status of ECOG 0.


A 69-year-old female patient (59.3 kg, 154.6 cm, body mass index 24.8) was scheduled for total knee replacement (TKR). Past medical history revealed that the patient underwent general anesthesia for prior TKR of the other knee three years at another hospital, and the patient failed to recall any specific events associated with anesthesia other than a sore throat, which is fairly common after intubation. The patient complained of occasional mild dyspnea during exercise, but chest radiographic readings by radiology were non-specific and we pursued further testing. Spirometry (FEV 2.27 liters (L), FEV1 1.84 L, FVC/FEV1 81%) and arterial blood gas analysis showed normal results. Both lung sounds were clear and no chest abnormalities were observed.
Upon entering the operating room, the patient was monitored with electrocardiograph electrodes, pulse oximeter, bispectral monitoring, and noninvasive blood pressure. After 3 minutes of pre-oxygenation with 100% oxygen, she was anesthetically induced with propofol (60 mg) and rocuronium (30 mg). After ventilating the lungs with a facial mask for two minutes without any difficulties, initial intubation was attempted with a conventional laryngoscope with the aim of inserting a 7.0 mm internal diameter endotracheal tube (ETT), which failed to pass the larynx. After a second attempt failed with a 6.5 mm internal diameter ETT due to continuous resistance when passing the vocal cords, we used a GlideScope® (Verathon Inc., Burnaby, Canada) to visualize and identify the source of the resistance. The GlideScope® view indicated that the subglottic area was divided into two sections with a septum (). A laryngeal mask airway (LMA, i-gel®, 4.0, Intersurgical Ltd., Wokingham, UK) was inserted for temporary ventilation with a tidal volume of 7 ml/kg and 12 breaths/min, but peak airway pressures of 30 mmHg did not improve even after injection of additional neuromuscular blockade. Predicting inadequate ventilation over several hours of anesthesia with i-gel® inevitably resulted in the attending anesthesiologist awakening the patient and postponing surgery until further evaluation. After reversing the neuromuscular blockade with sugammadex (Bridion®, MSD, Kenilworth, NJ, USA) 200 mg, the patient regained consciousness without any respiratory symptoms and the i-gel® was removed.
Neck computed tomography () and fiberoptic endoscopy () performed consecutively after surgery revealed fibrous tissue at the glottic level dividing the anterior and posterior portion into 5.8 mm and 1.7 mm lengths, respectively. An initial chest radiograph revealed evident narrowing at the level of the glottis (), with a post-anesthesia chest radiograph confirming the initial findings. Re-questioning the patient regarding any discomfort or complications from the previous surgery revealed that the patient suffered from severe dyspnea and dysphagia after surgery 3 years ago, which lasted several weeks. Afterwards, she complained of continuous mild dyspnea on exertion, but did not consider these symptoms to be anesthetic sequelae. An otorhinolaryngologist consulted for treatment diagnosed post-intubation tracheal stenosis, but did not recommend aggressive or invasive treatment. After constructing a plan including the use of a supraglottic airway (SGA) or smaller diameter ETT in case of failed regional anesthesia, the patient underwent successful surgery with continuous epidural block.


A 25-year-old 160 cm tall woman weighing 73 kg had recanalization of a previously coiled anterior communicating artery aneurysm. A Spetzler catheter was inserted at the L4-5 interspace and drained CSF but the volume was not recorded. The aneurysm was successfully clipped and the lumbar drain removed. Postoperatively, she was neurologically intact. On POD 2, she became confused and apathetic; this worsened over the next 3 days. She complained of a positional headache, present while walking or sitting and absent when lying supine, ().
Brain sag was diagnosed by progressive global neurological deterioration, orthostatic headache and computed tomography (CT) findings. On POD 6, an L4-5 EBP was performed with 25 mL of autologous blood. Within several hours, alertness improved, mental status returned to baseline, and headache fully resolved. She was discharged the next day.


A 54-year-old 175 cm tall man weighing 84 kg underwent right craniotomy for clipping of an unruptured middle cerebral artery aneurysm. A Spetzler catheter inserted at L4-5 interspace drained 100 mL of CSF, and was removed post-craniotomy. The patient did well initially, however, on POD 3, he developed a partial right third nerve palsy and lethargy. A Head CT revealed midline shift with an epidural air collection (). Re-exploration was performed to address the mass effect attributed to the epidural collection. At craniotomy, however, the dura and brain were depressed and not under pressure. Postoperatively, upright intracranial pressure (ICP) was -14 mmHg, and increased to 0 with supine positioning. Arteriography demonstrated no vasospasm; although the basilar artery was kinked (). A head CT revealed an oval shape midbrain (), consistent with brain sag. Two days after re-exploration, he was awake but confused, oriented to self, following only simple commands. His right pupil was dilated and nonreactive to light. He remained too lethargic to complain of positional headache but became more alert while supine.
Brain sag was confirmed by the constellation of persistent lethargy, third nerve palsy, radiographic findings and low ICP (0-3 mmHg). Seven days after aneurysm clipping, a L4-5 EBP was performed with 25 mL of blood. Within the hour, he became more awake and appropriate. Within four hours, he engaged in a telephone conversation and fully recovered to baseline neurological state. One day after EBP, he was ready for transfer to rehabilitation medicine and remained neurologically intact thereafter.


A 47-year-old 160 cm tall woman weighing 59 kg presented with a ruptured left posterior communicating artery aneurysm, Hunt-Hess Grade 4. She was hemodynamically unstable with pulmonary edema and Takotsubo's cardiomyopathy. A ventricular drain was inserted to relieve hydrocephalus. Following 2 days of medical optimization, the ICP remained normal, she followed commands, and underwent craniotomy for aneurysm clipping. A Spetzler catheter was inserted at the L4-5 interspace. Intraoperatively, significant brain edema was encountered and 50 mL of CSF was drained. After aneurysm clipping, the bone flap was not replaced. The lumbar drain was removed and she remained intubated. Her postoperative head CT showed hemorrhagic contusions of the left frontal and temporal lobes likely due to surgical retraction. On POD 1, her left pupil was dilated and minimally reactive to light. She spontaneously moved her left arm and withdrew on the right. A second Head CT showed diffuse cerebral edema, small lateral ventricles, effacement of the basal cisterns, and herniation of the left cerebellar tonsil through the foramen magnum (). The craniectomy site was soft and the ICP was 6 mmHg.
The neurological and radiological findings in conjunction with a soft skin flap and low ICP led to the diagnosis of brain sag. Twenty hours after drain removal, an L4-5 EBP was performed with 20 mL of blood. Within 24 hours, the left pupil returned to baseline, both pupils were reactive, the left arm briskly localized while the right elicited weak extensor posturing, the ICP increased to 12 mmHg, and the craniectomy site had normal tension. She gradually improved, and on POD 16 was transferred to rehabilitation facility. At 6 month follow-up, she had persistent right hemiparesis and breathed spontaneously on a tracheostomy collar.


A 54-year-old woman, with medical history of hypertension, type II diabetes, dyslipidemia and osteoarticular degenerative disease of the spine already being studied at our institution, was admitted to our emergency department complaining of bilateral hip pain following a minor trauma. Radiographic studies performed showed no fractures or apparent bone lesions. One week later, after having sustained a fall from her own height, the patient was admitted again to the emergency department. At this time, and having worsening of the complaints, another set of radiographic studies were performed and showed fracture of the right ischiopubic and iliopubic rami, as well as a large osteolytic lesion on the left ilium ala (). Conservative course of treatment was decided for the fractures and the patient was referenced to the outpatient consult at our institution to have the lesion studied. A CT was performed and confirmed the lesion suspected on the x-rays. Besides the iliopubic and ischiopubic fractures on the right pelvis already known, MRI showed a solid large mass extending from the left ilium to the left sacroiliac joint, with approximately 13.4×13×8.9 centimeters wide, with necrotic areas (). Bone scintigraphy could not characterize better the lesion but excluded other bone lesions. The patient was referenced to the hemato-oncology specialist. Bone marrow biopsy showed no involvement by clonal cells. Histopathologic studies confirmed the diagnosis of solitary bone plasmacytoma of the pelvis () and radiotherapy cycle was initiated.


This blond, 23-year-old man referred that the hair around his ears and occipital area had turned darker, shorter, and curlier during the last 3 years. He also mentioned that the hair in that area was more scarce and fragile and was rather concerned about it. He had not taken any medications in the previous years nor had undergone any cosmetic procedures. No other people in his family showed similar changes on their hair. He referred no family history of androgenetic alopecia.
Clinical examination showed his normal blond, straight long hair on the frontal and parietal areas of the scalp, whereas the hair on temporal and occipital areas was brown, lusterless, short, and curly [Figures and ]. Traction test was negative.


An 18-year-old female presented to us with multiple asymptomatic hyperpigmented lesions over body for 2 months. There was no similar complaint in the past or in the family. There was no history of waxing, application of topical medications or cosmetics, trauma or any oral steroids. There were no features suggestive of atopic dermatitis. The patient was averagely built and did not have a sedentary lifestyle. On gross examination, lesions appeared as hyperpigmented papules, but careful examination revealed hair rolled to give the appearance of papules over lateral [] and medial aspect of thighs [], back [], and extensor aspect of arms. There were no signs of inflammation. Palms and soles were normal. Clinically diagnosis of CHs was made. Dermatoscopic examination was done which revealed multiple hairs coiled asymmetrically []. Few circular hairs growing in horizontal distribution beneath the stratum corneum []. At places, more than one hair was seen emerging from follicular orifices [] which was labelled as pilli multigemini. Biopsy was advised but the patient denied.


A 55-year-old healthy male was incidentally detected to have a retroperitoneal mass in the left suprarenal location. Laboratory tests including serum creatinine, cortisol, aldosterone, 17-hydroxy progesterone, androstenedione, urinary vanillylmandelic acid, epinephrine, and norepinephrine were normal. Computed tomography and magnetic resonance imaging showed an enhancing left adrenal mass (8 cm) with a tumor thrombus extending into the infrahepatic IVC (thrombus extending up to 5 cm of IVC from renal vein), displacing the left kidney laterally [Figure and ]. A whole-body scintigraphy was negative for bone metastases.
Laparotomy was performed with a Chevron incision and lower sternotomy. We proceeded with an en bloc resection of the mass and the para-aortic lymph nodes after mobilization of the spleen and the tail of the pancreas. The infrahepatic IVC was exposed and venous control was achieved by placing four tourniquets; two on the IVC cranial and caudal to the thrombus, one around the left renal vein proximal to the thrombus and one around the right renal vein. After caval clamping, thrombectomy was performed by a longitudinal incision of the cava. The thrombus was also infiltrating the IVC wall, which was resected with the specimen. The specimen included the tumor thrombus, infiltrated IVC wall, distal left renal vein, adrenal vein, and the adrenal mass []. The IVC was reconfigured with a Prolene 5-0 continuous suture. The renal vein proximal to the thrombus was sutured with 6-0 Prolene, preserving the gonadal and lumbar veins [].
Postoperatively on day 1, the serum creatinine started rising due to acute tubular necrosis secondary to intraoperative hypotension. In view of rising creatinine, color Doppler was done which showed normal patency and flow in the IVC and renal vein. The patient needed renal replacement therapy and supportive intensive care unit management for a week followed by gradual return of renal function to normal. At 1 year follow-up, the patient is doing well without any evidence of metastasis on positron emission tomography contrast enhanced computed tomography (PET-CECT) with a serum creatinine of 1.1 mg/dL. CECT abdomen images acquired during the PET-CECT study at 1-year follow-up showed normal contrast uptake and enhancement in both kidneys []. Histopathology was consistent with poorly differentiated ACC. The tumor thrombus showed the same pathology. Five lymph nodes were present, and all were negative for metastasis.


A 21-year-old male presented with diffuse lesions over his left upper limb involving the full circumference of his arm extending till the elbow (). The lesions initially started as a small nodule first noticed by him about 6 years ago and recurred despite repeated excisions, each recurrence being more extensive and aggressive than the previous. Histopathological evaluation suggested nonspecific inflammatory lesions. There was no history of any precipitating factors.
On evaluation, magnetic resonance imaging of the left upper limb revealed a fairly large, locally invasive cutaneous and subcutaneous lesion along the middle and lower third of left upper arm. Medially the lesion was insinuating between brachialis and triceps brachii muscle up to the shaft of the humerus with dense periosteal thickening. He also had associated atrophic changes in the muscles of the upper arm ().
Excision of the lesion with skin grafting was performed. Histopathological examination of the excised specimen revealed regular acanthosis of keratinized stratified squamous epithelium with elongation of rete pegs. Superficial dermis showed diffuse infiltrate with inflammatory cells. Deep dermis showed sheets of lymphoid aggregates along with tangible body macrophages. There was destruction of adnexal structures. Immuno-histochemical (IHC) studies showed CD3 positivity in most of the cells, CD20 was focally positive, CD30 was negative and a Ki-67 was 1% (). Hence he was diagnosed with CPSL with predominant T-cell infiltrate. His bone marrow biopsy revealed a reactive marrow. Chest and abdominal imaging were normal except for mild splenomegaly. Blood counts and chemistries were normal. Post-excision, the lesions recurred within 2–3 weeks and progressed rapidly to involve the entire circumference of the arm.
Subsequently, he was treated with chemotherapy with oral cyclophosphamide and prednisolone for 4 months followed by maintenance prednisolone for a total of 9 months. Response to chemotherapy was partial and lesions progressed on withdrawal of chemotherapy. There was no significant response to steroids alone. He was referred for radiation oncology opinion in view of rapid progression after stopping chemotherapy. Clinical examination at that time revealed extensive skin lesions involving the entire left upper arm, extending from the level of deltoid insertion superiorly to the elbow inferiorly. Lesions were diffuse, erythematous, ulcero-nodular with foul smelling seropurulent discharge, bleeding and crust formation. Range of motion at the elbow joint was significantly reduced. Skin over the rest of his body was normal. He was in severe psychological distress due the nonhealing extensive skin lesions and the associated disability.
He was treated with radiation therapy to a total dose of 30 Gy in 15 fractions to the left arm. Radiation portals covered the entire involved area with 2-cm superoinferior margins. Treatment was delivered with 6 MV photons using parallel opposed fields of size 34 cm × 11 cm. During radiation, the lesions initially showed increased erythema and edema with spontaneous bleeding which subsided over 3 weeks. The seropurulent discharge gradually subsided and the treated area was replaced with healthy granulation tissue. There was near complete healing of the affected part, with few areas of scarring, over a period of 6 months (). The range of motion at the elbow improved considerably. At 26 months following radiation, he had no signs of recurrence and was able to do active work.


A 25-year-old male patient reported to our institution with a swelling in the lower left posterior region of lower jaw for 2 months that followed the extraction of 36 []. The swelling was gradually increasing in size. Medical history was not significant. Extraoral examination revealed swelling that was bony hard and nontender on palpation. Overlying skin was normal. Submandibular lymph nodes were not palpable. Intraoral examination revealed swelling extending from the left second premolar to the second molar region, causing the expansion of both buccal and lingual aspect of alveolar ridge [Figures –]. Radiographic examination (intraoral periapical radiograph [IOPA and OPG]) revealed well–defined, unilocular radiolucency with sclerotic borders in relation to 35–37 and 36 were missing [Figures and ]. Based on the clinical and radiographic findings, a provisional diagnosis of residual cyst or odontogenic keratocyst was made. Enucleation of the cyst was done and sent for histopathological examination.


A 30-year-old female patient reported to the institute with a complaint of gradually increasing swelling in the lower right back region for 2–3 months following the extraction of carious 46. Medical history was not significant. On intraoral examination, localized swelling was noticed in the edentulous, 46 buccal ridge area approximately measuring about 1.5 cm × 1 cm without the displacement of adjacent teeth. The overlying mucosa was intact and was of normal color. Swelling was non-tender and hard in consistency. IOPA revealed unilocular, well-defined radiolucency in the region of 46 with sclerotic borders. Based on the clinical and radiographic findings, a provisional diagnosis of residual cyst was made. Enucleation of the cyst was done and sent for histopathological examination.
Histopathological examination for both the cases revealed the presence of cystic lumen with epithelial lining and supporting connective tissue capsule. The epithelial lining was 2–3 cell layers thick with a flat epithelio-mesenchymal interface, and at places showed variable thickness with luminal proliferation. The epithelial lining showed few surface cuboidal eosinophilic cells (Hob-nail cells) and few goblet cells. Juxta-epithelial area revealed the hyalinized area suggestive of dentinoid. The connective tissue capsule showed parallelly arranged collagen fibers, few foreign body giant cells, and few blood vessels. Based on these findings, histopathologically it was diagnosed as GOC [Figures –].


A 17-year-old male presented with a 3 weeks history of a painless swelling in the left hemiscrotum. Examination revealed the swelling to be consistent as an epididymal cyst which was later confirmed on ultrasound examination. There was, however, a subtle mass palpable within the left testis, which had a sonographic appearance suspicious for testicular neoplasm. There had been no history of trauma or cryptorchidism. The patient had no other significant history apart from being a heavy cannabis smoker and tobacco smoker. He denied use of other illicit drugs.
Tumor markers (β-human chorionic gonadotropin, alpha-fetoprotein, and LD) were all negative. Staging chest X-ray and computed tomography scan of the abdomen did not reveal evidence of metastatic disease. Given the ultrasound appearances, malignancy was suspected and the patient underwent a left inguinal orchiectomy.
Histology revealed multiple infarcts of the testicular parenchyma with an obliterated artery adjacent to each infarct. The lesions varied in the stage of development but appeared similar in nature with evolving thrombosis and fibrous obliteration. The findings were consistent with thromboangiitis obliterans. There was no evidence of malignancy.
Further review of the patient did not reveal any further evidence of infarction though he did give a history of intermittent leg cramps and weakness, which may have been due to intermittent claudication. Unfortunately, the patient did not attend for further follow-up.


A 35-year-old woman was referred with an 11-month history of gradually swelling of the right maxilla and buccal spaces began during pregnancy two years ago. Patient felt no facial pain or paresthesia.
There was no history of trauma to the facial bones, nasal obstruction, dental problem, epistaxis, drugs consumption or visual change.
On physical examination, facial asymmetry was found due to swelling of right maxilla without significant tenderness.
No other clinical or laboratory problems were found. Postpartum CT scan of the maxillofacial region revealed a large lytic expansile multi-septated mass along the right maxillary sinus and buccal region (60 × 52 × 45 mm) (). In this patient, surgical excision of maxillary lesion was performed and histopathology was compatible with a giant cell tumor (GCT) of bone. Biopsy revealed a benign process consisting of significant number of osteoclasts with little osteoblast cells and small component of fibrosis and osteoid formation without evidence of malignant features.
Four months following surgery, gradual progressive swelling of the bed of tumor was recurred and revised pathological slices were compatible with GCT. Regarding patient recent paresthesia, repeated laboratory tests were performed. According to laboratory tests (elevation of serum calcium and parathyroid hormone), ultrasonography and radioisotope scan (Sestamibi) were considered. In ultrasonography, a 11 × 14 × 27 mm mixed hypo echo mass lesion was seen in posterior aspect of right thyroid lobe compatible with probable vascular parathyroid mass (). In sestamibi isotope scan, increased uptake in posterior aspect of right thyroid lobe suggested a right parathyroid adenoma or hyperplasia . Other bone survey was unremarkable.
After diagnosis of parathyroid mass, surgical excision was performed. Pathological findings of the right parathyroid gland revealed an encapsulated mass with solid-cystic component. Microscopically, the mass had a nodular growth pattern. Cells organizing the mass had a uniform shape with rounded nucleoli and pale eosinophilic cytoplasm without evidence of fat within the cytoplasm (). Pathological and surgical findings were compatible and consistent with parathyroid hyperplasia.
Diagnosis of brown tumor due to primary hyperparathyroidism related to parathyroid hyperplasia was achieved according to clinical and pathological findings.


A 16-year-old male subject visited the Department of Periodontics, The Oxford Dental College and Hospital, Bangalore complaining of bleeding gums following brushing and painless swelling in the left posterior area of the hard palate since 6 months. His medical and family history was noncontributory and was in good physical condition. The extraoral examination was unremarkable. No other abnormality was found.
Oral hygiene status of the subject was satisfactory. Intraoral examination showed the presence of swelling in the left posterior area of the hard palate of approximately 2 cm × 1 cm in size and color similar to that of palatal mucosa with slight bluish hue in the center of the lesion with a presence of sinus opening []. On palpation, the lesion was nontender and firm in consistency around the borders and soft at the center of the lesion. There was purulent discharge through the sinus tract.
Electrical pulp vitality test results were positive. To track the sinus tract, intraoral periapical radiograph was taken with gutta-percha point placed through the sinus opening. The gutta-percha point extended till the apex of mesial root of a maxillary first molar. There were no signs of alveolar bone resorption in the panoramic, periapical, and occlusal radiographs. The floor of the maxillary sinus appeared intact. Complete hemogram showed all the parameters within the normal range. Computed tomography peripheral nerve sheath reported soft tissue density on the left side of palate causing smooth bony indentation [].
Initially, the differential diagnosis of the swelling was made as periodontal abscess, palatal region vascular malformations such as hemangioma, mucocele, sialometaplasia, pleomorphic adenoma, adenoid cystic carcinoma, MEC, and adenosquamous carcinoma.
Incisional biopsy was done to establish a definitive diagnosis, to assign a histological grade and prescribe adequate therapy. On histopathological examination, H and E staining showed three groups of cells, namely large mucous cells with an empty cytoplasm and peripherally placed nucleus, intermediate cells with basaloid nucleus, and epidermoid cells with eosinophilic cytoplasm suggestive of intermediate-grade MEC []. Mucicarmine stain, a specific stain for the diagnosis of MEC, highlights cytoplasmic mucin in the tumor cells. This staining showed large mucous cells with magenta pink colored cytoplasm indicating the presence of mucous, intermediate cells with basaloid nucleus, and lastly epidermoid cells with abundant cytoplasm. In areas, cystic areas filled with magenta pink colored material could be appreciated indicative of mucous, suggestive of intermediate-grade MEC []. The treatment consisted of wide surgical excision of the lesion with free surgical margins which was carried out under local anesthesia with an electrocautery. Boundaries of excision extended anteriorly until canine, medially up to midline, posteriorly until junction between hard and soft palate, and laterally until marginal gingiva. The Greater palatine vessel was ligated []. The excisional biopsy report confirmed the diagnosis of intermediate-grade MEC. Postoperative healing was uneventful.
The patient was recalled at 1, 3, 6 months and 1-year postoperatively to check for any recurrence. At 1-year healing was uneventful [].


A 70-year-old female patient presented to the emergency room with progressive paraparesis and back pain. She underwent excision of skin lesion located at lower sacrum two days earlier. The exact details of the surgical procedures, which were performed at an outside hospital, were not available. Fever and lower back pain developed after operation. Her body temperature was 39℃. There was tenderness at lower lumbar area. Neurological examination revealed lower extremity weakness of grade IV, sensory deficit at L5, S1 dermatome. The patient was human immunodeficiency virus negative. No drug abuse history was obtained.
White blood cell count (9270/mm3) was normal, C-reactive protein (32.95, normal range 0.00 to 0.49 mg/dL) and erythrocyte sedimentation rate (63, normal range 0 to 20 mm/hr) were elevated. MRI of the lumbar spine on admission showed no definite abnormal mass lesion. There was irregular enhancement along the epidural space at L4-5 and L5-S1 without mass effect. It was thought to be enhancement of epidural venous plexus, suggestive of spondylitis (). She was managed with intravenous ceftriaxone and vancomycin. Her fever subsided after antibiotics therapy. Methicillin sensitive Staphylococcus aureus was identified at blood culture taken at initial evaluation. Vancomycin was changed to nafcillin according to culture report. There was no microorganism identified on follow-up blood culture. On 16th hospital day, she complained of aggravated lower extremity pain. Neurological examinations showed no change of mild lower extremity weakness and mild sensory deficit. There were no meningeal irritation signs. Follow-up MRI was performed on the next day. Elongated shape, rim-enhancing cystic lesion were noted at ventral side of the spinal canal, L2-4 level causing displacement and severe compression of the dural sac. On axial image obtained L2 level, rim-enhancing cystic lesion showed broad-base attachment to the vertebral body and dorsal convexity with compression of the dural sac (). It was thought to be epidural abscess.
An emergency L2 laminectomy was performed. The epidural space appeared to be free of inflammation, pus, or granulation tissue. A vertical durotomy was performed at exposed area. There found scanty cerebrospinal fluid with normal clarity, cauda equina without inflammatory change. A thin-walled abscess cavity was found at ventral side of the intradural space. Pus gushed out on incision of the yellow-colored wall. There was no discernable white fibrous layer at abscess capsule (). The cavity was irrigated with antibiotics mixed saline and the wall was removed partially. On postanesthetic recovery, her pain on lower extremities was markedly subsided. Pus culture revealed no growth of microorganism. She was managed with the same intravenous antibiotics for 3 weeks postoperatively. Then oral cephalexin was administered for 4 following weeks. Follow-up MRI obtained 2 weeks after operation showed markedly decreased abscess size (). The patient was transferred to rehabilitation medicine 3 weeks after operation. She was discharged after 2 months of hospitalization. She was ambulatory and complained no leg pain.


A 38-year-old man with a non-contributory medical history presented at the Department of Periodontology, SNUDH, Seoul, Korea, with a chief complaint of continuous buccal sinus tract formation of the maxillary left 1st premolar (#24). A clinical examination revealed a sinus tract with pus discharge at the buccal surface and hyper-tooth mobility, and Angle class III malocclusion and anterior cross-bite were observed. In the periapical radiograph, extensive radiolucency and active bone resorption around the root were noteworthy, and subgingival calculus deposition was observed (). The PPD was approximately 9–10 mm at the distal portion and 7–8 mm at the mesial portion of the #24 tooth. The diagnosis was localized chronic periodontitis with secondary TFO. Because of a periapical lesion, endodontic treatment was also considered. However, the tooth was responsive to the electric pulp tester (EPT), and periodontal treatment and occlusal adjustment were planned first.
Subgingival calculus was removed by root planning, and inflamed soft tissue was managed by subgingival curettage. Minocycline ointment was locally applied to the deep gingival pocket, and antibiotics (100 mg cefdinir 3 times daily) and anti-inflammatory analgesics (650 mg acetaminophen 3 times daily) were prescribed for 5 days. At the next visit 2 weeks later, the patient reported that the gingival condition was more comfortable than before the treatment. The gingival inflammation was dramatically reduced and showed no sinus tract or pus discharge upon oral examination. However, the tooth mobility was still severe, and occlusal interference during canine guidance and premature occlusal contact were observed. Tooth splinting with a dead soft wire and composite resin on the palatal side and occlusal adjustment were performed. The premature contact was marked as the ‘high spot’ with a check bite (AccuFilm II, Parkell, Edgewood, NY, USA), and it was simply removed with selective grinding. After tooth splinting and occlusal equilibration, root planing was performed once more, and antibiotics (500 mg amoxicillin, 3 times daily) and anti-inflammatory analgesics (100 mg aceclofenac, 2 times daily) were prescribed for 5 days. At a re-check after 2 weeks, the PPD was slightly reduced and the inflammatory signs were nearly resolved.
The patient was recalled periodically (3, 6, 9, 12, 16 months), and a follow-up radiographic examination showed noteworthy improvement of the periapical radiolucency (). Interestingly, alveolar bone regeneration was observed and maintained, showing new periodontal ligament attachment at the root surfaces including the surrounding teeth, as indicated with arrows in . The clinical examinations included a pulp vitality test with an EPT, recordings of the PPD, tooth mobility, and a percussion test performed 16 months after treatment (). The tooth (#24) vitality was maintained, PPD was recovered within a normal range around 3–4 mm, and there was no symptom in the percussion test. As wire was attached at both sides of the #24 tooth, a proper tooth mobility check was not performed until the 12-month examination. The wire that was attached to the tooth with a composite resin was partly detached after 12 months of follow-up, and the mobility was examined. Tooth mobility was dramatically reduced, and it was assumed that this was the result of alveolar bone regeneration (arrow, ). The gingival condition was well maintained without any signs of inflammation (); however, buccal gingival recession was observed ().


A 55-year-old man with hypertension, diabetes mellitus, coronary artery disease, pulmonary hypertension, and congestive heart failure presented with syncope. In the emergency department, the patient was alert and oriented with a blood pressure of 90/44 mmHg and a heart rate of 44 beats/minute. On examination, lungs were clear on auscultation, jugular venous distension was present, prominent S2 heart sound with a systolic ejection murmur 2/6 gradient auscultated loudest at the second left intercostal space, and bilateral pitting edema of the lower extremities reaching the knees was seen. Laboratory studies were significant for creatinine of 1.87 mg/dL, brain natriuretic peptide of 504 pg/mL, and troponin I of 0.06 ng/mL. Chest X-ray revealed cardiomegaly. Electrocardiography was significant for left atrial dilation and right ventricular hypertrophy. Transthoracic echocardiography showed severe right ventricular dilation decreasing the size of the left ventricle with left ventricular hypertrophy, dilated right and left atria, and severe tricuspid regurgitation with pulmonary artery systolic pressure of 85 mmHg. Ejection fraction was noted to be 55% with no evidence of atrial septal defect (ASD). Cardiac catheterization and computed tomography angiogram revealed severe pulmonary hypertension and drainage of the right pulmonary vein into the SVC ( and ).
Medications were titrated during hospital stay as patient was on a high dose of beta-blockers prior to presentation. Patient was discharged with bumetanide 2 mg BID and metoprolol 25 mg BID with options for elective pulmonary venous surgery.


A previously healthy 30-year-old man presented with sudden and intense back pain after lifting a heavy object. Radiological investigation demonstrated an L4 burst fracture with presence of bone fragments in the spinal canal (Fig. ). Clinical examination was normal except for a mild left foot numbness. His routine laboratory assessment revealed hypochromic microcytic anemia.
He underwent a complete L4 and a partial L3 laminectomy plus posterior lumbar fusion with pedicle screws from L2 to S1 vertebrae. Remarkable vertebral softness was documented during surgery. Postoperatively, bone mineral density was measured and showed osteoporotic findings. The postoperative course was uneventful. Further investigation found abnormally elevated serum tryptase levels: 25.2 μg/l (normal values <11.4 μg/l). Α bone marrow biopsy was performed and showed nests of spindle-shaped or ovoid cells with atypical morphology, eosinophilic cytoplasm and irregular or elongated nuclei. Ηistochemical staining with chloroacetate esterase and Giemsa and immunohistochemical staining with tryptase and CD117 demonstrated similar cell aggregates (Fig. ). A bone marrow sample tested by polymerase chain reaction was found positive for the D816V somatic mutation in the exon 17 of the c-KIT gene.
These findings established the diagnosis of systemic mastocytosis according to the criteria of the World Health Organization (WHO) [].
Treatment with biphosphonates and interferon was initiated, which is well tolerated at 18 months following the diagnosis. Over this period, he has not developed any skeletal or extraskeletal signs of the disease. Regular imaging follow-up did not show any instrumentation failure, new vertebral fracture or subsidence and signs of screw loosening (Fig. ). Soon after surgery, he returned to his normal activities free of pain without any neurological deficits.


A 66-year-old male with multiple prior lumbar spine surgeries presented with intractable, disabling low back and radicular pain, and neurogenic claudication with severe sagittal imbalance refractory to conservative measures. He was unable to walk more than 20 yards at a time and experienced severe pain and cramping with any movement. His quality of life had been severely affected by his symptoms. He had a history of SVC syndrome (right internal jugular stent), managed with long-term warfarin anticoagulation; he also had chronic left internal jugular and brachiocephalic veins occlusions.
Physical examination demonstrated normal motor strength in the upper extremities. No pathologic reflexes were noted in any extremity. He had a slight weakness in the right gastrocnemius and extensor hallicus longus (EHL) graded at 4+/5 strength.
Computed tomography (CT) and plain radiographics indicated pseudarthrosis of his prior construct []. CT myelography confirmed his neurogenic claudication by demonstrating severe spinal stenosis. He was scheduled for T10-pelvis instrumentation with L2–L3 interbody placement, L2 pedicle subtraction osteotomy (PSO), and T12–L2 two-column osteotomies and decompression.
After induction of general endotracheal anesthesia, electrodes were placed for routine neuromonitoring including somatosensory and motor evoked potentials as well as electromyography. Subsequently, a right frontal ICP monitor was placed. The initial pressure reading from the ICP monitor was 6 mm Hg (normal ICP <20 mm Hg). Once all lines and monitors were in place, the patient was then carefully turned prone onto the Jackson frame. The prone-view facial padding device notably needed to be modified to accommodate the anchor of the pressure monitor. A semicircular cut was made, so the anchor would rest without strain on the device. The pressure reading after turning the patient prone was 30 mm Hg. The decision was made to only proceed with the case if the ICP could be maintained <15 mm Hg at rest since surgical manipulation would likely lead to elevation of the ICP. The Jackson frame was then elevated to 30° of reverse Trendelenburg position. The patient's ICP gradually decreased over the next 10 min and stabilized at 14–15 mm Hg []; therefore, the decision was made to proceed with surgery. After exposure of the previous construct, the instrumentation portion of the operation began. There were no changes to neuromonitoring signals during the instrumentation portion of the procedure, and the ICP monitor demonstrated intermittent pressure elevation to approximately 18–19 mm Hg from a baseline of 15 mm Hg.
After successful instrumentation, laminectomies and a discectomy were performed. Next, an interbody spacer was then placed at the L2–L3 level via a transforaminal approach. A PSO was then performed at L2. During the exposure and removal of scar in preparation for the PSO, a durotomy occurred on the right side (approximately 5 h into the procedure) []. Cerebrospinal fluid (CSF) egress was controlled with cottonoid patties until full exposure was obtained. The dural defect was repaired primarily with suture and dural sealant. Incidentally, the ICP fluctuated between 0 and 3 mm Hg during this time. The monitor was checked at its entry site and noted to be in an ideal position. There were no changes in neuromonitoring signals during this period of time.
Once the PSO was closed, intraoperative long-cassette radiographs were obtained demonstrating significant improvement in lordosis. Two-column Smith-Peterson type osteotomies were then carried out, long segment rods were contoured, cap screws were placed and tightened, and the wound was closed expeditiously.
The patient was then carefully turned back supine onto the bed and taken directly to the Intensive Care Unit still intubated and in stable condition. The head of the bed was maintained at 30° as a compromise between improving cerebral venous drainage and protecting the dural closure.
ICPs were monitored overnight to evaluate for intracranial hypertension; however, the pressures remained in the normal range. His postoperative examination was grossly stable compared with his preoperative examination. The ICP monitor was removed, and he was extubated shortly thereafter. On discharge, he had significant improvement in his preoperative pain, and he continued to have stable slight weakness of the right EHL and gastrocnemius.
Standing long-cassette radiographs were obtained at his 3-month postoperative visit and revealed slight proximal junctional kyphosis. His postoperative pelvic incidence was 58.5°, his pelvic tilt was 29°, and his sagittal vertical axis (SVA) was 13.7 cm []. These deformity parameters were similar at 14-months postoperatively with further improvement of his sagittal deformity, and his SVA further improved to 11.7 cm. He reported dramatic improvement in his preoperative pain symptoms, and these improvements were maintained at his 14-month follow-up visit. He continues to have stable slight weakness involving the right EHL and plantarflexion.


A 29-year-old never smoker male patient was referred to the Pulmonary Medicine Outpatient Clinic for evaluation of possible drug resistant TB. The patient had received more than 1 year of anti-TB medications with no symptomatic improvement. Patient history and records were reviewed.
Two years ago, the patient developed insidious onset right sided pleuritic chest pain associated with a dry cough. It was associated with on and off fever with evening rise of temperature. There was a history of intermittent wheezing without any seasonal worsening and patient had noted 3–4 episodes of streaky hemoptysis. There was no history of anorexia or weight loss. The patient was evaluated at a local health care facility wherein based on the findings of a right sided chest radiographic opacity and thoracic ultrasound demonstrating mild right side pleural effusion, a possibility of pleuro-pulmonary TB was considered, and four-drug anti-TB treatment (directly observed treatment regimen) with first-line drugs was initiated. The patient was reassessed after initial regimen, but there was no radiological response. Sputum smear examination for acid-fast bacilli was negative on multiple occasions. Despite 12 months of regular treatment, there was no improvement in symptoms and cough persisted. The patient was initiated on treatment with an intensified anti-TB regimen (Cat II drugs administered on daily basis for 9 months) along with streptomycin and referred to our center.
General physical examination was normal. On chest examination, crackles were audible in the right infrascapular area, and breath sounds were reduced in the lower right hemithorax. Routine blood investigations were normal. Sputum cytology was negative for malignant cells. A thoracic computed tomography (CT) scan followed by flexible bronchoscopy was planned.
Contrast-enhanced CT thorax demonstrated a mass lesion measuring 5 cm × 7.5 cm × 4.5 cm in relation to the bronchus intermedius causing its significant luminal compromise with resultant atelectasis and bronchiectatic changes in middle lobe and lower lobe of the right lung [Figure and ]. No significant mediastinal/axillary lymphadenopathy or pleural effusion was noted. Findings were suggestive of a primary endobronchial mass with parenchymal extension with post obstructive pneumonitis changes. Flexible fiberoptic bronchoscopy showed a lobulated endobronchial growth in proximal right intermediate bronchus completely occluding the middle and lower lobe []. Endobronchial biopsy showed a malignant neoplasm comprising squamoid cells and mucin-secreting cells showing mild to moderate cytological atypia. Few mucin-secreting cells were seen lining glandular structures and foci of extracellular mucin were noted []. Occasional mitotic figure was seen, and necrosis was absent. Immunohistochemistry revealed CK5 and CK7 positivity, whereas, CK-20, S-100, and SMA were negative. A diagnosis of MEC (low grade) was given. Positron emission tomography-CT scan showed no significant uptake apart from the right lung mass. The patient underwent right middle and lower lobectomy and his postoperative period was uneventful. The final histopathology report was consistent with the result of the bronchoscopic biopsy. Follow-up bronchoscopy performed after 1 year showed an intact suture line with no tumor recurrence.


A 45-year-old female patient presented with complaints of skin lesions in the vulva for past 6 months with a history of intermittent exacerbations. Intense itching of the lesions was also present. At the time of presentation, she had developed oozing from the lesions of 1-week duration. There was no history of developing similar lesions in the past. She also had not taken any specific treatment for the lesions. She had a history of undergoing hysterectomy with bilateral salpingo-oophorectomy 2 years back. She was married for 20 years and had no previous history of exposure to sexually transmitted diseases.
General examination of the patient was normal. Multiple, firm, discrete, dome-shaped, skin-colored, follicular papules were seen over the pubic area and labia majora with few areas of oozing and crusting []. Regional lymphadenopathy was absent. There were no other specific skin lesions elsewhere on the body. Skin biopsy taken from the lesions showed features of spongiotic dermatitis with periadnexal and perivascular lymphocytic infiltrate [].
A diagnosis of Fox–Fordyce disease with secondary infection was made based on the typical history, clinical picture, and histopathology. The oozing and crusting over the lesions were due to secondary bacterial infection as a result of scratching.
The patient was initially started on antibiotics and antihistamines. After a week, the secondary infection had subsided, and the patient was started on topical corticosteroids and topical tretinoin 0.025% cream. The itching subsided, and partial improvement of lesions was noted after 2 weeks of treatment.
Genital involvement is rare in Fox–Fordyce disease. We report this case, with onset in the fifth decade and isolated involvement of the genital region.


A 36-year-old male was admitted to the Clinic of Thoracic Surgery for a slowly progressing chest mass and six-month pain of the thoracic spine and left chest. There was no medical history of trauma of the chest wall and no oncological disease. During clinical examination a slowly growing soft resistance located dorso-laterally in the range of the seventh to ninth rib on the left chest was found. Chest roentgenogram showed a left lateral soft-tissue mass of the chest wall. Chest magnetic resonance (MR) imaging showed a well-bordered tumor of the left chest wall, with a size of 9.5 x 9 x 3 cm with calcifications, overgrowing to the seventh and eighth intercostal space (). According to the result of MR, hemangioma was suspected. The patient underwent surgery. A complete resection of the tumor with the left seventh, eighth and ninth ribs and their intercostal muscles was successfully accomplished (). Blood loss was up to 500 ml. Reconstruction of the chest wall was achieved using polypropylene mesh (). Microscopically, structures of benign vascular lesions corresponding to intramuscular venous hemangioma with numerous phleboliths were found in adipose tissue and striped muscle in the resected chest wall. The surgical margins were negative for tumor structures. The patient was discharged on the seventh postoperative day, and presently, ten months after the operation, he is doing well, without any evidence of local recurrence.


A 4-year-old girl presented to us with headache and vomiting. She also has a single episode of generalized tonic-clonic convulsion. On neurological examination, she was conscious, oriented. Her motor examination revealed left hemiparesis (Medical Research Council grade 4 in both upper and lower limb); rest of the examination was normal. Her computed tomography (CT) scan showed a well-defined contrast enhancing lesion in right temporal lobe extending into the temporal horn with significant perilesional edema and mass effect. Magnetic resonance imaging (MRI) brain with gadolinium contrast was done which revealed contrast enhancing bright lesion in right temporal lobe with intraventricular extension, with significant edema and mass effect [Figures –]. The patient underwent right frontotemporal craniotomy with gross total tumor resection through transcortical approach. Intraoperatively tumor was located in the temporal horn of right lateral ventricle with no definite tumor - brain interface; it was grayish pink, vascular and suckable with cavitron ultrasonic aspirator. Gross total resection was achieved. The postoperatively patient recovered well and her power improved in both left upper and lower limbs. Postoperative CT brain showed gross total resection with postoperative changes []. Histopathology revealed large and pleomorphic rhabdoid cells with abundant eosinophilic cytoplasm, with filamentous cytoplasmic inclusions and vacuoles; along with eccentric round nuclei and prominent nucleolus. IHC revealed tumor cells to be positive for vimentin, epithelial membrane antigen (EMA), smooth muscle antigen (SMA), with patchy positivity for glial fibrillary acidic protein and synaptophysin, thus confirming the diagnosis of AT/RT. The patient was referred further planned for chemotherapy and radiotherapy at a specialist center [].


A 36-year-old man was referred to our department of neurosurgery, from a local clinic, for assessment of neck and bilateral shoulder pain. The patient reported that the pain had been continuously present for about 4 years, but had significantly increased over the previous 2 months. The patient had a unique physical appearance, shown in Figure , which included a short stature; prominent forehead; midfacial hypoplasia, including a flat nasal bridge and short-upturned nose; and prognathism. He was 136 cm tall, which is 6 standard deviations (SDs) below the population mean height for males, and weighed 44 kg, 2 standard deviations below the population mean weight for males. Plain radiographs identified an Arnold Chiari malformation, which the patient reported had been previously diagnosed with, owing to concave vertebral bodies, posterior scalloping, and metaphyseal striation (Figure ). Spinal magnetic resonance imaging (MRI) showed mild descent of the cerebellar tonsils into the foramen magnum, with syringomyelia from C2 to T7 (Figure ). The short stature, facial dysmorphism, and radiographic skeletal findings were consistent with SD, and decompression of the foramen magnum was recommended to correct the tonsillar descent and alleviate the patients’ pain.
Upon opening of the dura matter, adhesiolysis was performed for nonsevere adhesions of the arachnoid. This was followed by tonsillar cauterization, which led to a sudden release of cerebrospinal fluid (CSF) from the fourth ventricle (Figure ). A spontaneous CSF leak occurred at the surgical site on postoperative day 3, which was managed clinically using continuous lumbar drain until complete resolution. The patient's neck and shoulder pain improved gradually without sequelae. Follow-up MRI, performed 2 months postsurgery, showed a marked decrease in the size of the syringomyelia (Figure ).


A 73-year-old man was referred from a local hospital with impaired consciousness and left hemiparesis after a motor car accident. He was diagnosed with traumatic subarachnoid hemorrhage on the left parietal lobe and left lateral mass fractures on C2, C5, and C6, involving the transverse foramen (). A neurological examination revealed stupor with a Glasgow Coma Scale score of 8. Severe grade 2 hemiparesis of the left arm and leg was detected. High signal was seen at the C6-7 levels of the spinal cord on a sagittal cervical spine magnetic resonance imaging (MRI). The signal void on the left vertebral artery was lost on the C6 axial image (). He was diagnosed with left VAD and was managed conservatively. Neck computed tomography (CT) angiography showed obliteration of the left second segment of the vertebral artery (V2) (). The obliteration of the V2 segment remained on 2-week follow-up CT angiography. A brain MRI was performed to evaluate the cause for impaired consciousness and motor weakness. Diffusion weighted images revealed multiple area of abnormally high signals in the right side of the pons, left side of the midbrain, right thalamus, corpus callosum splenium, both parietal lobes, and the left frontal lobe, indicating multiple acute cerebral infarctions (). Ischemic areas were diffusely distributed to the anterior and posterior circulation of the Circle of Willis. Ischemic stroke occurred immediately after cervical spine trauma and neurological deficits after trauma resulted from brain ischemia. Aspirin was started for antiplatelet therapy 1 week after the trauma after confirming disappearance of the acute traumatic hemorrhage. He was discharged from the hospital on aspirin to receive neurological follow-up and rehabilitation therapy. A brain CT scan at discharge showed subdural fluid collection in both frontal lobes. His motor weakness and consciousness state were improving gradually to a grade 4 weakness and alert state on follow-up examination. Bilateral chronic subdural hematomas (CSDHs) were observed with headache 4 months after the trauma (). Burr hole trephinations were performed on both sides for the CSDHs.


A 56-year-old male, weighing 55 kg and 165 cm tall was posted for CABG. He had a history of Koch's chest. Physical examination revealed breath holding time of 15 s and reduced air entry. Pulmonary function tests showed moderate obstructive pathology (post-bronchodilator forced expiratory volume in 1 s 50% of predicted and reversibility postbronchodilator therapy of 15%). Echocardiography revealed left ventricular ejection fraction of 65% with no regional wall motion abnormality. Coronary angiography showed 90% block at left anterior descending (LAD) artery ostium. Functional capacity of the patient was NYHA Class II and objective assessment was Class C. All medications were continued till the morning of surgery except for aspirin and clopidogrel, which were stopped for 1-week. A day prior to the surgery the patient was counseled for the procedure and an epidural catheter placed at T2-T3 interspace.
On the day of surgery after applying electrocardiograph and pulse oximetry, premedication with 1 mg midazolam, 5 mg ondansetron and 50 μg fentanyl was given. This was followed by placement of the arterial cannula, central venous catheter, and Swan-Ganz catheter under local anesthesia. Epidural was activated with a mixture of 0.375% ropivacaine (10 ml) and 5 μg/ml fentanyl followed by infusion of the solution at the rate of 10 ml/h. A sensory block of C7 to T10 level was tested with pin-prick 20 min after drug administration. No significant hemodynamic changes occurred during the procedure. The occlusive screen was placed and patient kept on inhaled oxygen at 4 L/min by ventimask. An additional 100 μg fentanyl intravenous (IV) was given before sternotomy. Patient underwent all the surgical events without discomfort.
Planned bypass graft of left internal mammary artery (LIMA) to LAD artery could not be achieved due to LIMA injury during harvesting. The saphenous vein from the right leg was harvested under femoral nerve block and was used for the bypass graft. Hemodynamic and respiratory parameters were monitored and well maintained during the procedure. Immediately after surgery patient could sit upright with support as well as inhale deeply without any discomfort.
Postoperatively the epidural infusion was continued for 72 h using a mixture of 0.25% ropivacaine and 5 μg/ml fentanyl at the rate of 8-10 ml/h. Visual Analogue Scale score was used to assess pain relief. The only complaint in the immediate postoperative period was nausea, which responded to 5HT3 antagonist. Epidural catheter, all invasive lines and chest drain were removed on 3rd postoperative day and aspirin-clopidogrel started. He was mobilized on the same day and discharged from the hospital on the 7th day.


A 76-year-old male was referred to our hospital by a local clinic, with a preliminary diagnosis of pulmonary thromboembolism and a solitary pulmonary nodule. In the chest computed tomography (CT) performed at our hospital, an approximately 9-mm lobar nodule was observed (). A biopsy was performed and the pathological examination of the mass confirmed EHE. Immunohistochemistry was positive for CD31, focally positive (>5%) for ki67, and negative for CK. Metastasis was not discovered. A right lower lobectomy and lymph node dissection were then performed. The patient revisited our dermatology department due to a painful pruritic localized erythematous umbilicated nodule in the right lower leg approximately two years after his discharge (). The skin lesion was suspected to be a hypertrophic scar or granuloma. A skin biopsy was positive for CD31, CD34, factor VIII-related antigen, and S100 protein, confirming metastatic EHE from the lung. Subsequent evaluation of metastasis including fludeoxyglucose positron emission tomography/CT, chest CT, and brain magnetic resonance imaging did not discover any foci of metastasis. The patient was referred to the plastic surgery department, and was scheduled for elective surgical resection. Under spinal anesthesia, the patient underwent a wide complete excision with split-thickness skin grafting. Intraoperative examination of the mass in the right lower leg indicated that it was approximately 3×3.5 cm in size. We used a safety margin of 1 cm based on clinical experience, because no prior case had been reported regarding the appropriate resection margin for primary cutaneous EHE and skin metastases of PEH.
The resected specimen was approximately 3.9×3.8×1.1 cm, and the gross appearance of the skin exhibited a whitish elevated lesion that measured 1.6×1.4 cm (). Histopathologic images showed that the center of the tumor was often fibrotic and parvicellular, but the periphery of tumor had higher cellularity. The boundaries were grossly defined because peripheral cellularity was increased. Moreover, endothelial cells were distributed widely over the normal tissue, and the boundaries were therefore not clearly defined histopathologically. The tumor cells consisted of nests of epithelioid cells, having a somewhat glassy eosinophilic cytoplasm and relatively uniform nuclei. These cells were similar to the previous lung lesion, with epithelioid-like features, and did not show prominent nuclear atypia or mitosis. The cells were positive for the endothelial marker CD34 (). At six months after surgery, no deformity remained, and the patient recovered without complications or recurrence ().


A 76-year-old female was admitted to our university hospital with an obstructing tumor of the proximal jejunum for a curative surgical approach. Her past medical history included a severe three-vessel CAD with myocardial infarction (MI), complex coronary artery bypass surgery and reconstruction of the mitral and tricuspid valve 6 month prior to admission.
During the preoperative evaluation, she reported intermittent chest discomfort during exercise or stress. Thus, percutaneous transluminal coronary angiography was performed to evaluate further interventional options. The angiography showed a global hypokinesis of the left ventricle (LV) and akinesis of the posterior wall with a LV ejection fraction (EF) of 33%. Whereas the aorto-coronary vein bypass to the right coronary artery showed no pathology, the left internal mammary artery (LIMA) to left anterior descending (LAD) bypass was compromised by a 70% stenosis of the subclavian artery proximal the bypass graft. This stenosis was technically intractable for revascularization [Figures and ].
As she developed symptoms of an upper intestinal obstruction due to tumor progression, the operation could not be postponed. To stabilize LV function and diastolic blood flow via the crucial LIMA to LAD bypass graft the perioperative use of an IABP was advocated.
To minimize perioperative cardiac stress and to obtain a sufficient postoperative analgesia a combined epidural and general anesthesia was attempted under invasive hemodynamic monitoring. General anesthesia was induced with midazolam, sufentanil, and propofol. Balanced Anesthesia was maintained with sevofluran continuous infusion of sufentanil. After placing a transesophageal echocardiography (TEE) probe, the IABP was inserted via the right femoral artery. The first TEE examination showed a severely reduced LV function (EF 30%), an akinesis of the posterior wall and an II° insufficiencies of the mitral and the tricuspid valve. With an augmentation rate of 1:1 and moderate catecholamine support, LV function and mean arterial blood pressure could be stabilized and kept in the range of ±10% of baseline values. TEE examination after 30 min of IABP augmentation showed an EF of 40% and a MI I°. The LV diastolic diameter was significantly reduced. TEE and continuous electrocardiogram monitoring revealed no signs for myocardial ischemia throughout the surgery. The intestinal tumor mass could sufficiently be removed and a primary end-to-end anastomosis of the proximal jejunum was established. After 113 min operation time, the patient could be transferred to the intensive care unit in a hemodynamic and pulmonary stable condition. To prevent thrombo-embolic complications associated to the use of an IABP, a partial thromboplastin time between 40 s and 50 s was attempted postoperatively. By achieving sufficient pulmonary gas exchange and hemodynamic stability the patient could be extubated at the same day. Under further extended invasive hemodynamic monitoring and normovolemic volume substitution, catecholamine therapy was ceased and the IABP was removed on the second postoperative day. The following postoperative course was uneventful. Myocardial markers for ischemia were not elevated and stayed within the normal range. Consistently transthoracic echocardiography revealed no further myocardial damage. The epidural catheter was removed at the third postoperative day and the patient could be transferred to the normal ward. The patient left the hospital 15 days after surgery to the associated rehabilitation center and was undergoing chemotherapy 1.5 years after discharge.


A 28-year-old male presented to the emergency department with complaints of severe right testicular pain and swelling for the past 11 h. He stated the pain began acutely around 3 AM that morning with associated nausea. The previous day, he noted mild soreness in the right testicle which he attributed to having hit more than 100 golf balls at the driving range. He denied trauma to the area and reported being in a monogamous sexual relationship. His past medical history was significant only for mild intermittent asthma, and he noted allergies to cefaclor and certain types of alcohol. He denied any fevers, chills, or vomiting.
The patient was afebrile with a heart rate of 114 beats/min and blood pressure of 134/91 mmHg. Physical examination revealed a swollen, tender, and somewhat high-riding right testicle with a hydrocele. Laboratory testing was significant only for a white blood cell count of 13.6 × 109 cells/L. A urological surgery consultation was obtained for concerns of testicular torsion. A testicular ultrasound revealed normal testicular blood flow, normal bilateral epididymi, a large simple right hydrocele, a small left varicocele, and a possible right spermatic cord hematoma. Due to concerns that the patient's original complaints were secondary to testicular torsion that had spontaneously resolved, he was taken to the operating room for scrotal exploration with possible orchiopexy and orchiectomy.
General anesthesia was induced with propofol, fentanyl, midazolam, lidocaine, and succinylcholine, and endotracheal intubation was successful on the first attempt. Following induction and initiation of positive pressure ventilation, the patient's blood pressure progressively decreased from a preinduction mean arterial pressure (MAP) of 100 mmHg to a nadir of 40mmHg over a period of 30 min despite administration of 600 mL of normal saline, 400 mcg of phenylephrine in divided doses, and 500 mL of albumin. The patient's MAP increased to 60 mmHg only after temporary discontinuation of volatile anesthetic, serial administration of 10–50 mcg boluses of epinephrine and 2-8 unit boluses of vasopressin, and continued albumin administration. Hydrocortisone was administered in addition to epinephrine out of concern for a possible anaphylactic reaction.
During this period of hemodynamic instability, scrotal exploration revealed a normal right testicle with normal blood flow. A right-sided noncommunicating hydrocele with cord edema and varicosities was noted. As there was no significant pathology, the scrotal incision was closed, and there was minimal blood loss associated with the procedure.
As the surgical drapes were removed, it was noted that the patient was plethoric and that ST-elevation was developing in electrocardiogram leads II and V5. A TEE probe was placed for further evaluation of the patient's hypotension. TEE examination immediately revealed a 22 mm pericardial effusion with diastolic compression of the right atrium and right ventricle []. There was a mild, global decrease in systolic function with an estimated left ventricular ejection fraction (LVEF) of 45%, dilated inferior vena cava and hepatic veins, and spontaneous echo contrast in the IVC []. A diagnosis of pericardial tamponade was made, and the on-call cardiac surgeon was requested for the emergent consultation. A right internal jugular central venous catheter was placed and revealed a central venous pressure of 28 mmHg. An arterial blood gas sent at this time showed a lactate of 4.6 mmol/L. Upon arrival of the surgeon, a subxiphoid pericardial window was performed with drainage of approximately 500 mL of serous fluid and immediate stabilization of the patient's hemodynamics without the continued need for vasopressors or inotropes.
On postoperative day 1, the patient was successfully extubated. He remembered a globus sensation that he had experienced the day prior to the presentation, but no other symptoms that may have raised suspicion for an intrathoracic abnormality. A follow-up transthoracic echocardiogram demonstrated normalized biventricular function with an LVEF of 60–65% and no residual pericardial effusion. Bacterial cultures of pericardial fluid and pericardial tissue were negative as well as those for acid-fast bacilli, fungus, and anaerobic bacteria. Viral myopericarditis was made as the diagnosis of exclusion. On postoperative day 3, the patient was discharged with orders to follow-up with his primary care physician, a urologist, and a cardiologist in the next 2–3 weeks.


A 39-year-old male patient with poorly controlled diabetes mellitus presented with acute onset of severe vertigo, ataxia of all limbs, dysarthria, and dysphagia with step-wise deterioration over 9 days. On presentation 12 days after symptom onset, he was noted to have slurring dysarthria, right hemianopia, right Horner's syndrome, right palatal palsy, and bilateral limb and truncal ataxia. In addition, he was tachypneic with evidence of aspiration.
He had multiple diffusion restricted infarcts of different ages in bilateral cerebelli, left pons, left medulla, and left occipital lobe in MRI; and right vertebral artery dissection with occlusion in CT angiography. He was initiated on dual antiplatelets and high dose statin with management of risk factors for his stroke.
As he had pharyngeal pooling of secretions with evidence of aspiration pneumonia at admission, he was electively intubated and subjected to early tracheostomy. He had a second bout of aspiration 3 weeks after weaning from the ventilator. The patient's tracheostomy could be closed 2 months later.
A swallow assessment done at 8 weeks by the speech and language pathologist showed poor swallowing function predominantly due to pharyngeal phase dysfunction. While on conservative management, the patient and family were advised feeding through PEG for which they did not consent initially due to social and personal reasons. But as the patient developed significant malnutrition and weight loss, PEG placement was done after 4 months of the stroke. His nutritional status improved following this and neurological status improved to modified Rankin scale (mRS) 3 with residual ataxia.
The patient's dysphagia however persisted with recurrent spitting and inability to swallow own saliva even after 1.5 years of stroke. The patient had significant depression and impairment of social function related to the swallowing difficulty. On trial swallow test using 8 ml of semisolids and thin liquids, patient demonstrated intact oral preparatory and fairly adequate oral propulsive phases of swallow. Pharyngeal phase of swallow was affected with choking 3-5 s later with effective post swallow cough reflex and expectoration of more than 95% of bolus swallowed despite having adequate hyolaryngeal excursion. Delayed cough reflex was suggestive of post swallow aspiration due to a secondary laryngeal incompetency combined with an inability to swallow own secretions giving the clinical impression of cricopharyngeal dysmotility, which warranted further evaluation.
Videofluroscopic evaluation of swallowing (videofluoroscopy (VFS)) was performed on the patient using bolus of all consistencies to explore the physiology behind altered swallow function and to plan appropriate rehabilitation. Oral preparative and oral propulsive phases of swallowing were adequate. In pharyngeal phase; pharyngeal reflex, hyolaryngeal excursion, and velopharyngeal closure were adequate with fairly efficient laryngeal valving mechanism. Upper esophageal sphincter relaxation was severely affected. Severe cricopharyngeal dysmotility was noted for both semisolids and thin liquids [Figure and ]. Patient had adequate protective and efficient cough reflex and he was able to expectorate out the entire bolus. Secondary laryngeal incompetency was noted once out of five trials; which led to a minimal aspiration for thin liquids. Significant pharyngeal residue at the level of valleculae and pyriform sinus was noted.
He was initially given 40 units of botulinum toxin (20 units on either side) injection into the cricopharyngeus muscle under laryngeal electromyography guidance, which did not improve the dysphagia. Subsequently, he underwent cricopharyngeal myotomy without any postoperative complications.
On follow-up at 3 months after the procedure, he could swallow with the adoption of the chin-tuck maneuver. His VFS showed only minimal pharyngeal phase dysphagia with normal upper esophageal sphincter opening [Figure and ]. His PEG tube was subsequently removed and on follow-up after 10 months, he continued to maintain good nutrition and was able to swallow without any specific techniques. The improvement in dysphagia made a marked change in his quality of life.


A 40-year-old woman (weight, 70 kg; height, 165 cm) was scheduled for a repeat cesarean section at 38 + 1 weeks of gestation. She was a second gravida, and had been diagnosed with systemic lupus erythematosus (SLE) due to an erythematous rash on her nose and chins during the prior pregnancy. At that time, she had undergone a cesarean delivery under epidural anesthesia, and there had been a rash on the skin of neonate for several months after birth. After delivery, no residual symptoms were noted and no medication was administered. During the second pregnancy, she complained of similar rash on her nose along with mild itching and dry skin in the first trimester. An autoimmune disease such as SLE was suspected, and laboratory tests were performed to identify autoantibodies (). The results revealed that anti-Ro/SSA and anti-La/SSB antibodies were positive; hence, the patient was diagnosed with Sjogren's syndrome rather than SLE. Because of the risk of CHB, fetal echocardiograms were routinely checked from 15 weeks of gestation, and fetal heart rate was approximately 150 beats/min at each examination. The skin rash on the patient improved spontaneously after the second trimester, and there were no other symptoms such as dry eyes, dry mouth, or arthralgia. To prevent cardiac complications of fetus, the patient received hydroxychloroquine from 25 weeks of gestation until delivery.
An elective cesarean section was scheduled at 38 + 1 weeks of gestation. Preoperative laboratory tests, electrocardiogram (ECG), and chest X-ray were normal. After arriving in the operating room, noninvasive blood pressure, ECG, and pulse oximetry monitoring commenced. Her initial blood pressure was 118/71 mmHg, heart rate was 77 beats/min, respiratory rate was 16 breaths/min, and oxygen saturation was 100%. Oxygen at 5 L/min was supplied via a facial mask.
After placing the patient in the right lateral decubitus position, the median approach was performed with the 25 G Whitacre spinal needle at the L3-4 intervertebral space. After the stylet was removed and cerebrospinal fluid was confirmed to be draining well, 9 mg of 0.5% hyperbaric bupivacaine with 20 µg of fentanyl was injected. Then, she was positioned supine with a left lateral tilt of 15°, and the height of the block checked by a pin-prick test was T4.
Nine minutes after the skin incision, a female neonate (weight, 2.8 kg) was delivered and her Apgar score was 8 at 1 minute and 9 at 5 minutes. Two minutes after the delivery, the placenta was removed and intravenous infusion of 20 International Units (IU) of oxytocin mixed with 800 ml of 0.9% saline was started. The initial neonatal heart rate was 160 beats/min, and the neonate was transferred to the neonatal intensive care unit (NICU) immediately for continuous monitoring of ECG. The patient's vital signs were stable during the operation, and the estimated blood loss was about 500 ml. During the NICU stay, the neonate's ECG findings showed no abnormality, and the heart rate was approximately 140–170 beats/min. The patient and her neonate were discharged on the fifth postoperative day without any complication.


A 52-year-old Thai woman presented with asymptomatic annular erythematous plaques on the forehead and both cheeks that persisted for 2 years. The lesions gradually expanded peripherally. She had no history of previous trauma or foreign material injection. She is a government officer and regularly works indoor. Her underlying diseases were hypertension and dyslipidemia. Current medications include simvastatin 10 mg/day and manidipine 20 mg/day.
Dermatologic examination showed few discrete annular erythematous plaques on her forehead and both cheeks, 1–5 cm in diameter. Some lesions showed central hypopigmentation. There were solar lentigines and telangiectasias on the malar area, nose, and forehead as shown in fig. and fig. . She has no lymphadenopathy or hepatosplenomegaly. Blood pressure was 150/95 mm Hg. Mild pitting edema on both shins was noted. Other physical examinations were unremarkable.
A 4-mm punch biopsy was performed on the lesion of the left cheek. The routine histopathology demonstrated nodular and interstitial inflammatory cell infiltrate of histiocytes intermingled with some lymphocytes in the dermis as shown in fig. . Elastic stain showed elastotic material phagoticized by multinucleated cells and marked decrease of elastic tissue in some foci of the affected dermis (fig. ). According to the clinical and histopathological findings, the dermatologic diagnosis was actinic granuloma (AG).
Complete blood count, liver enzyme, fasting blood glucose, and glycated hemoglobin were within normal range. HIV serology, viral hepatitis profile, and antinuclear antibody were negative. Chest X-ray showed no pulmonary infiltration. Serum albumin was 35.9 g/l (35–50) and globulin was 39.5 g/l (20–39). Urinalysis showed proteinuria and serum creatinine was 1.26 mg/dl (0.55–1.02). Ultrasound of the KUB system showed bilateral parenchymal renal disease. The result of kidney biopsy was compatible with focal segmental glomerulosclerosis.
The patient's dermatologic condition was treated with prednisolone 15 mg/day for 6 weeks with a good response. However, rapid relapse of the lesions occurred after the treatment was discontinued. Currently, she has been treated with hydroxychloroquine (200 mg/day), topical 0.1% mometasone furoate cream, broad spectrum sunscreen, and sun avoidance with partial improvement.


A 4-year-old African American boy with Fragile X syndrome presented to the emergency department at Children’s Hospital of Michigan with diarrhea for 9 days and fever for 2 days. He had 4 to 7 nonbloody, nonmucoid, loose stools per day associated with abdominal pain. He had persistent fever in the last 2 days with maximum temperature of 39°C despite antipyretic therapy. On the day of admission he had decreased activity and appetite. There was no reported history of vomiting or skin rash; and he had no sick contacts and does not attend day care.
On admission, he was tachycardic and febrile. He was noted to have pharyngeal erythema and left anterior upper cervical lymphadenopathy of approximately 1.5 cm. He was noted to have abdominal tenderness most pronounced in the right lower quadrant. The rest of the physical examination was normal. His initial labs revealed leukocytosis of 14.2 (59% neutrophils) and thrombocytosis of 475 000. His electrolytes, amylase, lipase, and liver transaminases were all normal. Rapid strep test and a throat culture were negative. Abdominal ultrasound showed multiple prominent mesenteric lymph nodes in the right lower quadrant with no evidence of appendicitis. Stool studies including culture, selective stool culture for Yersinia, and Clostridium difficile toxin assay, as well as a blood culture were sent.
He continued to have fever despite antipyretics. On day 3 of admission a repeat complete blood count showed an increase in white blood cells to 21 700 (). C-reactive protein and lactate dehydrogenase were also elevated. His cervical lymph nodes increased in size, now 3 cm on the left and a palpable 1 cm node on the right, and became tender to palpation. He was given intravenous clindamycin and ceftriaxone for possible bacterial lymphadenitis.
On day 4, he developed a maculopapular rash beginning on his trunk and spreading to his extremities and neck. He developed erythema and swelling of his palms and soles and red, cracked lips. He also developed bilateral conjunctivitis with no exudates. The patient was diagnosed with clinical KD. In addition, his labs showed leukocytosis with left shift, elevated erythrocyte sedimentation rate and C-reactive protein, normocytic anemia (hemoglobin 10.5 with mean corpuscular volume 80.5 fL) and hypoalbuminemia (2.6 mg/dL). He developed thrombocytosis after 1 week of fever onset (). His urinalysis did not show pyuria, and his liver enzymes were normal. An echocardiogram was within normal limits. He was given intravenous immunoglobulin (IVIG) and high-dose aspirin.
The patient had persistent fever and the manifestations of KD were only mildly improving. He was noted to have worsening of the left upper cervical lymphadenitis and restricted neck movements. He was also noted to have difficulty swallowing and episodes of stridor. A computed tomography of the neck showed a retropharyngeal phlegmon extending to the superior mediastinum with no abscess visualized. Ceftriaxone and clindamycin were continued. Due to persistent fever and lack of clinical improvement, a second dose of IVIG was given on day 7 of admission. Following that, his fever resolved and the manifestation of KD were improving. His lymphadenitis gradually improved over the next few days.
On day 8 of admission, the stool culture grew Yersinia enterocolitica that was susceptible to ceftriaxone. All his blood cultures were negative, serologic testing for cytomegalovirus, Epstein–Barr virus, and parvovirus B-19 were negative for acute or past infection. Stool was negative for Clostridium difficile by DNA amplification. He completed a total of 9 days of ceftriaxone and 14 days of clindamycin.
On day 11 of admission, the patient was noted to have swollen, erythematous proximal interphalangeal joints and swollen bilateral knee joints. He refused to bear weight, and attempts to have him ambulate were unsuccessful. Radiographs of the pelvis and bilateral knees were normal. Rheumatology evaluation revealed negative HLA B27, and C3/C4 complement levels were normal. His symptoms were attributed to reactive arthritis from Y enterocolitica. He was given intravenous steroids followed by naprosyn. He also received physical therapy and prior to discharge he was able to ambulate. He was sent home to continue low-dose aspirin and naprosyn after 14 days of hospitalization.
Following discharge, he had peeling of skin on his hands and feet during the first week. He continued naprosyn for 6 days after discharge, and the swelling of his knees completely resolved. At follow-up 4 weeks after discharge, he had no signs or symptoms of KD, no cervical lymph node enlargement, and his musculoskeletal examination was normal. His repeat echocardiogram 5 weeks into his illness was normal.


A 54-year-old Marfan syndrome female was admitted to our department due to large (>7 cm) symptomatic dissecting aneurysm involving the thoracic aorta. Her history reveals acute type A aortic dissection 9 years earlier, with consequent aortic valve and ascending aorta replacement. Myocardial infarction and end-stage heart failure rapidly developed leading to orthotopic heart transplantation 2 years later.
The patient was not a candidate for endovascular repair, lacking an adequate proximal aneurysm neck, and was listed for an open procedure [].
Preoperative assessment included echocardiographic evaluation which reported mild left ventricular hypertrophy, normal function but altered diastolic pattern (ventricular septum 11 mm, posterior wall 10 mm, end-diastolic dimension 44 mm, end-systolic dimension 29 mm, tissue Doppler velocity 110 mL, telesystolic volume 48 mL, and left ventricular ejection fraction 56%); severe left atrial dilation (volume 100 mL); mild mitral regurgitation due to annular dilation and leaflet fibrosis; right atrial dilation, mild tricuspid insufficiency, normal right ventricular function (24 mm), and pulmonary pressures (30 mmHg).
Coronary angiography was performed with 60% stenosis of the left anterior descending artery. No other coronary artery had significant stenoses. Functional impact of the stenosis was not assessed, with dobutamine stress-test or computed tomography (CT), due to lack of adequate timing before surgery and overall assessment as not hemodynamically severe.
Brain CT, chest X-ray, functional respiratory evaluation, and carotid duplex scan were all negative.
A thoracic epidural catheter was placed (T7-8) for analgesia; an arterial access was gained cannulating the right humeral artery. General anesthesia was induced using propofol 200 mg, fentanyl 200 mcg, and cis-atracurium 20 mg. Intubation was performed via direct laryngoscopy using a double-lumen orotracheal tube (DLT) (robertshaw 37). A high-flow catheter (Fr12) was placed in the right internal jugular vein, together with a pulmonary arterial catheter (PAC) sheath (Fr8.5), and a quadri-lumen catheter in the right subclavian vein. Transesophageal echocardiographic (TEE) probe was also inserted.
Anesthesia maintenance was obtained with desflurane, Et 6–7%, and top-up 2 mg cis-atracurium every 60 min. Fenoldopam was infused for kidney protection and low-dose epinephrine, in the postclamp period, to maintain adequate cardiovascular performance.
Thoracic aorta aneurysm (TAA) repair was performed with left heart bypass (LHB) (biomedics centrifugal pump, superior left pulmonary vein to left femoral artery); the aorta was clamped proximally between left common carotid and left subclavian arteries. A 24 mm Dacron tube graft was used to replace the aneurysmal aorta.
Total intraoperative blood loss was 5500 mL, replaced by blood salvage and transfusion of packed red blood cells (800 mL) and fresh frozen plasma (1500 mL). No adverse events were recorded.
Due to significant blood loss (2000 mL), on the first postoperative day, from the left thoracic drainage, the patient was reopened, a hematoma was removed and all surgical anastomoses and possible bleeding sites were thoroughly checked. The patient then required low-dose epinephrine (maximum 0.02 mcg/kg/min) for approximately 18 h, and upon weaning transthoracic echocardiography was performed confirming good bi-ventricular function. Weaning from mechanical ventilation occurred 43 h from first intensive care unit (ICU) admission.
A clinical picture of acute-on-chronic kidney injury developed in the first few days, with spontaneous normalization of serum creatinine and a constantly maintained urinary output. Overall, the patient spent 3 days in ICU, was then sent to the vascular surgery ward, and on the eighth postoperative day was transferred to a rehabilitation center. At 6 months from the surgical procedure, the patient is alive and well.


A 68-year-old male with left hemiparesis admitted to our institute. Magnetic resonance imaging showed multiple spotty cerebral infarctions in the right middle cerebral artery. The right cervical ICA showed 75% stenosis with a plaque hemorrhage, which might have caused an artery-to-artery embolism. The cervical ICA showed a strong curved course in the medial direction after the stenotic lesion on magnetic resonance angiography (MRA) []. CEA was planned to reduce the risk reduction of recurrence. After final closure, a distal portion of the ICA was found to have been kinked after removal of the plaque due to the discrepancy in vessel wall thickness []. Fibrin glue and gelatin were used to reinforce the medial arterial wall and repair the kink. Gelatin was soaked with fibrinogen before fixation. The fibrinogen-soaked gelatin was applied to reconstruct the kinked ICA and return it to its optimal position. The gelatin was fixed with thrombin which converts fibrinogen to fibrin. Intraoperative Doppler sonography and indocyanine green angiography demonstrated the release of the kink. Postoperative MRA showed an appropriate course and no kinking of the ICA []. The ICA shape was preserved at 1 year after the operation [].


A 6-year-old boy presented with noneruption of teeth. His parents seemed to be normal and they denied any history of similar condition in their respective families. The parents revealed that the child was progressing at an average pace in school. The child had sparse, fine, blond hair, especially at the temple area and eyebrows. The lower facial height decreased due to an over closed profile, making the lips appear prominent. Examination of nails revealed no abnormality. His behavior in the dental office was age appropriate. An intraoral examination revealed complete anodontia in the mandibular arch and alveolar ridges appeared considerably shallow []. Hypodontia was observed in the maxillary arch with only maxillary left deciduous first molar and bilateral deciduous second molars present. Buccal mucosa, palate, and floor of the mouth were normal. Vertical dimension was considerably lost. Radiographic evaluation revealed that the tooth germs of only 11 and 21 were present in the maxillary arch and there were no evident tooth germs of deciduous and permanent teeth in the mandibular arch []. His nails were normal []. Child was referred to the Department of Pediatrics for assessment. A diagnosis of nonsyndromic oligodontia and anodontia was made. Family pedigree was not studied.
Oral rehabilitation, with removable prosthesis, mandibular complete denture, and maxillary removable partial dentures, was planned with frequent follow-up and multiple prosthesis to accommodate age changes. The first visit was purely introductory. The parents were explained the plan of treatment. The procedure of denture fabrication closely paralleled that for the conventional denture technique but with a few notable exceptions. Initial impressions were made in modeling compound (DPI Pinnacle, Mumbai, India). Custom acrylic resin trays were fabricated from the resultant casts. A wax spacer was adapted over the nonstress bearing areas. The maxillary and mandibular trays verified for accuracy and were border-molded with green stick compound (DPI Pinnacle Tracing Sticks, Mumbai, India). The final wash impressions were obtained with zinc oxide eugenol (DPI Impression Paste, Mumbai, India). Temporary record bases were fabricated using cold cure acrylic resin followed by wax occlusion rims over them. The pattern denture base was verified intraorally for accuracy and jaw relations were recorded. The mandibular rest position was estimated extraorally, and the upper lip was used as a guide for the location of the incisal edges of the upper anterior teeth. The orientation of occlusal plane was kept lower than the level of the mandibular foramen unlike the occlusal plane in the adult patient. Teeth arrangement was done following conventional technique. No attempt was made to balance the occlusion. During the try-in appointment, it was observed that the part of incisal edge of the maxillary right permanent central incisor had erupted above the gingival margin and was interfering with the retention of the maxillary temporary denture base, as it had not pierced through the gingiva till the secondary impression was made. A window was created just palatal to maxillary right deciduous incisors and canine to accommodate the erupting permanent tooth []. Furthermore, the right maxillary anterior had to be placed more labially for the same reason. Try-in was done and the child's joy to see his artificial teeth was very obvious. Dentures were processed with heat-cured acrylic resin following compression molding technique and polished. The maxillary removable partial denture retention was assisted with clasps on deciduous second molars. At the insertion appointment, the complete incisal edge of the maxillary permanent right central incisor had erupted in the oral cavity, so further widening of the window created to accommodate the erupting tooth was done. The maxillary partial and mandibular complete dentures were inserted [Figures and ]. Instructions about oral hygiene were given, and the parents were asked to supervise the child's oral hygiene. The patient was advised to maintain a soft diet for the first few days and to remove the dentures at night and during the sports activities. Recall appointments were scheduled for 24 h and then weekly.
The parents reported no problem in retention of the prosthesis. Initially, the patient had some difficulty in accepting the dentures and was unable to keep them in the mouth for long periods. However, shortly, he was fully adjusted to using the dentures. Patient was on a monthly recall schedule for continuous monitoring to track the eruption of 11 and observe the status of 21 and to allow the necessary adjustments of his denture to accommodate the erupting permanent tooth/teeth. The maxillary permanent right central incisor erupted completely through the window in the prosthesis. After 2 years, the patient reported difficulty in wearing the dentures. The dentures were replaced with the new prosthesis following the technique as earlier accommodating the erupted permanent right incisor and the growth changes in the jaws []. No change in the status of the unerupted 21 was observed.
At the beginning of therapy, the patient was quiet and withdrawn. He became communicative and his speech skills improved after the insertion of dentures. Development of a good psychological self-image was achieved through the esthetic improvement. Facial profile and expression improved with the prosthesis. The cosmetic effect alone seemed to transform the patient into a socially acceptable individual. Future treatment will include relining, rebasing, or remaking of the dentures to accommodate growth and development and definitive restorations at an appropriate age.


The first patient was a 46-year-old male heavy smoker whose chief complaint was pain in his left shoulder and back for 3 months. A chest computerized tomography (CT) revealed a mass in his left upper lung lobe with mediastinal lymph node metastasis. The patient received two cycles of chemotherapy with gemzar and cisplatin followed by radical resection of the left upper lung cancer. His pathological diagnosis was SCLC and immunohistochemical stains revealed that his specimen was positive for synaptophysin and carcinoembryonic antigen and negative for chromogranin A and neuron-specific enolase. The size of the resected tumor was 5×4× 3.5 cm, and his pathological TNM stage was T2aN2M0 (IIIA). After surgery, he received two cycles of chemotherapy (gemzar and cisplatin) and thoracic radiotherapy (planning target volume 56Gy/28F). The patient was followed up for 58 months and is still alive with no recurrence.


The second patient was a 61-year-old male heavy smoker who reported a cough and sputum with blood for over 10 days. A chest CT revealed a mass (5.5×4 cm) in his left upper lung lobe. The patient underwent a left total pneumonectomy. His pathological diagnosis was SCLC, and his specimen stained positive for CD56, neuron-specific enolase, and carcinoembryonic antigen, and negative for chromogranin A and synaptophysin. His pathological TNM stage was T2bN1M0 (IIB). He received six cycles of chemotherapy (etoposide and cisplatin), thoracic radiotherapy, and prophylactic cranial irradiation. The patient was followed up for 50 months and is still alive with no recurrence.


The third patient was a 58-year-old male moderate smoker. A mass (3.1×2.5 cm) was found in his right upper lung lobe during a physical examination. The patient received two cycles of chemotherapy with etoposide and cisplatin followed by a right upper lobectomy with systematic mediastinal lymphadenectomy. His pathological diagnosis was SCLC and his tumor stained positive for chromogranin A, synaptophysin, and CD56, and negative for TTF-1 and CK5/6. His pathological TNM stage was T2aN0M0 (IB). He received two cycles of chemotherapy with etoposide and cisplatin and prophylactic cranial irradiation (25Gy/10F) after surgery. The patient was followed up for 30 months and is still alive with no recurrence.