The publication of the case information and materials was approved by the Institutional Review Board of Keimyung University Dongsan Medical Center.
A 77-year-old man was referred with a 3-month history of an erythematous, hyperkeratotic, and inflamed eczematous patch with focal desquamation and itching sensation in the left axilla. Examination of the left axilla showed a discrete red patch with irregular margins and exudative surface, measuring 5×3 cm. No fungal hyphae were noted on the KOH test. Histological examination of a punch biopsy showed round, pale malignant cells scattered individually and in groups throughout the epidermis, particularly in the basal layer. Also, a focal intradermal invasive lesion was noted. The patient was treated with wide excision with margins up to 2 cm. The cut surface of the resected specimen showed a round, pale, tan to white and solid subcutaneous mass, measuring 0.8 cm in diameter. The mass was attached to the overlying skin. Histologically, the subcutaneous mass consisted of large, round to polygonal cells with abundant eosinophilic cytoplasm, indicative of apocrine carcinoma. Some sweat glands in the dermis were filled with malignant cells, similar to those in the subcutaneous mass. These cells also involved the epidermis and showed a typical pagetoid spread. The infiltrative and intraepithelial tumor cells stained positive with periodic acid Schiff and showed strong positive immunohistochemical staining for cytokeratin 7 (CK7) and HER2, confirming the diagnosis of invasive apocrine carcinoma with EMPD (). The tumor cells showed focal and weak positivity for anti-gross cystic disease fluid protein-15 (GCDFP-15) and were negative for GATA-3, estrogen receptor, and progesterone receptor.
Based on these results, the patient was evaluated for evidence of breast cancer to rule out metastatic apocrine carcinoma from the breast. Chest radiograph and breast ultrasonogram showed no definite lesion. After 6 months of follow-up, the patient is healthy and free of symptoms.


A 39-year-old woman, known case of oesophageal carcinoma, was scheduled for TTE with extended two-field lymphadenectomy with gastric pull-up with cervical neck oesophago-gastric anastomosis and feeding jejunostomy. She had history of hypertension since 4 years and controlled on amlodipine (10 mg) and atenolol (50 mg). She had also received pre-operative radiotherapy. The anaesthetic management and monitoring were as per institutional protocol and was administered epidural and general anaesthesia. As a part of operative procedure, right intercostal drain (ICD) and corrugated neck drain were placed. The intraoperative period was uneventful. She was shifted to Intensive Care Unit (ICU) for post-operative monitoring and analgesia. Three hours later, she developed respiratory distress and air leak through right ICD. Her oxygen saturation decreased from 97% to 84% over ½ h in spite of oxygen supplementation with Hudson mask. On auscultation, air entry was decreased on the right side and the percussion note was tympanic. She was put on oxygen at 15 L/min through Venturi mask (FiO2 0.60). Subsequent chest radiograph revealed right pneumothorax despite ICD being in situ. Another ICD tube was inserted in the right thorax to relieve pneumothorax. The respiratory distress was only partially relieved and the air leak from the ICD continued. Due to on-going respiratory distress, the patient's trachea was intubated. Fibreoptic bronchoscopy was done to rule out airway injury that was also normal. Hence, we suspected air leak from the cervical drain and it was decided to remove the cervical drain and suture the defect. After removal of the cervical drain, the air leak stopped. Chest X-ray showed inflated lungs and patient had symptomatic improvement. The patient was subsequently extubated and shifted to the ward.


A 56-year-old man, case of carcinoma mid-oesophagus underwent TTE with extended two-field lymphadenectomy with gastric pull-up and oesophago-gastric anastomosis in neck. He had received pre-operative chemo-radiotherapy. The procedure was done under epidural and general anaesthesia with conventional monitoring. Right ICD and corrugated neck drain were placed. Intraoperative period was uneventful. Patient was shifted to ICU for post-operative management. The patient developed respiratory distress and air leak through right ICD and saturation decreased to 86% despite oxygen supplementation. Air entry was decreased on the right side. Chest radiograph revealed right pneumothorax despite ICD being in situ. It was decided to conduct bronchoscopy. Before bronchoscopy, we observed bubbles (air leak) from neck drain site. On removal of corrugated neck drain and resuturing the neck wound, air leak stopped and there was no further respiratory distress. Oxygen saturation improved to 96% over next 30 min. Chest X-ray revealed no pneumothorax and patient was shifted to the ward.


On April 30, 2014, a 46-year-old male patient was admitted to the gastroenterology department with dyspepsia, abdominal pain, vomiting, and a 4 kg weight loss. The patient had previously undergone an appendectomy and abdominal abscess debridement for right abdominal pain and fever in January 2008. Seven months after the operation, he underwent a resection of the ileocecum for a spontaneous perforation that occurred in August 2008. The pathological diagnosis was ITB and the patient underwent antituberculosis therapy for 1 year.
The patient was hospitalized for right lower quarter pain on April 30, 2014. He had a fever, and physical examination revealed a bulge on the right lower abdomen, obvious tenderness, no fluctuation, no rebound pain, and muscle tonus. The laboratory results for the patient revealed the following: a white blood cell count of 11.77 × 109/L (normal range 4–11 × 109/L), thrombocytosis (platelet concentration of 469 × 109/L, normal range 100–300 × 109/L), and a fecal occult blood test of 1+. All other tests were normal. The computer tomography (CT) scans showed a segmental and irregular thickening of the anastomosis, ascending colon, and hepatic flexure with thickened mesenteric fat; dense shadows of anastomosis; and multiple stripes, nodes, exudation, and bubbles. Colonoscopy revealed a severe hyperemia and edema of mucosa in the anastomosis that was associated with inflammation, a fistulous opening, mucopurulent exudate, and multiple deep ulcers. The pathology showed mucosal chronic inflammation associated with ulcers and acute inflammation, moderate atypical hyperplasia of the glands, and a crypt abscess. The patient became asymptomatic after anti-inflammatory and nutritional support therapy.
The patient was hospitalized for right lower quarter pain again on June 15, 2014. His vital signs were normal and physical examination revealed a mass on the right lower abdomen (5 × 4 cm in size). All laboratory tests were normal. The CT scan showed the wall thickness of the right colon and the anastomosis, and the gas shadow in swelling soft tissue of the right lower abdominal wall (Figure ). A right hemicolectomy was performed after the preparation because of the persistent right lower abdominal mass. Macroscopic histopathology showed that the intestinal wall was thickened with luminal narrowing (Figure ).
The pathology after the operation showed colic mucosal ulceration along with transmural inflammation, mixed inflammatory infiltrate, and granuloma (ie, lymph cells and plasmacytes infiltrated the abdominal wall, and a granulomatous change occurred in the muscular layer) (Figure ). The Ziehl–Neelson stain for acid-fast bacilli was negative. As the time between the first diagnosis and the second diagnosis was 6 years, 2 of our pathology experts rechecked the pathological data with the permission of the patient and the hospital. Both experts considered that the pathological diagnosis should be CD rather than ITB. Ultimately, we made a diagnosis of CD, which is indicative of the pathological changes and the history of recurrent intestinal fistula. According to the patient's CDAI, he was treated with infliximab. At the time of the 8-month follow-up, the patient had remained in complete remission and made a good recovery.


A 32-year-old primigravida was referred by her local obstetrician at 17 weeks' gestation regarding positive second trimester quad screen results, in which the risk of trisomy 21 in the fetus was estimated to be 1/130. The results indicated no increased risk for either trisomy 18 or an open neural tube defect. Ultrasound examination identified a single intracardiac echogenic focus, increasing the risk of trisomy 21 to 1/49. The patient was counseled regarding prenatal genetic testing options and declined both amniocentesis and NIPT. The patient returned to her local obstetrician for pregnancy management.
At 34 weeks, the patient was referred for further evaluation after a third trimester ultrasound revealed a fetal growth lag. After additional counseling, the patient elected to have the Verifi® NIPT. A result of “aneuploidy detected” was returned for chromosomes 18 and 21 and interpreted as consistent with trisomy for both chromosomes. The result for chromosome 13 was “aneuploidy not detected.” The patient was counseled regarding diagnostic testing options. Amniocentesis was declined.
At 38 weeks, oligohydramnios was identified by ultrasound, and labor was induced. A male infant was delivered with Apgars of 7/7 and weighing 2450 g. The newborn's facial features, including upslanting palpebral fissures, epicanthal folds, and flat nasal bridge, were consistent with trisomy 21. There were no features concerning for trisomy 18 by physical examination. At 7 months of age, the infant was healthy and developing as expected for a child with trisomy 21.
A cord blood sample and eight placental biopsies (four from the fetal side, four from the maternal side) were taken for routine cytogenetics and FISH (fluorescence in situ hybridization) analyses. An extensive workup was performed to screen for evidence of fetal or placental mosaicism (Table ). The cord blood sample was positive for trisomy 21 in all 50 cells analyzed by routine cytogenetics. FISH analysis was performed using probes for chromosomes 21 and 18 at the RUNX1 and BCL2 loci, respectively, in conjunction with a chromosome 12 probe (ETV6) to control for the ploidy level (Abbott Molecular, Abbott Park, Illinois, USA; Fig. ). A total of 500 interphase cells from the cord blood sample was examined, and a fluorescence pattern consistent with trisomy 21 was observed in all. No evidence of trisomy 18 was observed.
Independent direct cytotrophoblast preparations were established from the eight placental biopsies. From each biopsy, 100 interphase cells were examined by FISH for evidence of aneuploidy for chromosomes 18 and 21. A fluorescence pattern consistent with trisomy 21 was observed in all eight specimens. A fluorescence pattern consistent with double trisomy for chromosomes 18 and 21 (48,XY,+18,+21) was observed in 49/800 cells distributed among only three of the eight biopsies. The majority (46/49) were found in one biopsy from the fetal side of the placenta. Two cells with double trisomy were identified in an additional biopsy from the fetal side, and only one cell with double trisomy was identified among the 400 cells examined from the four independent biopsy preparations from the maternal side of the placenta. There was no evidence of aneuploidy for chromosome 18 in the remaining five specimens. All 140 metaphase cells examined by routine cytogenetics from the eight biopsy sites had a trisomy 21 karyotype.


A 43-year-old female with past medical history significant for anxiety attacks presented to an outside institution emergency room with a short duration of chest pressure. A chest computed tomography (CT) revealed a 7.7-cm anterior mediastinal mass. This was biopsied at an outside institution. The findings were consistent with a low-grade spindle-cell neoplasm. Further in-house evaluation of the CT scan revealed numerous cysts in the lungs with associated pleural effusions. The biopsy slides were rereviewed at our institution and essentially verified the outside pathologic interpretation of the presence of spindled cells within smooth muscle fascicles []. Given the patient's sex and age, LAM was considered in differential diagnosis; however, the immunostains performed at our institution on the outside material were not contributory due to the absence of sufficient tissue for a definitive diagnosis. The presence of a left pleural effusion triggered a pleural aspirate, which yielded a diagnostic cytopathology sample. The fluid was evaluated by a ThinPrep and cytospin samples supplemented by a formalin-fixed cellblock. These samples showed scattered clusters of bland spindled cells in a background of histiocytes and mesothelial cells []. At a higher magnification, spindle cell balls were lined by lymphatic-like endothelial cells [Figure and ]. Immunohistochemical stains were performed on the cell block and were positive for smooth muscle actin (SMA) (Ventana, Tucsan, Arizona, USA) [], Desmin (Ventana, Tucsan, Arizona, USA) [], HMB-45 (Dako, Carpinteria, California, USA) [], and ER and PR (Ventana, Tucsan, Arizona, USA). No immunoreactivity was noted with cytokeratin AE1/AE3 (Dako, Carpinteria, California, USA), Calretinin (Ventana, Tucsan, Arizona, USA), CD68 (Dako, Carpinteria, California, USA), and WT-1 (Ventana, Tucsan). The immunohistochemical staining pattern confirmed the suspected diagnosis of LAM. The patient was tested for tuberous sclerosis with a negative result. Treatment with sirolimus was suggested; however, the patient was reluctant to initiate therapy due to the side effects. Since the diagnosis, she remains asymptomatic.


A 48-year-old man was referred to our hospital because of a supraclavicular mass. He had been well until 3 months before admission, when he had developed cough and noticed the mass. He had a history of pulmonary emphysema. Fluorodeoxyglucose-positron emission tomography (FDG-PET)/computed tomography (CT) showed increased FDG uptake in the supraclavicular lymph nodes, and a bulky anterior mediastinal tumor (Fig. A–C). Fine needle biopsy from the mediastinal tumor was performed. Hematoxylin and eosin-stained mediastinal sections showed diffuse infiltration of medium-sized tumor cells (Fig. F and G). Immunohistochemistry demonstrated that the tumor cells were negative for CD1a, CD3, CD8, CD20 and TdT, and positive for CD4, CD43, CD56 (Fig. H) and CD99 (Fig. I). BM examination revealed no evidence of the infiltration of tumor cells throughout the course. The patient was diagnosed as having T-lymphoblastic lymphoma of clinical stage IIA and underwent an acute lymphoblastic leukemia-type chemotherapy regimen []. After the induction chemotherapy, he achieved partial response, and received subsequent post-remission and central nervous system prophylaxis therapies according to the treatment schedule. He also underwent 30 gray (Gy)/15 fraction (Fr) radiation therapy (RT) for the mediastinal bulky mass according to the treatment schedule. However, marginal relapse of the irradiated field was detected during the post-remission therapy. He underwent an additional 36 Gy/18 Fr RT for the lesion that progressively increased in size.
Because he noticed painless right testicular swelling 10 months after the start of treatment, right orchiectomy was performed for diagnosis (Fig. D). Histopathologically, slides of testicular mass sections showed diffuse stromal infiltration of medium- to large-sized atypical cells (Fig. J and K). Immunohistochemical analysis revealed that the tumor cells were negative for CD3, CD20, CD68 (PGM1) and TdT, and positive for CD4, CD56, MPO (Fig. L) and CD34 (Fig. M). Initial slides of mediastinal sections were retrospectively examined and positivity for MPO was confirmed. The tumor was diagnosed as MS. Although he had no neurological symptoms, cerebrospinal fluid examination showed infiltration of myeloid blasts. We started high-dose cytarabine (HDAC) therapy. However, the patient gradually developed headache, and head magnetic resonance imaging (MRI) detected multiple intraparenchymal masses, which were considered as the invasion of MS (Fig. E). He underwent 30 Gy/10 Fr whole-brain RT. We also started intrathecal (IT) injection of cytarabine, and blasts in cerebrospinal fluid were decreased.
After a total of three courses of HDAC therapy and IT cytarabine therapy, he achieved first complete remission (CR). However, he developed acute renal failure and abdominal CT showed hydronephrosis due to retroperitoneal mass. Needle biopsy from the retroperitoneal mass revealed recurrence of MS. In addition, pleural and pericardial effusions developed, and G-banding analysis of the cells in pericardial effusion showed an abnormal karyotype of 47,XY,add(2)(q21),del(9)(q?),+10,t(16;21)(p11.2;q22),add(17)(p11.2)[15]/47,idem,add(2)(p13)[5]. FUS gene break-apart fluorescent in situ hybridization (FISH) analysis showed split signals in biopsy sections of the mediastinum at initial diagnosis and the testis at recurrence (Fig. A and B). Reverse transcriptase polymerase chain reaction (RT-PCR) and direct sequence analysis demonstrated the presence of the FUS-ERG chimeric gene transcript (Fig. C and D) []. As described previously [], the outer primer set of 4F1-8R was used in first PCR, and the inner primer set of FUS1-ERG3 was used in second PCR and direct sequencing. The sequences of the PCR primers used were as follows: 4F1, 5′-CTATGGACAGCAGGACCGTG-3′; 8R, 5′-CATAGTAGTAACGGAGGGCG-3′; FUS 1, 5′-GGTGGCTATGAACCCAGAGG-3′; and ERG 3, 5′-TTGAACTCCCCGTTGGTGCC-3′. Furthermore, upper gastrointestinal endoscopy showed a gastric mass, which was thought to be MS invasion.
The patient received salvage chemotherapy and subsequently underwent cord blood transplantation in non-CR, but died of severe pneumonia on day 64. Autopsy was performed, and unexpectedly, we found a residual MS lesion only in the left testis, despite the aggressive clinical course.


A 73-year-old retired man, known diabetic and well controlled on oral metformin alone for last 3 years presented in the emergency in a drowsy state with severe generalized weakness. He reported to have nausea and occasional palpitations for the last week with occasional headache, confusion and severe lethargy in work.
Except being diabetic, he was absolutely well 3.5 months before, when he was diagnosed with asymptomatic moderate hypertension. Some routine blood tests done at that point of time are shown in . He was started with oral losartan, 50 mg daily and his blood pressure was adequately controlled within 2 weeks after taking the drug. He had no other relevant medical or surgical history. He was taking no other concomitant medications except metformin (500 mg twice daily). His bowel and bladder habits were also normal.
On examination, the patient was in a drowsy delirious state. The pulse rate was 90/min and blood pressure was 134/88 mmHg. Except peripheral edema, no other significant findings were noted. Relevant blood and urine investigations done immediately after admission are listed in . Twelve-lead ECG showed a picture of increased PR interval. CT scan of brain revealed cerebral edema.
The patient was managed with sodium repletion, in the form of isotonic saline, coupled with dietary water restriction and promotion of water loss in excess of sodium using 40 mg i.v. twice daily frusemide for 5 days. He was discharged after 1 week in a stable condition with normalization of blood reports. He was prescribed oral hydrochlorothiazide 25 mg daily for controlling blood pressure along with 500 mg twice daily metformin as before.


A 36-year-old male with no conventional coronary risk factors was treated elsewhere for fever, cough with expectoration and diarrhea with antibiotic (Inj. Cefotaxime 1 gm as an infusion) and analgesics. He experienced generalized itching 5 minutes after cefotaxime infusion along with sweating, headache, chest pain and facial swelling for which he was brought to our hospital. His medical records revealed the administration of corticosteroid (Betamethasone) injection along with analgesics after the onset of reaction. Five years ago he had hypersensitivity to an unknown tablet. On examination he was afebrile, mildly tachycardic and tachypneic with a blood pressure of 80/60 mmHg.
An electrocardiogram (ECG) taken immediately after the reaction and subsequent ECG taken at our hospital are similar and revealed sinus rhythm, ST depression V3–V5 and incomplete right bundle branch block, ST elevation-I, aVR []. Hemogram revealed relative neutrophilia (92.7%), normal ESR and eosinophil count with normal red blood cells. Serum electrolytes, creatinine and random blood sugar were normal while potassium was low (3.24 mEq/L). Arterial blood gases revealed mild hypocapnia [pCo2-31.9 mmHg, pO2-111.9 mmHg]. Troponin T was elevated (1027 pg/ml) and liver enzymes were slightly increased. The patient was immediately administered with intravenous antihistaminic, a H2 receptor blocker, and an anti-emetic. He was started on a standard protocol for the management of ACS including dual anti-platelets, statin, betablocker, low-molecular-weight heparin after which the patient improved symptomatically. Echocardiogram showed good left ventricular (LV) systolic function with no regional wall motion abnormality (RWMA). A coronary angiogram performed on the subsequent day revealed normal epicardial coronaries with no evidence of spasm or thrombus. Work up for young myocardial infarction was negative with an exception of serum homocysteine levels (49.3 µmol/L). The patient was diagnosed with KS and was treated suitably which lead to his discharge after 4 days with an anti-platelet, nitrate and a statin.


A 47-year-old lady presented with type II diabetes mellitus for the past 2 years on metformin, systemic hypertension for the past 1 year on telmisartan, hyperthyroidism for the past 1½ years was initially on T. carbimazole 20 mg once daily then changed to 30 mg once daily (at the time of hysterectomy) but was taking 10 mg once daily for the last 1 year. She presented with redness on both eyes 1 month ago, initially over left eye in late December 2013 which subsided next day, then followed by redness in the right eye which subsided after the application of eye drops within 5 days. There was no pain or discharge from either eye. She had on and off fever (100–101°F) since 3 weeks which was associated with severe B/L bifrontal headache initially but subsided within 1 week. She also had weight loss of 6 kg within 1 month (56–50 kg) as well as loss of appetite.
Routine investigations were done which showed anemia, neutropenia, leucopenia and high CRP (C reactive protein) []. Peripheral smear showed normocytic normochromic anemia with Rouleaux formation, leucopenia with 2% atypical cells and mild thrombocytosis. She was empirically started on inj. Cefoperazone sulbactam 2 g IV (intravenously) twice daily in view of neutropenia, tachycardia and elevated CRP. Blood cultures, both aerobic and anaerobic, urine culture Widal test, RA factor (rheumatoid factor) test, Ig M (immunoglobulin M) dengue, Ig M Lepto, TORCH infections (Toxoplasmosis, Other (Syphilis, varicella-zoster, parvovirus B19), cytomegalovirus and herpes infections) and ANA (antinuclear antibody) screen all tests were found to be negative. Second option of bone marrow aspiration studies was sought from pathology department which showed normo to hypercellular marrow with 15% atypical cells and plasma cells, and advised correlation with flow cytometry. Carbimazole was withheld in view of leucopenia.
Workup for multiple myeloma was done. Serum Ig G was 3196 mg/dL, Ig M 85.0 mg/dL, Serum beta 2 microglobulin 1.6 mg/dL, lambda freelite 102.93 mg/L, kappa freelite 63.88 mg/L but serum protein electrophoresis showed only polyclonal gammopathy. Bone marrow aspiration/biopsy as well as cultures was repeated. A bone marrow biopsy showed focally hypercellular marrow with increased plasma cells amidst trilineage maturation.
In this case, differential count showed reduced neutrophils (8%) and predominant lymphocytes. Bone marrow aspirate showed markedly reduced mature form of granulocytes. Bone marrow trephine also showed reduced myeloid series with increase in plasma cells. These findings are typically associated with agranulocytosis.
Endocrinology opinion was sought during the hospital stay for the modification of anti-thyroid medications as well as glycemic control since TFT (thyroid function test) done twice was within the normal range, anti-thyroid medications were not started for the time being. For glycemic control T. sitagliptin 50 mg once daily was added with metformin.
Since there was a possibility of autoimmune etiology for bicytopenia, rheumatology opinion was sought following which CANCA (cytoplasm antineutrophil cytoplasmic antibodies) and PANCA (perinuclear anti-neutrophil cytoplasmic antibodies) results showed negative results.
With the treatment she received her counts gradually showed an improving trend and she got discharged with T. folic acid 5 mg once daily. The WBC (white blood cells) count and neutrophil count became normal during the follow-up visit after 1 month.


A three year old boy sustained a road traffic accident and presented to emergency department with pain, swelling of left shoulder and functional inability to use the left upper limb along with multiple grazed abrasions and bruise on the arm. There was no neurovascular deficit or other skeletal injury. Radiograph revealed Physeal separation of proximal humerus physis with dislocation of the proximal humerus epiphysis.
In the operating room, under endotracheal general anaesthesia, closed reduction of both the dislocated humerus epiphysis and Physeal separation could be achieved by abduction and minimal traction. This was followed by percutaneous fixation with three smooth pins. Support was provided by a chest arm bandage. Wires were removed at six weeks, and physiotherapy was started. The follow up radiographs taken at six and twelve months showed satisfactory fracture healing. Functional outcome was excellent. At 12 months follow up, flexion of 180 degrees, extension of 70 degrees and adduction of 40 degrees was possible. External rotation and internal rotation measured 90 degrees. Abduction was painful only in terminal 10 degrees and measured 160 degrees, as compared to 170 degrees on opposite side. There was no pin tract infection or any evidence of physeal growth arrest.


A 27-year-old woman was injured in a motor vehicle accident. She had back pain with no neurologic deficit. Neurological examination found no abnormalities. No associated injury was detected. Plain radiographs of the thoracic spine revealed fracture and anterolateral dislocation of T7 and T8 vertebrae ( and ). Axial views of thoracolumbar computed tomographic scans showed an intact spinal canal with fracture of the pedicles (). Three-dimensional reconstruction confirmed fracture and lateral dislocation of T7 and T8 vertebrae (). Closed reduction was not attempted. Laminectomy followed by subtotal corpectomy and anterior reconstruction using a Kaneda device in the lateral decubitus position was undertaken 9 days after injury. Postoperatively, the patient was neurologically intact and radiographs showed almost normal alignment ( and ). At 7 months follow-up, the patient had no back pain or paralysis.


A 35-year-old woman was injured in a motor vehicle accident, and had back pain with slight numbness in both lateral thighs. Neurological examination revealed no motor or sensory abnormalities and there were no associated injuries. Preoperative radiographs of the thoracolumbar spine revealed rotational fracture-dislocation of the L1 and L2 vertebrae ( and ). Axial views of computed tomographic scans confirmed rotatory dislocation of the two vertebrae, and the pivot seemed to be in the spinal canal (). Three-dimensional reconstruction showed the fracture-dislocation clearly (). Closed reduction was not attempted, and the same surgical procedure undertaken in Case 1 was performed 5 days after injury. No neurological deterioration was noted and postoperative radiographs showed the reconstructed spinal column with mild local kyphosis (, ). The patient had no back pain and was neurologically intact at 11 months follow-up.


An 18 year old male, Muslim by religion, student by occupation, residing in rural region of North West Maharashtra presented in our institute with pain in the right hip region since 1 week. Pain was continuous type, acute in onset, throbbing in nature initially relieved on analgesics. There was history of fever on and off for one and half months, Pain was associated with swelling and induration. On physical examination, swelling was tender, non fluctuant, Trans illumination was negative, non-pitting. No bony mass was palpable due to bulk of gluteal muscles. Local temperature was slightly raised. Patient had selective restriction of movements and associated pain at hip joint with flexion possible up to 80 degrees and internal rotation restricted to 10 degrees. All other movements were normal. There was no previous history of trauma or massage. No history of systemic illness. No similar complaints in family or any hereditary trait. A general surgery opinion was sought, the surgeon opined of it being a deep seated abscess as the patient had history of fever, pain, induration, restricted movements with supportive MRI report. The patient underwent the following investigations. Investigations
The laboratory blood investigations were done with reports as Hb – 10.2, WBC - 11400, ESR – 30, Deranged PT – 17 sec, INR 1.4, control - 14 sec.
Radiographs were taken, AP and Lateral views (),() which were inconclusive.
Ultrasonography () with 7.5Mhz linear probe revealed a hypoechoic solid mass with linear calcifications within, seen in gluteal muscle plane of size 65 × 42 cm. Aspiration was done with 18 gauge needle, aspirate was blood and sent for cytology, culture and sensitivity. Aspirate was reported as sterile, ruling out any infection or malignancy.
Magnetic resonance imaging () showed evidence of large loculated collection in right gluteal region just posterior to greater trochanter of size 3.9 × 4.3 cm, collection was hyperintense on T1 and STIR images, hypointense on T2 images suggestive of an abscess.
The patient was operated primarily assuming as abscess for incision and drainage. A mass of bony consistency was noticed between the gluteal muscles and external rotators ( & ). The mass was excised and sent for histopathology.
On histopathological evaluation. Gross appearance () showed non capsulated, irregular mass of size 6 × 5 × 3 cm, firm consistency, friable bony tissue with central area showing brownish haemorrhagic and necrotic areas. On microscopy, ( & ) (a) central zone showing congested capillary network showing plump endothelium surrounded by zonal proliferation of fibroblasts merging with peripheral bone forming osteoblastic elements and cartilage. (b) Peripheral area showing ill defined trabeculae lined by osteoblasts diagnostic for myositis ossificans.


A 48-year-old, married woman diagnosed with RA in 2007 underwent irregular conventional management. Her symptoms, as described by her, began with moderate to severe pain associated with swelling, stiffness (more in morning) in multiple joints, especially over small joints, elbow, shoulder, knee, and hip joints with symmetrical distribution and deformities of fingers and toes. RA-factor was positive and her physician advised methotrexate and hydrochloroguine. Patient underwent those medications for 1-year and stopped them after her symptoms improved.
Three years later, she was affected again with similar problems and admitted in a private hospital for 6 days, underwent treatment with methotrexate, hydroxychloroquine, prednisolone, calcium, folic acid, multivitamin supplements, and physiotherapy. At home, she was advised to continue same medications with naproxen, rabeprazole sodium, and diclofenac. Patient underwent those medications for 30 months, but she developed puffiness of face, greying of hair and generalized weakness, because of which she developed fear of taking medication and stopped taking medications. Following this, all those symptoms reduced, except joint pain. Hence, she underwent locally available herbal therapy (patient did not know the name of herbs), but her symptoms worsened day by day and she became stressed and depressed, especially due to deformities. In 2013, she experienced palpitation and underwent electro cardiogram, but findings were normal. Later, she underwent Ayurvedic medicine such as Sinhanad-guggul and Punarnava-mandoor with diclofenac sodium but she could not get improvement and became very much depressed, which was associated with poor QOS and QOL.
When she visited us with the same complaints in July, 2014, we suggested her to take combination EMMS therapies. She stopped taking diclofenac and other Ayurvedic medications on 1st and 3rd day of her stay in the hospital, respectively.
A detail of the study from admission of the patient in hospital to follow up has been given in .
Patient received clinical acupuncture for symptomatic relief of RA. We used 27-needles/session. Points given were GV-20, LI-4, LI-11, BL-11, GB-34, SP-6, KI-3, ST-44, EX-28, and EX-36, as described in .[] All points were pricked bilaterally except GV-20. Patient was informed about the procedure and sensations of needle insertion, and response was sought. All needles left for 30-min, including 20-min of electrical stimulation/session to all points except GV-20, EX-28, and EX-36 by using CMNS6-1 needle stimulator, China. We used 1-cun filiform locally manufactured stainless steel needles with 0.38-mm diameter and 25-mm length. Patient received 14 sessions of EA with 7 days rest period after first 7 sessions. This rest is traditionally indicated for improvement and adaptation.[] Along with acupuncture, patient received 45-min of Swedish massage, which included touch, stroking, mild friction, mild kneading and joint movements and 30-min of hot-mud application to bilateral hands and legs for 1-session/day for 6 days/week; and sauna-bath once/week for a period of 3 weeks. Assessments were done before, during, and after intervention [].
It was used to evaluate the patient's overall pain intensity of all the joints on a scale of 0–10, where 0 indicate no pain and 10 indicate worst pain. Patient was asked to mark a point on the scale to indicate her pain intensity.[]
It was used to assess walking speed in self-selected velocity and fast velocity. Patient was advised to walk about 10-m without assistance and the time was measured for the intermediate 6-m. Four meters was left out to allow for acceleration and deceleration. We assessed 3-consecutive trials, average of which was considered as final value.[]
Sphygmomanometer cuff was inflated till the mercury column rose to 30-mmHg. Patient was advised to squeeze the cuff as much as possible on 3-successive occasions with 10-s interval. Maximum height of the mercury column reached on each occasion was measured, average of which was considered as final value.[]
It consists of 7-components in 9-item sleep questionnaire. It was used to evaluate patient's QOS over the preceding month. A total score of 0–4 indicates good sleep quality, 5–10 indicates poor sleep quality, and >10 indicates sleep disorder.[]
It is a 42-item questionnaire that includes 3-self-report scales designed to measure state of depression, anxiety, and stress. Each scale contains 14-item where patient was asked to use 4-point severity/frequency scales to rate the extent to which she has experienced each state over the past week.[]
It is a 36-item questionnaire that measures health in 8 dimensions. For each dimension item scores were noted, averaged and transformed into a scale of 0–100 where 0 indicates worst possible health and 100 indicates best possible health. Reliability of its domains was shown to have improvement over the previous version of short form-36.[]
Blood and urine analysis were done to assess hemoglobin, ESR, white blood cell (WBC) (total and differential counts); reaction, protein, sugar, pus-cells, red blood cells, epithelial-cells, casts, and crystals, respectively.
Patient's follow-up was through mobile communication, after 12th and 49th week of her discharge. From recent follow-up, as per patient and her son (who was with the patient during hospital stay), there is no aggravation of symptoms and improvement was seen in her health status, moreover she started taking part in domestic activities such as cooking etc., which was not the case before EMMS therapy. Since, the patient did not visit our hospital after discharge with any complaint; we did not do any kind of clinical assessments.


A 79-year-old man presented with a 5-year history of lancinating tongue, deep pharyngeal, and ear pain in the distribution of the glossopharyngeal nerve on the left side. Episodes of pain were triggered by talking, coughing, and especially swallowing, and interfered with his quality of life. GN was diagnosed and initially treated using CBZ, which achieved relief of severe throat pain. However, the efficacy of CBZ gradually decreased and severe throat pain recurred regardless of the maximum dose of medication. Other agents such as GPT, pregabalin (PGB), and diazepam (DZP) were tried, but provided no relief. The patient experienced debilitating generalized weakness and syncopal episodes with dose escalations. He was therefore referred to our department from neurology for consideration of surgical intervention after hospitalization for exacerbation of pain and symptoms related to the escalating doses of DZP and PGB. MVD was considered because MRI demonstrated an offending vessel compressing the root exit zone (REZ) of the glossopharyngeal nerve on the affected side. Surgery was performed via a transcondylar fossa approach using BAEPs and facial MEPs during the microsurgical procedure as IONM to minimize postoperative sequelae. The oribicularis oris and oculi muscles were used for recording transcranial MEPs for monitoring facial nerve function. The patient was placed in a park bench position while keeping the head slightly above the level of the heart to avoid venous engorgement. The head was rotated slightly to the right side, angled 30° toward the right shoulder. A unilateral hockey stick incision was performed. The skin together with the muscle was detached from the suboccipital surface. Lateral suboccipital craniotomy extending to the condylar fossa was performed and the dura mater was opened. The lateral medullary cistern was opened to expose the lower cranial nerves entering the jugular foramen. Arachnoid dissection and retraction of the cerebellum exposed the REZ on the ventral surface of the medulla oblongata. The offending vessel was confirmed to be a loop of the posterior inferior cerebellar artery (PICA) compressing the proximal sites of the glossopharyngeal and vagus nerves, which were also recognized under microscopy []. The arachnoid membrane surrounding the lower cranial nerves was dissected to mobilize the PICA. As a prosthesis, a piece of shredded Teflon was inserted into the space between the bundles of the glossopharyngeal and vagus nerves and the PICA [Figure and ]. Postoperatively, the patient was completely free of pain, and no recurrence has been seen after 18 months of follow-up. No hearing loss or facial paresis was observed. Mild dysphagia and hoarseness occurred postoperatively, but resolved completely within 2 months.


A 71-year-old woman had been suffering from left paroxysmal transient throat and ear pain, precipitated by drinking and eating. She underwent surgical intervention because CBZ provided insufficient relief of pain after several years of treatment. MRI showed a loop of the left PICA conflicting with the REZ of the glossopharyngeal nerve. She underwent MVD via a left condylar fossa approach in a park bench position. During the microscopic procedure, the loop of PICA was confirmed to be compressing the glossopharyngeal and vagus nerve fibers exiting the medulla oblongata []. The tortuous vessel impinging on those nerve roots was dissected carefully and displaced from the nerves by hanging the vessel using the sling technique with dura mater[] []. During the procedure, pharyngeal MEPs demonstrated a significant decrease in amplitude to <50% of the control level. The maneuver was therefore stopped temporarily and a self-retaining retractor was released until improvement of MEPs was obtained. After confirming improvement of MEPs to within normal limits, the microscopic procedure was resumed with careful attention to excessive retraction of the cerebellum and excessive stress on the glossopharyngeal and vagus nerves. Transposition of the offending vessel was finally accomplished within the normal range of IONM []. Postoperatively, the patient reported no facial pain or throat pain and has not shown any sequelae such as dysphagia or hoarseness.


A 74-year-old man with a history of hypertension had started to feel intermittent serious throat pain in the left side while swallowing 4 years earlier. These symptoms had been treated using CBZ and PGN. Three years after initiation of medical therapy, recurrence of severe lancinating throat pain on the same side during swallowing proved refractory to CBZ pharmacotherapy. Other types of pharmacotherapy including DZP and trigeminal neuralgia were ineffective for the pain this time. MRI demonstrated the left PICA compressing the ventral side of the proximal glossopharyngeal nerve. Surgical intervention was performed using a transcondylar fossa approach with IONM, including BAEPs and facial, pharyngeal, and vagal MEPs. Lateral suboccipital craniotomy extending to the right condylar fossa was performed to obtain the operative trajectory in the inferolateral direction. The arachnoid membrane was dissected carefully and gentle upward retraction of the cerebellum exposed the cerebellomedullary cistern, where the glossopharyngeal and vagus nerves originate from the ventral surface of the medulla oblongata. The PICA proximal to the loop was observed to compress the ventral aspect of the glossopharyngeal and vagus nerve roots in the REZ []. The arachnoid membrane supporting and connecting the surrounding vasculature and nerve roots was dissected gently and the mobilized loop of PICA was moved away from the REZs of the glossopharyngeal and vagus nerves, and affixed to the jugular tubercle using fibrin-coated collagen fleece (Tachosil; Nycomed, Linz, Austria) []. Slightly elongated latency of wave V was observed several times during retraction of the cerebellum, but recovered immediately with the release of retraction. Transcranial MEP did not reveal any evidence of significant reductions in facial, pharyngeal, or vagal MEPs, even while manipulating around the glossopharyngeal and vagus nerves []. Postoperatively, severe throat and ear pain were completely absent. The patient was able to eat and drink without pain and showed no difficulty in swallowing.


A 15 years old girl came to our hospital with a complaint of pain and swelling over her left hand with history of fall. She also complained of occasional pain over lower third and inner aspect of her forearm. While we were managing the patient for hand injury we took x-ray of hand with wrist and forearm suggesting of fracture of fifth metacarpal. X ray also showed findings of expansile lytic lesion with multiple septas in diaphyseal region of left ulna. Examination of forearm revealed a mild diffuse swelling over the lower third and inner aspect of her left forearm. The overlying skin was normal. No signs of inflammation were visible. On palpation, there was tenderness over the swelling. The swelling was soft in consistency with a feeling of ‘egg shell crackling’. Movement at all the joints was full in range and was painless. There was no neurovascular deficit. Clinically diagnosis came out to be either Aneurysmal bone cyst or Simple bone cyst. We decided to take FNAC. The report of FNAC was suggestive of Giant cell tumor. For confirmation of diagnosis, we took open incisional biopsy which came out to be giant cell tumor. Diagnosis of giant cell tumor was confirmed as we sent specimen at two different histo-pathology laboratory, both suggestive of GCT. Then after proper counseling of patient and relatives, we decided to excise whole tumor and reconstruct it with a fibular graft. We expose entire tumor with standard ulna surgical approach. We had removed tumor with 1 cm clinically normal looking bone both side. We had also sent intra operative frozen section for safe margin. Report came as negative. The bone gap after excision of tumor in ulna was about 8 cm. We took cortical bone graft from ipsilateral fibula of respective size. We took cancellous bone graft from ipsilateral proximal tibia. Implantation of fibula at recipient site after appropriate freshening of margins, fixation of fibula in between the two ends of ulna with intramedullary ulna nail from proximal to distal. Then we put cancellous bone graft at both ends which were taken from ipsilateral proximal tibia & then closure was done in layers. The tumor was reddish brown, ovoid in shape and soft in consistency. Frozen section was done to know the extent. It extended from the diaphyseal area of the distal ulna to the distal third. It was removed cleanly. After doing Histology examination diagnosis of giant cell tumor was confirmed. After discharge, first 6 month patient was followed every 2 monthly. After six month, next visit every 6 monthly up to 2 years. Complete fibula incorporation at the end of one year. Next follow ups were uneventful.


A 45 years old man presented in our out patient department with complaint of inability to extend middle finger of his left hand along with a mass growing over volar aspect of forearm for over 2 months []. There was previous history of pain at wrist on finger movement which subsided gradually along with the decline in extension of middle finger. There was no associated history of fever, loss of weight or appetite, night sweats, malaise or fatigue. There was no history of trauma, pain in other joints of the body, morning stiffness of the back or hand joints, or continuous use of vibratory tools.
On physical examination a firm – hard mass around 2 * 2 cm was found over volar aspect of forearm just proximal to flexor retinaculam. It was non tender, non compressible, mobile at right angle to anatomical axis of forearm. Movement at wrist was normal with restriction of movement of middle finger in sagittal plane.
Laboratory findings showed all within normal limits except serum uric acid which was 8.6 mg/dl. And that brought a diagnosis of gouty tophi as among differentials. Findings on chest X-rays were normal. Right wrist joint X-ray showed no significant findings. Magnetic resonance imaging (MRI) showed that the mass was within the FDS which on axial T1 [ ] appeared as heterogenous isointense lesion while on coronal T2 STIR [] showed heterogenous mixed hypointense–hyperintense lesion. Clinical suspicion of Tubercular tenosynovitis, soft tissue neoplasm and tophaceous gout was made and subsequently surgical exploration was performed. The patient was operated under brachial block. An incision along the flexor crease, extending further proximally while maintaining the longitudinal orientation taken. On longitudinal slit of thickened tendon sheath chalky white liquid emanated. On futher exploration there was whitish chalky infiltration of tendon of FDS [], synovial adhesion of other tendons along with median nerve embedded within hypertrophied synovium of flexor tendons. Since the mass was noted well proximal to flexor retinaculam that probably could be the reason for flexor contracture and sparing of median nerve. Patient underwent synovectomy and tenotomy of FDS to middle finger because of heavy intratendinous infiltration of the tophus along with destruction of the tendinous tissue. Histopathological evaluation of the chalky white substance showed fibroconnective tissue showing hyalinized areas with evidence of saponification surrounded by palisades of foreign body type giant cells and chronic inflammatory cells. Needle like crystals are also seen []. All findings were consistent with the diagnosis of tophaceous gout. The postoperative course was uneventful with no remarkable functional deficit from the removal of the superficialis endon to the middle finger [].


A 25 month old male child presented to our casualty following a slip and fall from a slide while playing in a park. He presented 3 hours following fall. He had severe pain in the right hip and limb was adducted and internally rotated. An emergency radiograph of the pelvis taken in emergency showed a posterior dislocation of his right hip[]. Emergency closed reduction under general anaesthesia was performed. Gentle traction with minimal rotation was sufficient to achieve reduction, the congruency of which was checked under image intensifier. Once congruency was confirmed, an above knee broom stick plaster was applied to both lower limbs with hips in 30° abduction. Check radiographs[] was taken along with a MRI[] of the hip to check if there was any traumatic injury to the physes. He was kept on the plaster for 6 weeks following which plaster cast was removed and child mobilized with as tolerated weight bearing. Follow-up X-ray was taken at 6 weeks[] and serial MRI scans taken at 6 and 18 months [& ] showed no chondrolysis or osteonecrosis. He had restriction of flexion of knee beyond 120° at 6 weeks which improved to 140° by 8 weeks.


An 83-year-old woman was referred to the Hanyang University Guri Hospital for the treatment of a remnant gastric cancer. She had poor oral intake and repetitive vomiting a month ago and had lost more than 10 kg in the past six months. She had a history of open gastrectomy for gastric cancer 28 years ago. Although she had no specific underlying disease, her American Society of Anesthesiologists (ASA) score was graded as an ASA score of three because of old age and weight loss. Her body mass index (kg/m2) was 20.7 (height of 139 cm and weight of 49 kg).
Laboratory results revealed anemia (11.1 g/dl) and hypoalbuminemia (3.3 g/dl). Preoperative imaging studies, including abdominal-pelvic computed tomography (CT) and positron emission tomography CT scan, suggested T4aN1M0 as the clinical stage when accounting for evidence of serosa exposure. Levin tube placement and total parenteral nutrition (TPN) therapy were continued for six days prior to surgery. The Levin tube was removed in the operating room, and TPN was continued until the patient began a soft diet after surgery.
Despite her advanced preoperative clinical stage, this patient underwent laparoscopic gastrectomy at the request of her caretakers. The patient was placed in the reverse Trendelenburg position. After the initial trocar had been placed, lysis of peritoneal adhesions performed throughout the abdominal cavity. After completion of adhesiolysis, we were able to confirm the type of prior reconstruction (Billroth II without jejunojejunostomy). Dissection was begun by dividing the lesser curvature of the remnant stomach. However, it was impossible to dissect the posterior side and the greater curvature side of the remnant stomach because of the cancer's direct invasion of the transverse colon (). Therefore, a colectomy including resection of the tumor was performed using a laparoscopic linear stapler (ECHELON FLEX™ ENDOPATH® Stapler 60; Ciudad Juarez, Chihuahua, Mexico). Small bowel resections using the laparoscopic linear stapler were conducted in both the efferent and afferent loop. Next, the transverse mesocolon and the posterior side of the remnant stomach were dissected in order. All lymph nodes surrounding the splenic artery and greater curvature areas were dissected. After mobilization of the remnant stomach, distal gastrectomy with clear resection margins was performed using the laparoscopic linear stapler. We did not perform a total gastrectomy because the length of the proximal margin was grossly adequate. The specimen extraction was conducted through the umbilical port by extending the incision (). After remaking the pneumoperitoneum, the side-to-side anastomosis of the colon was performed using a laparoscopic linear stapler (). The jejunojejunostomy was then created before reconstructing a gastrojejunostomy because of the short length of the afferent loop. Finally, the Roux-en-Y gastrojejunostomy was reconstructed (). The operation time was 200 minutes (from skin incision to skin closure). The 100 ml of estimated blood loss was calculated by an anesthesiologist. A soft diet was commenced on the seventh postoperative day. The patient was discharged from the hospital on the thirteenth postoperative dya. There were no postoperative complications during the recovery period. shows the appearance of the entire abdomen after surgery. Ultimately, the patient and her caretakers decided to discontinue the adjuvant chemotherapy because of the patient's advanced age.
From the pathology results, the tumor was noted to directly invade the transverse colon and jejunum. The tumor size was 7 cm. The proximal and distal resection margins were 2.5 cm and 4.5 cm, respectively. The number of retrieved lymph nodes was 24, and there were no metastatic lymph nodes.


A 57-year-old male patient was hospitalized for chemotherapy on November 20, 2013, at 1 year and 11 months after being diagnosed with small-cell lung cancer in the left lung. The patient underwent fiber optic bronchoscopy at the First Affiliated Hospital of Dalian Medical University on December 9, 2011. Pathology results indicated small-cell lung cancer, and a diagnosis of small-cell lung cancer of the left lung was made (limitation period). After the diagnosis was confirmed, the patient underwent an etoposide chemotherapy regimen (VP-16 plus cisplatin). The efficacy evaluation after 2 weeks indicated stable disease (SD). The patient refused radiotherapy. After an additional cycle of chemotherapy, the patient voluntarily terminated treatment due to poor compliance. The chest computed tomography (CT) examination on July 3, 2012, indicated a space-occupying mass at the hilus of the left lung, which was accompanied by obstructive pneumonia in the upper lobe of the left lung and nodules in the left lung. Compared with the CT results from February 14, 2012, mediastinal lymph node metastases and an enlarged lesion were observed, indicating disease progression. With the patient’s consent, VP-16 capsules were administered as oral chemotherapy, and SD was achieved after two treatment cycles. The treatment was stopped again due to poor patient compliance. In late July 2012, the patient suffered hoarseness and was hospitalized because of chest tightness and shortness of breath. The imaging examination suggested disease progression. The patient began irinotecan and carboplatin chemotherapy on July 28, 2012, and completed four treatment cycles. The lung CT examination on April 3, 2013 indicated a space-occupying mass at the hilus of the left lung, accompanied by obstructive pneumonia in the upper lobe of the left lung. Compared with the CT results from January 6, 2013, the space-occupying mass at the hilus of the left lung was enlarged, and the inflammation in the upper lobe of the left lung was aggravated; furthermore, both nodules in the left lung were considered malignant based on increased size, whereas the mediastinal lymph node metastases remained stable. The efficacy evaluation indicated progressive disease (PD). The patient began the third-line chemotherapy regimen CAV (ifosfamide + epirubicine + vincristine) on April 7, 2013, and completed four treatment cycles. In October 2013, the patient experienced headache and pain in the right shoulder. Chest and abdominal CT examinations and head magnetic resonance imaging indicated tumor progression. Bone electroconvulsive therapy and cervical magnetic resonance imaging examinations revealed no clear bone metastasis. After consultation among different departments in our hospital, the patient began one cycle of the fourth-line pemetrexed combined cisplatin chemotherapy regimen (pemetrexed in combination with lobaplatin) on October 21, 2013.
The patient was given oral ibuprofen sustained-release capsules at a dosage of 600 mg every 12 hours for right shoulder pain (numeric rating scale [NRS] =3), and the pain was relieved (NRS =1).
At the time of admission, the pain manifested as dull and pricking sensations in the neck, shoulder, chest, and back, with mainly pricking pain (NRS =6). The pain was mostly evoked by activity and was slightly relieved upon rest, with 2–4 episodes of breakthrough pain (NRS =7) everyday. The patient exhibited emotional irritability due to the pain, which affected his diet, sleep, and daily activities and led to his unwillingness to communicate with others.
The patient received an assessment and opioid titration immediately after hospitalization. According to the recommendations in the National Comprehensive Cancer Network guidelines for treating cancer pain, the incremental dose was calculated based on the total dose of opioid drugs within the first 24 hours, and the dose was increased for a specific time or need.
The patient was first administered OxyContin on November 20, 2013, with titration starting at 10 mg Q12h. The analgesic dosage was determined the next day at 40 mg Q12h and was increased to 120 mg Q12h after 1 month. The dosage was increased to 660 mg Q12h in January 2014, but there was no improvement in pain management associated with the dosage increase. Instead, the patient began to have acid reflux after taking the drug. Therefore, the dosage was reduced to 600 mg Q12h. Later, because the analgesic effect did not last for 12 hours and the patient refused to take the drug at an incremental dose each time, 600 mg Q8h was attempted. Acceptable pain management was achieved through dosage adjustment and combination with adjuvant medication. The patient was given 50 mg oral morphine immediate-release tablets, 2–5 times per day, at the onset of breakthrough pain. The NRS score was 2–3 after analgesic treatment, with only difficulty in urination during treatment. However, at the end stage of the disease, the patient was in poor physical condition, with a performance status (PS) score of 3–4 and brain metastasis. It was unclear whether there was spinal cord metastasis that caused spinal cord compression, and there was insufficient evidence to prove whether the symptoms were related to the drugs. No other obvious adverse reactions were observed. During the period when OxyContin was used, ibuprofen controlled-release capsules, carbamazepine, gabapentin, and alprazolam were utilized as adjuvant medications based on symptoms and clinical reactions ().
After two cycles of chemotherapy with pemetrexed combined with lobaplatin, the efficacy assessment indicated PD. After considering the report on chemotherapy-sensitive genes and the toxicity prediction for the patient, he began to take oral Gimeracil and Oteracil potassium capsules as fifth-line monotherapy on December 2, 2013. The efficacy evaluation after two treatment cycles indicated PD. Multiple bone metastases were observed. The patient received one cycle of Docetaxel combined with Cisplatin as sixth-line chemotherapy. The patient was hospitalized on February 8, 2014, with a PS score of 3 and poor appetite, and received best supportive care. The patient was pronounced clinically dead on February 20, 2014. The cause of death was end-stage lung cancer and respiratory failure ().


A 48-year-old female with complaints of prominence of left forehead and asymmetric left-sided hemifacial atrophy, alopecia, asymmetric thinning of left lower leg, without any history of trauma, presented to the Dermatology Department of our hospital. She also had slight skin pigmentation over the left eyebrow and the left palpebral conjunctiva. Her symptoms started around 6 years ago with mild hemifacial atrophy on the left forehead, and progressed slowly with alopecia. The asymmetric thinning of her left lower leg had started around one year before. No facial motor and sensory deficits were noted physically with normal tongue movements, without any enophthalmus or ptosis of the left upper eyelid. Her neurologic and fundus examinations were both normal with normal psychomotor attitudes. The right face appeared completely normal. On physical examination, the left-sided facial and forehead asymmetry was detected mainly due to subcutaneous fatty loss with prominent bony ridges on the left forehead and left maxillary region. Intra and extraoral examination revealed normal physical yields without any atrophy of chewing muscles and/or tongue. Paranasal sinus x-ray examination also presented a normal frontal and maxillary sinus on the left side. There was asymmetric prominent subcutaneous fat and tissue loss in the left cruris region on inspection (Figures ). She had several normal brain CT scans and electromyographic approaches during the first 6 years. Following consultation, she was admitted as inpatient admission to the Surgery Department, then referred to Egerad private medical imaging center for brain MRI. The brain MRI revealed asymmetric, prominent fatty loss in the dural and galeal parts of the left frontal region. No cortex or deep white matter involvement, including white matter hyperintensities-cortical atrophy was indicated (Figures ).
Laboratory results for a complete blood count and biochemistry revealed hemoglobin: 13.58 [normal value (NV): 12-16 g/dl], hematocrit: 41.3 [NV: 37-50 g/dl], mean corpuscular volume: 90.2 [NV: 80-99 g/dl], mean corpuscular hemoglobin 28.5 [NV: 33-37 g/dl], white blood count (4700/µlt [NV: 4800-10800/µlt], C-reactive protein 2.23 mg/dL [NV: 0-10 mg/dL], sedimentation 38/hour [NV: 0-20/hour], and mild thrombocytosis (430.000 g/dl) were indicated. Prothrombin time, and activated partial thromboplastin time were normal with negative hepatitis B surface antigen, anti hepatitis B surface antibodies, hepatitis C virus, and human immunodeficiency virus. The triiodothyronine - thyroxine - thyroid stimulating hormone levels were within normal range. Urine analysis was normal, CSF analysis showed mildly elevated protein (16 mg/dL; NV: 0-10 mg/dL), normal glucose and no pleocytosis. In the differential diagnosis, scleroderma or connective tissue disorders were considered, however, she had negative HLA-B27 with normal glucose and electrolyte levels in serum blood. Based on the clinical findings and history, a diagnosis of Parry-Romberg syndrome was made. Alloplastic aesthetic surgery with autologous fat injection to the atrophied left forehead was suggested to our patient by a plastic surgeon, but due to financial difficulties, she declined any surgical management. The treatment plan excluding the surgical management of our patient was physical and clinical follow-up in our research hospital; the follow up included physical rehabilitation including sports and exercise, use of a chin mask, and/or analgesic use.


A 22-year-old man presented with severe photophobia and decreased visual acuity in the right eye. He was diagnosed initially with nephropathic and ocular cystinosis at the age of 4 years. The patient also had chronic renal failure and rickets. The visual acuity was hand motion in the right eye and 4/4 in the left eye. The intraocular pressure was 17 mmHg in the right eye, while that of the left eye could not be measured because the patient was uncooperative. In slit lamp examination, we found the moderate corneal edema and multiple crystal deposits in the right eye and an anterior segment photograph also showed opacity, moderate edema, and multiple progressive refractile polychromatic crystal deposits in the right cornea. Cystagon® (cysteamine bitartrate, Mylan, France) eye drops were prescribed, but there was no improvement in the patient's visual acuity or symptoms. Therefore, we performed penetrating keratoplasty of his right eye. Preoperative anterior segment OCT (Visante, Carl Zeiss Meditec) showed hyperreflectivity at the stroma of the cornea, indicating the presence of corneal cystine crystals []. Ex vivo light microscopy (LM) of the right cornea performed using special stains for colloidal iron and Masson's trichrome failed to show the crystalline deposits []. TEM of a corneal biopsy specimen obtained during the operation showed needle-shaped crystalline deposits within keratocytes in corneal stroma of the right eye []. To examine the genetics of ocular cystinosis, genomic DNA was extracted from peripheral leukocytes using standard protocols. Sequencing analysis identified three known single nucleotide variants (SNVs) and two novel mutations in exon 11 of the CTNS gene [].


This study conforms to the principles outlined in the Declaration of Helsinki and was conducted after obtaining approval from the Institutional Ethics Committee on Human Research and informed written consent from the patient.
A 33-year-old gentleman presented to our outpatient department with complaints of itching of eyelids in both eyes on and off since 10 years. On ophthalmic examination, unaided visual acuity was 20/20 in both eyes, anterior segment examination revealed rows of yellow-white color, round or oval, bead-like excrescences on the margins of all four lids and the caruncle, resembling a string of pearls, the pathognomonic, moniliform blepharosis [Figs. and ]. The lesions were continuous, overlying the entire lid margin and obscuring the details of the lid margin with thickening of the free ends of the lids considerably. Rest of the anterior segment examination was otherwise normal including intraocular pressure measurement. Fundus evaluation of both eyes was within normal limits. Systemic examination revealed thickened and hard tongue with teeth indentations [], hoarseness of voice, multiple small yellow-colored soft and partially translucent nodules over the skin in bilateral axilla [], and normal neurological and psychiatric evaluation. Otorhynolaryngologist's evaluation for hoarseness of voice showed thickening and irregularities of the vocal cords’ mucosa on laryngoscopy. Similar clinical features including pathognomonic moniliform blepharosis and hoarseness of voice were noted in his sibling who was asymptomatic. Baseline laboratory data including biochemical and hematological parameters were within normal limits. Biopsy of the axillary skin lesions performed by a dermatologist was consistent with the histopathological diagnosis of lipoid proteinosis. The patient has been managed with artificial tear supplements and antihistamine eye drops with the symptomatic improvement of ocular manifestations within 4 weeks’ time. He has been further advised and counseled regarding the chronic nature of the disease, other ocular manifestations, multisystem involvement, and the need for follow-up under a multidisciplinary team of specialists including ophthalmologist, dentist, dermatologist, otorhynolaryngologist, and neurologist.


In 2013 a 72-year-old female patient was admitted to the Clinical Department of General and Colorectal Surgery for elective resection of a tumor located in the perianal area with the TEM technique. The patient had an extraordinary medical record with no clear concluding diagnosis. In August 2005 the patient had laparoscopic cholecystectomy due to symptomatic cholecystitis. The surgery was not performed in our hospital. The postoperative course was reported as uncomplicated and the patient was discharged. However, 3 years later, in 2008, the patient complained about consistent, sharp, abdominal pain which was not accompanied by fever, nausea or vomiting. Improper food intake was also ruled out as a potential source of consistent abdominal pain. The patient was subsequently hospitalized several times in gastroenterology wards with no clear diagnosis. It was suspected that symptoms were connected with diverticular disease, hemorrhoids or gastroenteritis. From March 2011 the patient additionally complained about consistent pain within the lower part of the rectum. In June 2011 the patient was again hospitalized and underwent computed tomography of the abdomen and pelvis which, apart from diverticular disease, revealed chronic perianal abscesses which were diagnosed as a postinflammatory process after diverticulitis. Laboratory tests were within the normal range. Colonoscopy showed diverticular disease and a 2 mm polyp in the descending colon which was removed and sent for histopathologic examination, which revealed a tiny tubular adenoma with low-grade dysplasia with complete removal. After the hospitalization and the patient's discharge, symptoms were somewhat reduced, but not entirely alleviated.
In November 2011 symptoms again intensified and the diagnostic process needed to be repeated. Computed tomography was repeated and revealed diverticular sigmoid colon with numerous diverticula sized up to 18 mm as well as segmental, irregular thickening of the sigmoid wall and the rectum up to 9 mm. This image was considered to be an inflammatory process rather than a hyperplastic process. Curiously, two oval objects approximately 30 mm in size were identified in the sigmoido-rectal region. They were communicating with the colon lumen and, at first glance, they could be characterized as chronic diverticulitis.
Transanal endosonography showed a tumor located on the posterior rectal wall between 9 and 13 cm from the anal verge. Due to numerous artefacts and an unacceptably high level of discomfort, it was impossible to define the tumor's depth of mucosal invasion. Nevertheless, it was defined as T1/T2 grade tumor. During this round of examination an enlarged lymphatic node was also revealed. Colonoscopy was repeated. There were no apparent changes in the rectum. In the anal canal there were small hemorrhoids. The sigmoid colon (20 cm from the anal verge) exhibited diverticulum with surrounding intense mucosa redness and edema accompanied by slight bleeding from its bottom. In the entire colon, especially in the proximity of the sigmoid and descending colon, there were multiple diverticula and many of them were filled with fecal masses. In the transverse colon, 70 cm from the anal verge, there was a tiny 2 mm round polyp which was completely removed (tiny tubular adenoma with low-grade dysplasia removed completely). Tumor markers were within the normal range: CA-19.9 < 0.600 U/ml, CEA 2.52 ng/ml.
The patient was qualified for surgery using the TEM technique for the removal of the tumor from the retrorectal space. Transanal endoscopic microsurgery surgery was performed in the gynecological position. The per rectum examination showed hard, oval, 3 cm long resistance of the posterior wall of the rectum, 8 cm from the anal verge. Initially, after using the rectoscope attachment, the performing surgeon visualized the rectum and sigmoid colon for a distance of up to 20 cm from the anal verge and observed no apparent pathologic changes. However, during instrument retraction, we observed partial deformation of the posterior wall, which constituted evidence of a tumor just beyond the rectal wall. In the first stage of the surgery the mucosa was incised transversally above the tumor. During mesorectum preparation with the ThermoStapler sealing system the surgeon found an object resembling a 3 cm gallstone in the presacral area and removed it. During the preparation, the peritoneal wall was slightly opened, causing a gradual increase of the pneumoperitoneum. A 10 mm trocar was inserted into the left lower part of the abdomen. Laparoscopic inspection of the peritoneal cavity did not reveal any damage to adjacent internal organs. An incision in the peritoneum was sutured and carbon dioxide leakage was stopped. The trocar was removed and replaced with a Redon drain. The aperture in the rectal wall was closed with sutures. The patient's postoperative course was uneventful. On the third day after surgery the drain was removed and the 72-year-old patient was discharged after five days. Approximately a month after surgery, the patient's wound was healed and all symptoms subsided.
After the surgery the removed object was submitted for histopathologic examination. Its results confirmed that it was a gallstone. The chemical analysis yielded a makeup of: cholesterol 75%, bile acid 0%, oxalates 10%, calcium 10%, phosphorus 5%, magnesium 0%, ammonia 0%, cystine 0%.


A 67-year-old man presented with abdominal pain. Clinical work-up included a computed tomography (CT) scan which revealed a 4.5 cm mass consistent with an ascending colon carcinoma with pericolonic lymphadenopathy, liver, and lung metastases. Also seen was a 3.5 cm left kidney mass. A CT-guided biopsy of a 2.2 cm lesion in the right lower lobe of the lung revealed metastatic adenocarcinoma of colon origin. The kidney lesion was described as a hypoenhancing solid mass. It was felt initially to represent either a metastasis or a primary renal neoplasm. The patient was treated with chemotherapy for metastatic colonic adenocarcinoma and no renal biopsy was performed. About 7 months later, the renal lesion remained unchanged with chemotherapy whereas other metastatic sites decreased in size. CT-guided FNA and concurrent core biopsies were performed at this time.
FNA smears were stained with Diff Quik and Papanicolaou stains. Smears were cellular and showed crowded small and large clusters and branching sheets of bland epithelial cells with uniform round to ovoid nuclei and small but visible nucleoli [Figure –]. Pseudopapillary aggregates lacking vessels in the center were present []. Cells ranged in appearance from round/oval epithelial to spindled []. Background contained metachromatic mucoid material staining magenta color with Diff Quik and pale blue on Papanicolaou stains []. Cell block contained epithelial cells arranged in loose sheets/aggregates and tubular/acinar pattern []. No significant atypia, mitosis, or necrosis was present.
Core biopsy revealed several small fragments of tumor cells with uniform low grade nuclei that formed a tubular/acinar architecture intermixed with mucinous material []. Immunohistochemistry studies showed that the tumor cells were positive for PAX8, CK7, and AMACR and negative for CD10.
A diagnosis of MTSCC was made.
A year later, the patient developed new and enlarging metastases to his liver from his colon carcinoma and was treated with ablation and embolization. The left renal MTSCC was not resected and continues to remain stable in size and appearance on imaging.


A 9-year-old female child was referred to our Institute for evaluation of right midzone patchy consolidation. She had episodic wheezing dyspnoea and nonproductive cough for 4 years, which had increased over the last fortnight with no acute distress, pallor, clubbing or cyanosis. Bilateral expiratory rhonchi were audible in all areas of the chest. The total leucocyte count was 7,190 cells/cumm, with neutrophils 68%, lymphocytes 25%, monocytes 2.6%, and eosinophils 4.4%. The absolute eosinophil count was 350 cells/cumm. In addition to the midzone patchy consolidation, an ill-defined opacity abutting the right cardiac border with loss of cardiac silhouette was detected on the chest radiograph (). A right lateral view showed a wedge shaped density extending from the hilum anteriorly and inferiorly along with loss of volume confirming a MLS (). High resolution computed tomography (HRCT) of the thorax confirmed MLS and also revealed central bronchiectasis () which prompted investigations for ABPA. Skin prick test with antigens of Aspergillus fumigatus and Aspergillus flavus elicited a type I reaction. Strong bands of serum precipitins were detected against the same antigens. Specific IgE and IgG were positive for A. fumigatus and total serum IgE levels were elevated (1,488 IU/mL). Spirometry was suggestive of moderate obstruction with significant reversibility.
A diagnosis of ABPA presenting as MLS was made as she met 7/8 major diagnostic criteria (; Rosenberg-Patterson criteria []) and was initiated on oral prednisolone in the dosage of 0.5 mg/kg daily, which was tapered to alternate day dosages after a fortnight and tapered off after 6 months as the patient improved. She also received inhaled steroids for asthma. Marked symptomatic relief was noted within a fortnight with radiographic resolution of the MLS and reduction in total IgE levels to 903 IU/mL after 3 months. Informed written consent was obtained from mother.


A 22-year-old Nepali male came to the Emergency Department of a teaching-hospital in central Nepal with chief complaint of sudden appearance of blisters on oral mucosa after taking Ibuprofen 400-mg tablets 8 hourly for 2 days for eye pain. He developed multiple maculae initially over trunk, then chest, face, lower limbs on the third day. He was admitted to the Emergency and upon examination, had extensive erythema (), necrosis, and exfoliating bullous detachment of the epidermis () and mucous membranes (conjunctival, oral, and genital), with a positive Nikolsky's sign. The body temperature was 38℃, respiratory rate being 24 breaths/min, pulse rate 110 beats/min, blood pressure 130/90 mm Hg, SPO2 98%, and glucose random blood sugar 91 mg/dL.
The laboratory analyses are as follows: Na+, 138.8 mmol/L; K+, 4.02 mmol/L; urea, 41.0 mg/dL; creatinine, 1.0 mg/dL; platelet count, 60,000 mm3, white blood cell, 3,600×106/L; hemoglobin, 11.8 g/dL; prothombin (test), 17.5 seconds; prothombin (control), 13.0 seconds; international normalized ratio, 1.37; packed cell volume, 32.05%; bleeding time, 3 minutes; clotting time, 9 minutes; immunodeficiency virus I&II, nonreactive; hepatitis B surface antigen, nonreactive; urine routine examination, pus cells (8–10); C-reactive protein level, 340 mg/L; aspartate aminotransferase, 85 IU/L; alanine aminotransferase, 150 IU/L; total proteins concentration, 50 g/L; and albumin, 20 g/L.
Skin biopsy revealed prominent cell death with basal vacuolar changes and lymphocyte infiltrates with haziness in the dermo-epidermal junction which corroborated the clinical diagnosis of SJS-TEN.
Ibuprofen was immediately withdrawn and the patient was transferred to the intensive care unit (ICU). On admission to ICU, arterial blood gas analyses are as follows: pH, –7.442; pCO2, 28.5; pO2, 95.5; HCO3, 19.7; blood urea nitrogen, 17.0 mg/dL; blood-sugar random, 162.0; antinuclear antibody enzyme linked immune sorbant assay method, negative.
Patient had extensive sloughing off the face () painful oral erosions with severe crusting of the lips and increased salivation. The plaques with vesicles, sloughed off more than 50% of body surface area which rendered difficulty to access vein on patients limbs. So, central venous pressure line insertion was done and enteral-nutrition was provided via a nasogastric tube. The patient's specific treatment with plasma exchange and fluid resuscitation with crystalloid infusions (1 mL/kg of body weight per hour) fine-tuned on the bases of the arterial blood pressure (>65 mm Hg), central venous pressure (≤10 mm Hg) and diuresis rate [] was done. The basis for early plasma exchange was to remove/reduce the level of residual ibuprofen and its metabolites, critical cytokines (tumor necrosis factor-alpha [TNF-α], interferon-gamma [IFN-γ]), and drug-induced inflammatory mediators (perforin, granzyme-B released from cytotoxic T-lymphocytes and granulysin secreted by cytotoxic T-lymphocytes and natural killer cells) from the circulation []. However, the plasma exchange remain unsupported by controlled studies []. Subsequent systemic treatment included intravenous Ceftriaxone 1.0 gm 12 hourly (microbial findings on skin: Staphylococcus aureus and Pseudomonas aeruginosa; the symptoms and signs being warm, tender, erythematous, and edematous plaque over lower extremities with ill-defined borders), intravenous immunoglobulins (IVIG) 1.0-g/kg body weight/day infused over 6 hours for 3 successive days and corticosteroids 0.5-mg/kg body weight. Intravenous tramadol 25 mg was given for analgesia as per the patient's condition. The patient recovered completely after 5 weeks of intensive systemic and topical treatment.


A 63-year-old female with breast cancer was referred from the Oncology department for the management of pain in both buttocks of 3 months' duration. She had multiple bone and lung metastases, and her pain was rated as 9/10 on an NRS, where 0 represents no pain and 10 corresponds to the worst imaginable pain. Her treatment had included chemotherapy and radiotherapy, and at the time of referral she was using a 25 µg/hr fentanyl patch (Durogesic DTrans®, Janssen Pharmaceutica, Turnhoutseweg, Belgium) with oral medication of pregabalin 300 mg/day, oxycodone 20 mg/day, and amitriptyline 10 mg/day for pain control. The dosage of opioids couldn't be increased because of the side effects such as nausea and vomiting. The pain was characterized as constant, deep aching pain localized in the buttocks, with radiation to the left thigh, and her pain decreased slightly on lying down. Her physical examination revealed marked tenderness over the SI joint and positive Gaenslen's tests, but no motor/sensory change. A bone scan and computed tomography showed metastases in the pelvic bone, spine, femur, and lung (). After SI joint injections, her pain intensity was reduced from 9 to 4 on an NRS, but this improvement was maintained only for 2 days. At this point, we decided to proceed with PRF.
After an informed consent, she underwent PRF neuromodulation of the dorsal rami of L4, L5, and the lateral branches of S1-S3 bilaterally under fluoroscopic guidance. The target locations for the L4-5 dorsal ramus were the notch between the transverse process and superior articular process of L5 and the notch between the ala of the sacrum and the superior articular process of the sacrum. For S1-S3 lateral branch neuromodulation, the cannulas were inserted to the perimeter of the foramen in a semi-circumferential pattern. At the S1 and S2 levels, lesion locations were targeted on the right at the 2:30, 4 o'clock, and 5:30 positions, and on the left at 9:30, 8 o'clock, and 6:30 positions. At the S3 level, lesion locations were targeted on the right at the 2:30 and 4 o'clock positions, and on the left at the 9:30 and 8 o'clock positions. An RFK-C10520S-P cannula (Cosman, Burlington, MA, USA) with 5-mm curved active tips was used at each level; placement of the electrode in close proximity to the nerve was confirmed using electrostimulation at 50 Hz, with concordant sensation achieved at voltage from 0.3 V to 0.5 V. Before lesioning, the absence of leg and sphincter contractions was verified with stimulation at 2 Hz up to 2 V. After confirming correct placement of the needle, two or three PRF lesions were made at each location using a PRF lesion generator (RFG-1A, Cosman, Burlington, MA, USA) (). For S1-S3 lateral branch neuromodulation, after the first cycle was performed, the needle was rotated 180 degrees and a second lesion was made at a target point to increase the area exposed to the electrical field. This procedure was repeated for all lesions at each level. The PRF parameters were 45 V for 120 s. Registered temperatures during the procedure ranged from 39 to 41℃. After the procedure, the patient was transferred to the recovery room and monitored for 30 min. While the NRS was 9 before the procedure, it had decreased to 4 after the procedure. Seven days after the procedure, the NRS had decreased to 2. No complications related to the procedure were observed. The patient experienced about a 70% reduction in pain, and could sit and move after the treatment. She was able to discontinue her use of oxycodone, but continue to take pregabalin, amitriptyline, and use the fentanyl patch. Afterwards, she received repeated chemotherapy in the Oncology department. Bone scans showed no interval change at 5 months and 9 months after PRF neuromodulation. The pain relief was sustained for 10 months until the patient's death from pneumonia.


A 72-year-old man was admitted to our institute complaining of severe neck pain and quadriparesis without any significant history of trauma. Plain radiographs showed atlantoaxial instability with osteolytic lesions on the C2 (). Magnetic resonance imaging (MRI) showed a well-enhanced soft tissue mass (5.9×5.5×5.8 cm) involving the whole compartment of C2 with cortical destruction. The epidural mass extended from the C1 to C4 vertebra at the ventral portion of the dura and from the C2 to C3 vertebra at the posterior portion (). The spinal cord was compressed at the C2 vertebra by the mass and showed slightly increased T2 signal change, suggesting compressive myelopathy. The bilateral vertebral arteries were involved at the C2 level, but retained intact distal flow. Computed tomography (CT) revealed a 5.6×4.3 cm adrenal mass at the left retroperitoneal space (). Subsequently, the patient underwent an F-18 FDG whole body PET/CT examination, which revealed a hypermetabolic soft tissue mass (SUVmax=5.4) involving the C2 body, lamina, and spinous process. The adrenal mass was mildly hypermetabolic (SUVmax=2.8), which ordinarily suggests a benign tumor; however, the possibility of malignancy remains.
At first, we suspected the axis lesion to be a metastatic paraganglioma from the adrenal mass. We requested a needle biopsy from a skeletal radiologist; however, the radiologist recommended an open biopsy and surgery because of the hypervascularity of the tumor and the possibility of neural injury by the needling. On preoperative day 1, trans-femoral spinal angiography was performed, which revealed that the axis mass was fed from both the vertebral and deep cervical arteries. Feeder embolization was done by embolization particles. Under intra-operative neurophysiological monitoring, removal of the tumor was performed with a Cavitron Ultrasonic Surgical Aspirator (CUSA). After C1 lateral mass screw (posterior arch entry) and lateral mass screw fixation at C3 to C5 was applied, the axis tumor's lateral mass and pedicle was removed by CUSA. The tumor compressing spinal cord was grossly removed from the posterior to anterior poles; however, the bony structure around the left C2 pedicle was severely damaged. Therefore, we reconstructed the atlantoaxial joint with a Harms Cage, a surgical titanium mesh cage, filled with allograft cancellous bone chips. After the occipital plate placement, occipitocervical fixation was performed using a polyaxial screw-rod system with multiple rods ().
The patient's postoperative course was uneventful. A frozen biopsy examination revealed that the tumor tissue was more likely to be metastatic paraganglioma. Nevertheless, the final diagnosis of the tumor was reported as plasmacytoma, following immunohistochemistry (IHC) analysis. The IHC staining of the neoplastic plasma cells revealed immunoglobulin kappa chain and CD138 & CD56 & MUM-1 positive expression, and ki-67 positive expression in 3-5% of cells. Bone marrow aspiration biopsy was performed when the plasmacytoma was diagnosed, and normocellular marrow with a slight increase of plasma cells (3.6% of nucleated cell count) was observed. Immediate postoperative MRI showed appropriate decompression of the cervical spinal cord. Follow-up CT revealed successful atlantoaxial joint fusion evidenced by bony bridge formation through the implanted mesh. Adjuvant chemotherapy is being administered for myelomatosis, with alkeran and prednisolone to prevent the disease from spreading and to control the remnant enhancing lesion extending to the C4 ventral epidural space.


A 49-year-old female with no prior ocular complaints presented with a painless progressive decrease in vision in her right eye. The best corrected visual acuity in the right eye was 6/24, N18 and in the left eye was 6/6, N6. Slit lamp examination and intraocular pressure was within normal limits. Fundus examination revealed hyperemia and edema of the right optic nerve head. Flame shaped hemorrhages were seen radiating from the disc and there was presence of granuloma at the nerve head []. B-scan ultrasonography revealed mass lesion extending from optic nerve head to superotemporal peripapillary region with high surface reflectivity and low to moderate internal reflectivity which was suggestive of a granuloma. Chest X-ray was normal. High resolution computed tomography (HRCT) of chest revealed hilar lymphadenopathy; however, patient had no systemic symptoms. Skin test for tuberculosis was negative. Laboratory studies revealed a normal blood count. The blood level of serum angiotensin converting enzyme (ACE) was raised. The antibody assays for toxoplasmosis were negative. A diagnosis of sarcoid optic nerve granuloma was made and the patient was started on intravenous methylprednisolone 1 g for 3 days. This was followed by a course of oral steroids 1 mg/kg body weight and methotrexate 15 mg/week. At 1-month follow-up, the best corrected visual acuity in the right eye was 6/9, N6 with a decrease in the disc edema []. The patient was maintained on minimum doses of oral steroids and methotrexate for a period of 2.5 years. During this period, she did not show any manifestations of systemic sarcoidosis. At final follow-up, 4 years after the first episode, the patient had a best corrected visual acuity of 6/6, N6 in the right eye with complete resolution of the optic nerve head granuloma [].


A 49-year-old female with no prior ocular complaints presented with a painless progressive decrease in vision in her left eye. The best corrected visual acuity in the right eye was 6/6, N6 and in the left eye was 6/24, N18. Slit lamp examination and intraocular pressure were within normal limits. Fundus examination revealed hyperemic, edematic left optic nerve head with surrounding engorged retinal veins []. Fluorescein angiography revealed optic nerve head hyperflourescence due to dye leakage consistent with disc edema. The erythrocyte sedimentation rate was elevated. Serum ACE level was elevated. Skin test for tuberculosis was negative. HRCT chest was suggestive of sarcoidosis though the patient did not have any systemic complaint. Therapy was started with intravenous methylprednisolone 1 g for 3 days followed by a course of oral steroids 1 mg/kg body weight. At 3 months follow-up, the best corrected visual acuity in the left eye was 6/9, N8. The fundus picture also showed improvement in disc edema []. However, the patient was subsequently lost to follow-up.


A 48-year-old female presented with a painless, progressive decrease in vision in her left eye and headache. The best corrected visual acuity in the right eye was 6/6, N6 and in the left eye was counting fingers at 1 m, <N36. Slit lamp examination and intraocular pressure were within normal limits. There was the presence of a relative afferent pupillary defect in the left eye. Fundus examination revealed hyperemic, oedematic left optic nerve head with exudates at the macula forming a macular star configuration. Fluorescein angiography showed disc hyperflourescence due to dye leakage consistent with disc edema and presence of blocked choroidal fluorescence due to exudates at macula []. The erythrocyte sedimentation rate was elevated. Serum ACE level was elevated. Skin test for tuberculosis was negative. HRCT and X-ray chest were within normal limits. Magnetic resonance imaging brain revealed subcortical vasculitis in parietal and frontal region. Therapy was started with intravenous methylprednisolone 1 g for 3 days followed by a course of oral steroids 1 mg/kg body weight and methotrexate 15 mg/week. In view of fluctuating blood glucose levels and the suspicion of a neurosarcoid, immunosuppressive agents were administered along with oral steroids. At 1-month follow-up, the best corrected visual acuity in the left eye was 6/9, N10 with resolving fundus lesions []. At 2 months follow-up, the best corrected visual acuity in the left eye was 6/7.5, N8. At final follow-up 5 months after presentation, her disc edema showed significant resolution and the best corrected visual acuity in her left eye was 6/9, N6.


A 36-year-old male presented with a painless progressive decrease in vision in the right eye. The best corrected visual acuity in the right eye was 6/9, N6 and in the left eye was 6/6, N6. Slit lamp examination and intraocular pressure was within normal limits. There was presence of relative afferent pupillary defect in the right eye. Fundus examination revealed a granuloma at the right optic nerve head with presence of peripapillary subretinal fluid []. The erythrocyte sedimentation rate was elevated. Serum ACE level was elevated. Skin test for tuberculosis was negative. B-scan ultrasonography revealed mass lesion extending from optic nerve head to superotemporal peripapillary region with high surface reflectivity and low to moderate internal reflectivity which was suggestive of a granuloma. HRCT chest and X-ray chest were within normal limits. Therapy was started with oral prednisolone 1 mg/kg body weight along with methotrexate. At follow-up after 3 months, the granuloma had decreased in size [] and the vision was maintained at the last follow-up after 7 months.


A 38-year-old woman was admitted to our emergency department complaining of a 2-hour history of sudden, severe right lower abdominal pain. She appeared to be acutely ill. The pain was both severe and progressive. Her medical history was unremarkable. She had undergone a cesarean section 17 years prior, followed by abdominal myomectomy to remove uterine fibroids 7 months prior. During myomectomy, two intramural myomas and one subserosal myoma were removed. Uterine myomas were removed entirely without morcellation; we minimized myoma tissue disruption. The abdominal cavity contained no visible tissue remnants.
Physical examination revealed lower abdominal rigidity and guarding, with an associated rebound tenderness suggesting that surgery might be required. All vital signs were within normal ranges and the patient's consciousness was clear. The white blood cell count was mildly elevated, to 11,800/mm3, but all remaining laboratory test data were normal. Pelvic examination revealed a large, tender, non-mobile mass that filled the lower abdomen.
Ultrasonography revealed her uterus (8.6×7.4×6.3 cm in dimension) to contain a 4.4-cm-diameter subserosal fibroid and a 2.7-cm-diameter intramural myoma. A huge mass was evident in the upper pelvis; this extended into the upper abdomen to a position 8 cm above the level of the umbilicus. The mass was slightly heterogeneous in echotexture, and the degree of through-transmission was poor.
A computed tomography (CT) scan of the entire abdomen revealed a well-defined, lobulated heterogeneously enhanced mass 17×15×7 cm in dimension in the abdominal cavity (). Inferiorly, the mass lay separate from the uterus and ovaries. A small amount of fluid was noted within the pelvic cavity. The coronal CT image showed a whirling pattern of fatty streaks within the omentum (). This is a relatively characteristic feature of omental torsion.
We performed an exploratory laparotomy on the basis of a preoperative diagnosis of omental torsion. During this operation, a large encapsulated mass, 17 cm in diameter, was found in the greater omentum. The mass was fed by small vessels extending from the omentum, but was nonetheless easily removed. The mass was twisted 1.5 rotations clockwise around the stalk (). The operative findings were consistent with the CT data. A dark brown parasitic myoma was identified on the twisted pedicle. No other connection was evident between the omental mass and the uterus. En bloc excision of both the mass and the omentum was performed, followed by total abdominal hysterectomy due to the presence of multiple small uterine myomas.
Gross examination revealed a globular soft tissue mass 16×13×6 cm in dimension. The cut surface was fasciculated and dark gray in color. Histopathological examination of multiple sections revealed features compatible with a leiomyoma. The leiomyomatous tissue exhibited multifocal hemorrhages, congestion, and dilated vessels; all are typical pathological features of omental torsion. The tumor cells were immunopositive for smooth-muscle actin. These findings are consistent with the presence of an infarcted leiomyoma. Thus, we made a final diagnosis of an iatrogenic parasitic myoma complicated by omental torsion. The patient was discharged from the hospital 6 days after surgery. No abnormality was evident at follow-up 12 months later.