This boy was a healthy, active 11-year-old who played soccer in his spare time. He and his father were enjoying downhill skiing at a resort in Norway, when another skier, travelling faster, suddenly approached and the collision was unavoidable. The boy was hit on the lateral aspect of his right knee with his foot planted on the ground. This resulted in a pivoting movement with knee valgus and external tibial rotation. The patient was initially cared for at a local hospital, close to the resort. On first examination, he was unable to extend his knee fully and had a knee flexion of about 70°. The patellar apprehension test was negative, he had no pain when palpating the tibiofemoral joint line and he was stable to valgus and varus stress. Plain radiographs showed that the boy had suffered a tibial eminence fracture (). However, what particularly caught the radiologist’s attention was a bony avulsion fragment of uncertain origin. It was assumed to originate from the tibial side, since no femoral defect could be seen. The patient was given a temporary high leg cast and was transferred to another hospital for inpatient care and an MRI evaluation.
The MRI confirmed the medial intercondylar avulsion fracture of the tibia but dismissed the initial thought regarding the origin of the other fragment. This fragment was instead described as ‘a skull-shaped fragment corresponding to the ACL origin of the medial aspect of the lateral femoral condyle’. An additional CT was performed to further assess the pathology of the proximal bony fragment and the interpretation was identical ( and ). So, this patient had suffered a simultaneous avulsion fracture of both the proximal and distal insertion sites of the ACL.


A 1-year-old female consulted our hospital with the complaint of an ulcer of the perineal region. She had a congenital low type of imperforate anus, and the bowel had a narrow opening to the vagina. Initially, she had undergone anoplasty, involving moving the anus to an appropriate place. The perineovaginorectal wound had been sutured directly. However, the mid-vaginorectal wound developed dehiscence. On examination, a 1.5 cm × 1.5 cm ulcer was found between the anal and vagina []. A bilobed perforator flap was elevated from the left gluteal lesion and rotated toward the skin defect [Figure and ].
The viability of the flap was favorable without infection or necrosis, and it also showed an excellent appearance. She also gained favorable bowel control [Figure and ].


A 3-year-old female consulted our medical center with the complaint of an ulcer of the perineal region. She showed congenital hypoplasy of the perineovaginorectal lesion revealing a skin defect. She consulted the department of paediatrics, and it was verified that she had no other functional disorders. On examination, a 1.0 cm × 1.5 cm ulcer was found in the perineal area []. The ulcer was excised completely, and the skin defect was reconstructed with a bilobed perforator flap [Figure and ].
The viability of the flap was favorable without infection or necrosis, and it also showed an excellent appearance [].


A 50-year-old female was admitted to our hospital after the diagnosis of infiltrative ductal carcinoma of the breast. She had received the diagnosis 2 months ago and had begun chemotherapy according to the EC schedule (epirubicin 140 mg/m2 and cyclophosphamide 800 mg/m2). The physical examination after admission revealed a remarkable abnormal finding, a palpable mass was examined at the anterior clavicle of the neck. Chest computed tomography (CT) findings demonstrated a mass in the anterosuperior mediastinum (). Blood tests including alpha-fetoprotein, acetylcholine receptor antibody (AchR-Ab) and titin antibody (Titin-Ab) as markers for myasthenia gravis, beta-human chorionic gonadotropin (β-HCG), CA19.9 and human immunodeficiency virus (HIV) were all within normal range. Abdominal CT, brain magnetic resonance imaging (MRI), colonoscopy, otolaryngological and gynecological examinations revealed no evidence of other abnormalities.
Partial thymectomy via median sternotomy and radical mastectomy were performed, and the surgically resected tumor was a 4.0 × 3.0 × 3.0 cm3 solid white mass obtained from the anterosuperior mediastinum. Histopathological examination with H&E staining showed the tumor with a lobulated architecture composed of undifferentiated clear cells, with the abundance and density of fibrous stroma (). The tumor appeared to have radially penetrated the peripheral adipose tissue. showed homogeneous neoplastic cells with abundant, clear cytoplasm, round or ovoid nuclei and a low nuclear/cytoplasmic ratio. Nuclear atypia was not marked, and nuclear chromatin was finely dispersed. Mucicarmine stain was negative in this case when tested, while the material was positive for Periodic acid Schiff (PAS) (). The neoplastic cells were positive for CKpan, p63 and 34βE12 (). In contrast, neoplastic cells were negative for TTF-1, GATA-3 and HMB45 (), and histological examination from left breast tumor demonstrated the typical breast infiltrating ductal carcinoma. Immunohistochemistry with estrogen receptor (ER) and progesterone receptor (PR) demonstrated negative cells in the breast tumor. The human epidermal growth factor (HER2/neu) IHC score was 3+, and the Ki-67 labeling index was 30% in the resected breast tumor.
We made a diagnosis of thymic clear cell carcinoma based on the histological and immunophenotypical findings. According to the Masaoka staging system, the tumor at the diagnosis presented in stage IIb. The patient was also evaluated as having stage IIIa (T3N1M0) breast cancer. Later, our patient was treated systemically with four cycles of chemotherapy which consisted of epirubicin, cyclophosphamide, docetaxel and trastuzumab (herceptin) after surgery. She underwent another operation for total thymectomy and the removal of surrounding adipose and received adjuvant radiotherapy administered to mediastinal lesion in the other hospital after our treatment. The patient performed well within 12 months after surgery, and the follow-up tests showed no symptoms of local recurrence or metastasis.


A 46-year-old male with a history of drug, alcohol and tobacco abuse was admitted to the emergency department with altered level of consciousness. At admission, no close companion was present to provide a detailed medical history. A complete clinical examination and various laboratory tests were performed, and uremia was diagnosed. The lab tests showed a serum creatinine level of 17.2 mg/dL (reference range [RR] = 0.7-1.2 mg/dL); serum urea 318 mg/dL (RR = 10-50 mg/dL); hemoglobin 4.8 g/dL (RR: 13-18g/dL) with intense poikilocytosis; peripheral white blood cell count 5,220 cells/mm3 (RR = 4,000-11,000 cells/mm3); total peripheral lymphocyte count 400 cells/mm3 (RR = 900-3,400 cells/mm3); arterial pH 7.208 (RR: 7.37-7.44) and serum bicarbonate 6.1 mmol/L (RR: 23-29 mmol/L). A head computed tomography (CT) and a lumbar puncture were also carried out, both of which showed normal results. Dialytic treatment and adjuvant measures were then initiated, and the patient’s mental and general condition improved progressively over the next few days. The serology panel requested at admission showed two ELISA positives for HIV antibodies, non-immunization for HBV, a positive Toxoplasma immunoglobulin (Ig)G (by electrochemiluminescence, with 650.0 IU/mL [RR ≥ 3 IU/mL]) and a positive HVA IgG. Other serologic tests, including anti-hepatitis C virus (HCV) and anti-T. cruzi antibodies were negative. The HIV infection was then confirmed by Western blotting. However, the patient was not aware of his HIV status. The TCD4+ peripheral count was 74 cells/µL, TCD8+ peripheral count was, 171 cells/ µL (TCD4+/TCD8+ ratio = 0.43) and the HIV-1 RNA viral load in the blood was 66,309 copies/mL (branched DNA) or 4.82 Log. The blood cultures were negative.
On the 28th day of hospitalization, the patient manifested acute hepatitis, with significant elevation of serum canalicular enzymes (direct bilirrubin (DB) = 2.63 mg/dL [RR < 0.3 mg/dL], alkaline phosphatase (AP) = 1,248 U/L [RR: 40-129 U/L]) and liver enzymes (AST = 172 U/L [RR < 37 U/L], ALT = 447 U/L [RR < 41 U/L]) attributed to trimethoprim/sulfamethoxazole (TMP/SMX) prescribed to prevent opportunistic infections. The detection of HCV RNA by the real-time polymerase chain reaction assay was negative in the blood. These antibiotics were discontinued for 2 weeks, when the canalicular enzyme levels returned to the reference range. Combined antiretroviral therapy (ART) was not prescribed during hospitalization due to the patient’s liver dysfunction. On the 55th day of hospitalization, the patient developed refractory shock attributed to nosocomial pneumonia as he presented cough, fever, and thoracic rales (see chest x-ray and chest CT in ). Bronchoalveolar lavage (BAL) was not performed due to the poor clinical condition of the patient.
Broad-spectrum antibiotics and vasoactive drugs were prescribed associated with dialysis and mechanical ventilation, but the patient did not respond favorably and died. The blood cultures were negative, and the microscopic analysis and culture of the sputum were negative. The autopsy was requested and was performed with the agreement of the patient’s relatives.


A 37-year-old female patient sought dental care due to dissatisfaction with the esthetics of the maxillary anterior teeth. During the anamnesis (interview), information about systemic conditions and the history of dental treatments was collected. On oral physical examination, the soft tissues, muscles, teeth, periodontal and occlusal relationships, and oral hygiene were examined. At the end of the clinical examination, asymmetries were observed in the shape and contour of the maxillary central incisor and irregularities in the gingival regular concave arch of the left maxillary central and lateral incisors []. For the improvement of dental esthetics, the patient was in the final stage of orthodontic treatment. The left maxillary central incisor had a temporary crown over a malpositioned implant []. A panoramic radiograph was requested for the analysis of the tooth and bone condition [].
To fix the gingival gap and malpositioning of the implant, was proposed following treatments:increasing the clinical crown on the left maxillary lateral incisor, removal of the implant of the left maxillary central incisor with further bone grafting and insertion of a new implant, or the preservation of the tooth implant with the fabrication of a gingival veneer. For the improvement of dental esthetics, the placement of a crown on the maxillary central incisor and a resin laminate veneer on the right maxillary lateral incisor was accepted by the patient, with written informed consent.
Orthodontic treatment was finalized. First, the upper orthodontic brace was removed, and a new provisional crown on the left maxillary central incisor implant was made. Subsequently, the clinical crown of the right maxillary lateral incisor was increased to stabilize the periodontal tissues []. Then, lithium disilicate crowns were made (IPS e. max Press®, Ivoclar Vivadent, Liechtenstein, Austria) for the left and right maxillary central incisors, and a composite resin laminate veneer (Filtek® Z350 XT, 3M ESPE, Landsberg, Germany), shade A1, was made for the maxillary lateral incisor to restore form, function, and esthetics [].
For the gingival veneer, alginate impressions (Jeltrate®, Dentsply, São Paulo, Brazil) were initially taken to obtain diagnostic casts with type IV dental stone (Herostone®, Coltene, Rio de Janeiro, Brazil). In the model, a relief was made with a #7 wax blade (Wilson®, Polidental, São Paulo, Brazil) from the middle thirds of the left maxillary central and lateral and the right maxillary central incisors until reaching the buccal vestibule. A custom tray was made in acrylic resin, shade 62 (Patter Resin® LS, GC America, Alsip, United States). It included the incisal and middle thirds of the buccal surface, the incisor region, and incisal third of the palatal surface of the anterior teeth. Using the custom tray, a polyether impression of the upper anterior was taken (Impregum medium® 3M-ESPE, Landsberg, Germany) and casted in type IV dental stone (Herostone®, Coltene, Rio de Janeiro, Brazil) to make the working model.
In this clinical stage, the gingival color was chosen following the Tomaz Gomes System color scale (STG®, Vipi, São Paulo, Brazil) []. In the working model, the gingivae were waxed and confirmed in situ. After clinical tests, we proceeded to laboratory processing through standard inclusion in wax to obtain the gingival prosthesis in polymerized acrylic resin shade 2 (VIPI Cril Plus®, VIPI, São Paulo, Brazil). The prosthesis was properly finished and polished. Internally, its extensions filled the proximal niches, which favored retention and prevented the escape of air. Finally, we proceeded to the installation of the gingival veneer subject to adjustment in the proximal niches and analyzed the stability of the prosthesis through lip movements [Figures and ].
During the control phase, the patient was satisfied with the esthetics. It was observed that the gingival veneer was not compressing the periodontal tissues and did not require adjustments. Directions to maintain the stability of the prosthesis and oral hygiene were provided.


An 18-year-old girl admitted in our department on February 2014 with the complaints of pain and swelling over medial aspect of upper one-third of the left forearm [] for the past 6 months, and the mass was gradually increasing in size, for which incisional biopsy was done outside and referred with biopsy report as glomangioma or epithelioid haemangioendothelioma. On examination, there was a palpable firm mass on the medial volar aspect of the left forearm measuring about 7 cm × 5 cm × 3 cm with surgical scar with few dilated veins over the swelling with no bruit. There was no distal neurovascular deficit. Hand functions were normal. Magnetic resonance imaging of the upper forearm showed the mass with high vascularity, involving mainly the muscular plane. The biopsy report showed the possibility of glomangioma or epithelioid haemangioendothelioma, which was a benign condition, and so excision biopsy was done.
A lazy 'S' incision was made over the swelling. Highly vascular mass was found encapsulated within the flexor digitorum superficialis (FDS) muscle at the common flexor origin [ and ]. The ulnar nerve was found closely adhered to the capsule of the mass and was dissected after dividing its muscular branches []. Mass was excised along with part of FDS muscle up to the musculotendinous junction; the remaining tendinous part was attached to flexor digitorum profundus muscle with adequate tension.
Histopathology examination showed nests of large polygonal cells with abundant eosinophilic cytoplasm having pseudoalveolar pattern [ and ], separated by delicate vascular structures. All the findings confirmed ASPS.
The patient was screened for metastasis post-operatively. Computed tomography (CT) chest showed multiple coin-like opacities in both the lung fields, more in lower lobes []. CT brain, CT abdomen and whole-body skeletal survey were normal.
After discussion with oncology department (radiation oncology, medical oncology and surgical oncology), we decided to give cycles of chemotherapy and radiotherapy.
The patient received 6 cycles of chemotherapy with adriamycin, cyclophosphamide and vincristine as suggested by the oncologist. The patient was closely followed for 11 months. There was no locoregional recurrence or metastasis elsewhere. Full range of movements in the hand and elbow was possible.
After 11 months, the patient had good functional improvement [ and ], due to financial constraints, PET scan and other investigations were not done on subsequent follow-up.


A 33-year-old man with MPS IS presented neck and radicular pain with an onset of symptoms of 3 months, along with a recent onset of insecure gait, of about 2 weeks. The patient was of below-average stature, and regarding his metabolic disease he claimed that he had never received any treatment. In addition, he maintained a rather athletic lifestyle, which was significantly affected by the presenting symptomatology. Conservative treatment had not been able to relieve him from his symptoms, and clinical examination showed sensorimotor deficits corresponding to C6 and C7 dermatomes bilateral with the left upper extremity being slightly more affected. Bilateral paresthesias were also present over the plantar sides of the feet, along with hyperreflexia of the left leg. Bilateral upper extremity weakness [4/5] in three muscle groups was noticed, and the electrophysiological study that was performed was indicative of myelopathy. Plain radiographs were consistent with the characteristic abnormal vertebral formation that occurs in MPS, without evidence of atlantoaxial instability whatsoever (). Magnetic resonance imaging (MRI) revealed spinal stenosis at C2-5 levels with concomitant myelopathy hyperintense signs, secondary to a marked soft tissue thickening that was lying mainly posterior to the dens (). Surgical management was deemed necessary for reversing the patients incipient myelopathy symptomsor at least forpreventing them from deteriorating. During the preoperative planning, serious doubts existed with respect to the bone healing properties of the patient, and considerations were made regarding whether a revision surgery would be necessary in the future. This led us to the decision, to perform posterior decompression and fixation, with the minimum instrumentation possible, nonetheless, to preserve sufficient bone stock. Under a rather difficult and challenging general anesthesia, the patient underwent posterior decompression with C2-C3 laminectomies, and C4-C6 hemilaminectomies. Intraoperatively, a gluey soft tissue thickening covering the spinal cord was discovered; this tissue formation was strongly adherent to the dura and itscomplete resectionwas not feasible, due to great risk of dural tear. We noticed also a hypertrophic ligamentumflavum, which was rather underestimated in the MRI. A posterior C1-C7 fixation was performed with Cl/2 transarticular and C7 pedicle screws(Neon™, Ulrich Medical, Ulm, Germany), under navigation (Brainlab AG, Munich, Germany). At day2 after surgery, the patient was ambulatory and pain free, with mild paraesthesias remaining over the feet. He was discharged home 5 days later, and was strongly advised to return gradually to his athletic activities (at least after 3 months). Due to his great improvement though, the patient returned to sports rather sooner than advised (4-6 weeks), and 6 months after surgery a relapse of severe neck pain occurred. Plain radiographs showed that both C7 pedicle screws had failed; a cutout of the right and breakage of the left screw had occurred (). The patient was readmitted and a reoperation was scheduled. The initial instrumentation was revised and extended to a C1-T2 posterior fusion, with screws at Cl/2, C5, Tl, and T2 levels (). Patient s post-operative course was uneventful without pain or motor deficits, and 4 days later he was discharged.
Four months later, the patient had a motor vehicle accident and sustained a severe head injury, for which he underwent brain surgery at another institution. Surprisingly enough, the spinal instrumentation remained intact, and the patient fully recoveredó months after his latter injury. At the last follow-up (24 months postoperatively) the patient remained pain free with no motor deficits, and no gait disturbances. A mild discomfort resulting from the limited neck range of motion was present throughout the follow-up period. Mild paresthesias of the left foot with ipsilateral leg hyperreflexia remained, not creating any severe discomfort whatsoever.


A 52-year-old Caucasian female attended ECT clinic for the treatment-resistant depressive disorder. She was due to commence a third set of bilateral ECT treatments. The patient was prescribed lamotrigine 100 mg twice a day, agomelatine 25 mg twice a day, and buspirone 5 mg three times a day.
In the first ECT treatment, the anesthesia was induced with intravenous etomidate, and intravenous suxamethonium was given to provide muscle relaxation; oxygen was administered with intermittent positive pressure ventilation. A dose range of 0.15–0.3 mg/kg body weight of intravenous etomidate for induction of anesthesia and 0.5–1 mg/kg body weight intravenous suxamethonium for muscle relaxation are normally used in our hospital for ECT treatment under anesthetics. The first ECT treatment was uneventful. The patient had a motor seizure of 63 s duration, and an electroencephalogram (EEG) recording showed seizure activity lasting 121 s. The initial dose given was 75 mC.
In the second ECT treatment, when AAGA was reported to have taken place, the anesthetist was not a regular ECT anesthetist. Anesthetic agents used were again intravenous etomidate induction and suxamethonium. The ECT treatment was uneventful. This time there was no evidence of a motor seizure; however, the EEG recording illustrated spike and wave activity lasting 76 s. The stimulus dose was set at 75 mC.
After the second ECT was completed, the patient was taken into the recovery room where she was reported being aware and unable to move within the ECT suite. She was also able to recall the movement of being wheeled into the recovery room. The patient said that “.. all I remember is being aware of voices. I couldn’t make out what the voices were saying but I can remember trying to open my eyes, trying to speak, trying to move my feet but I could not move any part of my body, and it felt like forever. I didn’t feel like I could breathe properly. I was desperate, thinking ’I’ve got to let them know.’ As soon as I could, I let out a noise and cried out. I heard a voice saying ’its ok P’ and I recognized her voice, she was my nurse. I did not think anyone knew until I yelled and I vividly remember being wheeled through to recovery.” Further clinical consultation confirmed that the patient had in fact experienced true AAGA following delivery of the treatment.
Subsequently, in third ECT treatment, the sleep was again induced with the intravenous etomidate, and intravenous suxamethonium was administered for muscle relaxation. The patient had a motor seizure lasting 38 s, and the EEG showed seizure activity for 63 s. The stimulus dose was set at 75 mC. The patient was observed attempting to open her eyes immediately after the cessation of motor seizures. As the muscle relaxant was still in effect and the patient was unable to breathe hence was on assisted manual ventilation with oxygen by face mask. A decision was made to add a volatile anesthetics sevoflurane (minimum alveolar concentration >1) through the facemask until the return of spontaneous breathing. The patient did not recall any of the events during the ECT treatment this time.
Consequently, it was decided that the addition of a volatile anesthetic agent such as sevoflurane to maintain the anesthesia after intravenous etomidate anesthetic induction should be used in this particular patient, and in others, if and when AAGA is suspected, during future ECT treatments.
The patient required ongoing reassurance and dedicated consultation time with the anesthetic team to manage her heightened anxiety. There was no evidence of PTSD. However, the patient continued to be able to recall vivid distressing memories of the event.
The patient completed the course of 12 bilateral ECT treatments without any further anesthetic complications. Subsequently, the patient commenced maintenance ECT treatment and achieved good progress. The patient has since become an “Expert Patient” in advocating ECT to patient groups.


A 49-year-old male with a background of infantile paralysis presented with a midline anterior neck mass with associated pain, inarticulacy and swallowing discomfort. Despite a 2-week course of oral antibiotics, there was no significant improvement in the clinical symptoms. The patient was originally diagnosed with TGDC 4 years prior, but he declined for surgery at that stage. On examination, he had a tender, hard midline anterior neck mass (6.0 × 4.0 × 4.0 cm) at the level of hyoid bone that elevated on swallowing (). On nasal endoscopy, no abnormality was found in his nasal, oral, pharyngeal or laryngeal areas. Ultrasonography demonstrated a solid-cystic multilocular mass (5.8 × 3.6 cm) with irregular shape and well blood supply connecting with hyoid bone. Magnetic resonance imaging (MRI) without contrast was guided for inspection due to iodine allergy. MRI showed a 5.6 × 3.2 × 3.6 cm lesion with mixed signals and unclear margins. The lesion appeared to arise from notch thyroid and extend to midline tongue base (). There was no evidence of abnormal thyroid gland and cervical lymphadenopathy. Based on these findings, a TGDC with inflammation was suspected, and Sistrunk procedure was consented. However, intra-operatively, the mass was found to adhere densely with surrounding tissues. Thus, Sistrunk procedure with additional wide local excision was performed. In view of the large open wound cavity in proximity to the floor of mouth and potential laryngemphraxis post-operatively, tracheotomy was performed following surgery, with nasogastric tube inserted. The tracheotomy and nasogastric tubes were removed 1 week after surgery without any complications. The mass specimen was sent for histopathological review. Grossly, the mass (6.0 × 4.0 × 4.0 cm) composed of chief solid lesion with partial cystic lesion adhering to hyoid bone and surrounding muscles (). Microscopically, the mass presented numerous differentiated malignant squamous cells (). Whole body positron emission tomography (PET) scanning did not reveal any regional or distant metastatic diseases (). Based on these findings, this mass was diagnosed as SCC arising from a TGDC. The patient made an unremarkable post-operative recovery and underwent further chemotherapy (docetaxel, 75 mg/m2 (Day 1) and cis-platinum, 70 mg/m2 (average Days 1–3), every 3 weeks, total twice) and radiotherapy with 60 Gy of intensity dividing into 30 fractions. Following radiotherapy, the patient had no evidence of recurrence or metastasis for 24 months.


A 12-year-old girl weighing 14 kg presented with lumbosacral meningomyelocele without sensory deficit over the anterior abdominal wall. Her medical history revealed hydrocephalus and spina bifida. She was scheduled to undergo a laparoscopic cholecystectomy. Her physical examination did not reveal any significant findings. Hemoglobin, hematocrit, platelet count, coagulation profile, liver enzymes, bilirubin levels, blood glucose, serum creatinine, serum urea, serum sodium and potassium levels were within normal limits in preoperative investigations. There were no abnormal findings on the preoperative chest x-ray (). Preoperative investigations revealed no abnormal findings.


A 5-year-old boy weighing 15 kg presented with neurogenic bladder dysfunction due to lumbosacral meningomyelocele. He had no sensory deficit over the anterior abdominal wall. His medical history included hydrocephalus and spina bifida. He was scheduled for bilateral ureteroneocystostomy. The physical examination did not reveal any significant findings. Hemoglobin, hematocrit, platelet count, coagulation profile, liver enzymes, bilirubin levels, blood glucose, serum creatinine, serum urea, serum sodium and potassium levels were within normal limits in preoperative investigations. There were no abnormal findings on the preoperative chest x-ray (). Preoperative investigations revealed no abnormal findings.


A 12-year-old girl weighing 17 kg presented with lumbosacral meningomyelocele. She had no sensory deficit over the anterior abdominal wall. Her medical history included scoliosis, hydrocephalus, and spina bifida. She was scheduled for laparoscopic insertion of a peritoneal dialysis catheter. Her physical examination did not reveal any significant findings. Hemoglobin, hematocrit, platelet count, coagulation profile, liver enzymes, bilirubin levels, blood glucose level, serum sodium and potassium levels were within normal limits in preoperative investigations. Blood urea level was 80 mg/dl and serum creatinine level was 2.4 mg/dl. There were no abnormal findings on the preoperative chest x-ray (). Preoperative investigations revealed elevated urea and creatinine levels.


A 10-year-old boy weighing 35 kg presented with lumbosacral meningomyelocele. He had no sensory deficit over the anterior abdominal wall. His previous medical history included spina bifida. He was scheduled for laparoscopic intraabdominal testis exploration. There were no significant findings on physical examination. Hemoglobin, hematocrit, platelet count, coagulation profile, liver enzymes, bilirubin levels, blood glucose, serum creatinine, serum urea, serum sodium and potassium levels were within normal limits in preoperative investigations. There were no abnormal findings on the preoperative chest x-ray (). Preoperative investigations revealed no abnormal findings.


A 13-year-old girl weighing 18 kg presented with lumbosacral meningomyelocele. She had no sensory deficit over the anterior abdominal wall. Her medical history included scoliosis, hydrocephalus, and spina bifida. She was scheduled for laparoscopic insertion of a peritoneal dialysis catheter. Her physical examination did not reveal any significant findings. Hemoglobin, hematocrit, platelet count, coagulation profile, liver enzymes, bilirubin levels, blood glucose level, serum sodium and potassium levels were within normal limits in preoperative investigations. Blood urea level was 74 mg/dl and serum creatinine level was 2.1 mg/dl. Her preoperative chest x-ray revealed scoliosis. Pulmonary function tests were within normal limits (). Preoperative investigations revealed elevated urea and creatinine levels.


A 35-year-old female with primary infertility was diagnosed to have uterine fibroid distorting the uterine cavity. Diagnostic laparoscopy to study the pelvic anatomy and hysteroscopic fibroid resection was planned. Standardized general anesthetic technique was used, and patient's airway was secured with an endotracheal tube. After an uneventful diagnostic laparoscopy, hysteroscopic resection of uterine fibroid was initiated. Uterus was distended with glycine under pressure (no documented pressure). Ten minutes into the procedure, patient's heart rate (HR) suddenly dropped to 40 beats/min from 96 beats/min and the blood pressure (BP) fell to 80/50 mmHg from 130/90 mmHg. This drop was accompanied with fall in end-tidal carbon dioxide (EtCO2) to 14 mmHg from 36 mmHg. Surgery was stopped immediately. On auscultation, bilateral fine crepitation was audible and hemoglobin saturation (SpO2) displayed the value of 85% with 50% oxygen and 50% nitrous oxide. Injection atropine 0.6 mg was immediately administered, and 100% oxygen was also administered. Hypotension was treated with rapid intravenous saline infusion and 6 mg boluses of intravenous mephentermine. HR, BP, and EtCO2 responded to these measures. When hemodynamics and EtCO2 were stable for 15 min, surgeons were requested to assess the amount of pervaginal bleeding which was not significant. The patient was then shifted to the Intensive Care Unit for cardiac evaluation. Cardiac evaluation was found to be normal, and a retrospective diagnosis of VAE was made as the cause of crisis during surgery.


A 55-year-old female presented to the ophthalmology department of the hospital with complaints of a painful swelling in the left eye. The swelling had been gradually increasing in size over the last 8 months with dull continuous pain in the eye and periorbital area. There was progressive diminution of vision for the last 6 months in the affected eye, and at the time of presentation in the hospital, the affected eye was completely blind. The progressive increase in the size of the swelling and pain in and around the eye compelled the patient to avail hospital services. The treatment history was not significant. The patient was being treated by a local doctor with eye drops and certain oral medicines the records of which were not available with her. She did not have any history of significant ocular disease or any ophthalmic surgery. There was no history of similar disease in the family.
On examination, an intraorbital mass protruding from the left eye was visible. Axial proptosis with stretched out sclera along with dilated blood vessels covering the entire exposed part of the eye ball was seen. The underlying cornea was barely visible through the widened palpebral aperture with hyperemic keratinized conjunctiva tissue. The swelling was more prominent in the region superior to the upper eye lid. The skin appeared stretched along with dilated vessels in the superior part of the eye ball []. On palpation, the mass was tender and soft in consistency. Fundus examination was not possible because of overlying vascularized keratinized tissue over cornea. The intraocular tension was also not recorded because of these reasons. The status of the pupil of the diseased eye could also not be commented upon, even though it appeared slightly dilated. The patient had no perception of light in the left eye. Ophthalmological examination of the right eye did not show any abnormality both in the anterior as well as in posterior chamber. The fundus examination of the right eye was normal. The intraocular tension of right eye was also normal.
Systemic examination of the patient was normal. Breast examination and gynecological examination were also normal. Clinically, at that stage, differential diagnoses of metastatic carcinoma, astrocytoma, and adult-onset retinoblastoma were considered by treating ophthalmologist and investigations were planned.
Blood examination was within normal limits. This included hemoglobin values, total leucocyte count, differential leucocyte count, and erythrocyte sedimentation rate. Peripheral blood smear was normal. The kidney function tests, liver functions tests, serum alkaline phosphatase, serum calcium, and serum phosphorus were normal. Urine examination was also normal. Electrocardiogram was also normal.
Noncontrast computed tomography (NCCT) scan off the orbit and Para Nasal Sinuses (PNS) revealed marked left proptosis with markedly expanded left ocular globe by a hyperdense mass, few cystic components with extension into left anterior cranial fossa, left anterior ethmoid, left frontal sinus, left frontal fossa soft tissues with destruction of left orbital walls, and great wing of sphenoid bone []. A precise diagnosis was not possible based upon CT findings. The radiologist considered provisional diagnosis of primary intraocular tumor, metastatic carcinoma, malignant melanoma, or lymphoma and advised further investigations. Chest CT and abdomen ultrasonography were carried out and found to be normal. The patient was referred to us for fine needle aspiration cytology (FNAC) at this stage.
FNAC was done using a 22-gauze needle. Smears were prepared, air dried, and stained with Giemsa stain and Periodic Acid Schiff's stain (PAS stain). The microscopic examination of Giemsa-stained smears showed small, round cells in cluster and rosettes formation, suggestive of retinoblastoma []. PAS positive granules in the cytoplasm of tumor cells were seen in PAS-stained smears, consistent with the diagnosis of retinoblastoma [].


An 87-year-old woman presented to our hospital with a complaint of spontaneous massive rectal prolapse. She had been suffering from persistent rectal prolapse for over 5 years, and the length of the prolapsed rectum continued increasing. At the time of presentation, the prolapsed rectum was over 20 cm long and severely edematous (Fig. ); therefore, it was completely irreducible. She had no apparent past medical history, and no other remarkable finding was present on physical examination. Her QOL was severely impaired since she was unable to even sit normally. Pelvic computed tomography showed full-thickness prolapse of the redundant rectosigmoid colon from the anus (Fig. ); thus, she was diagnosed with Tuttle II type complete rectal prolapse.
Since it seemed that resection of the redundant rectosigmoid colon would provide a complete cure, she underwent Altemeier’s procedure. Under spinal anesthesia, the patient was placed in the lithotomy position. The ventral side of the prolapsed rectum was incised across its full-thickness at 1 cm proximal to the dentate line, and Douglas’s pouch was opened. The dorsal side of the prolapsed rectum was also incised at the same distance from the dentate line. After circumferential incision, the redundant rectosigmoid colon was pulled out through the anus. The vessels of the mesosigmoid colon were carefully ligated and cut, and the redundant rectosigmoid colon was resected. A subsequent levatorplasty was performed by suturing of bilateral puborectalis muscles to each other. A coloanal anastomosis was performed using a hand-sewn maneuver with circumferential 3-0 absorbable sutures.
The operation was completed in 63 min with little intraoperative blood loss. More than 30 cm of rectosigmoid colon was resected (Fig. ). The patient’s postoperative course was uneventful and the rectal prolapse was completely resolved (Fig. ). She became to be able to sit in a normal way, and her bowel movements also improved. She was discharged 13 days after the operation with satisfactory QOL, and has since been healthy without prolapse recurrence for over 2 years.


A 72-year-old right hand-dominant Caucasian female presented with history of anemia, osteoarthritis, type 2 diabetes mellitus, hypertension, congestive heart failure, hyperlipidemia and >20 years duration of bilateral hand contractures.
Hand deformities at the base of digits were visually noted and confirmed via radiographic images. Assessment revealed diffuse swelling, joint instability with subluxation, and generalized weakness/tenderness of the hands. Cords were palpated over palmar surfaces of the right fourth and fifth metacarpals and left fourth metacarpal. Right palmar contractures were more severe than the left, with right digit ROM extending from 30° to 82.5° (Fig. A) with inability to fully flex all digits (Fig. B). Limited ROM prevented normal activities (writing, dressing, bathing, grooming and gripping objects, i.e. cane). Daily ongoing pain score of 8/10 was characterized as intermittent, sharp, stabbing and aching. Discomfort was aggravated by grasping, lifting, carrying and reaching and could be alleviated with rest. Multiple years of failed rehabilitative therapy led to the decision for staged contracture removal through OPF, beginning with the dominant and more symptomatic right hand.
Under intraoperative loupe magnification, a Brunner-type incision was made over the right fourth metacarpal palmar surface. Dissection proceeded bluntly using scissors to raise and secure skin flaps in an open retracted fashion with simple interrupted 3-0 nylon sutures, allowing for visualization of the fibrous cord (Fig. A). Digital neurovascular bundles over the fourth metacarpal bone were identified and dissected away from the posterior deep cord surface and folded up over the metacarpal. The cord was divided proximally and dissected along the superficial surface and lateral borders to its distal terminus at the MCP joint. Ulnar-directed lateral cord extensions to the fifth metacarpal bone were isolated and dissected away. A separate and individual contracture over the fifth metacarpal was not identified. The excised 4.5 × 1.5 × 0.5 cm3 fibrous cord (dense tan-pink rubbery tissue with adherent yellow adipose) was collected in formalin for pathologic examination (Fig. B). The wound was irrigated and bleeding vessels cauterized with bipolar Bovie electrocauter. A 5 × 5 cm2 viable cryopreserved placental membrane (vCPM) (Fig. A) was prepared per manufacturer’s instructions and placed proximally in the dissection space as direct MCP joint overlay (Fig. B). Skin incision was closed with simple interrupted 3-0 nylon sutures and dressed with XeroformTM followed by bulky hand gauze and 4-inch Ace-wrap. Patient was discharged home same-day with pain medications and instructed to keep dressing clean and intact.
On post-op Day 7, the right palmar incision was clean, dry and intact without evidence of erythema, tenderness, fluid collection or drainage. Improved digit motion with a pain score of 2/10 was reported. On post-op Day 21, sutures were removed, pain score decreased to 0/10 and patient was prescribed occupational therapy (OT) (22 sessions/51 days) consisting of neuromuscular re-education, cold laser, manual therapeutic exercise programs for joint and soft-tissue mobility, ROM, soft-tissue extensibility, motor control and strengthening.
On post-op Day 63, hypertrophic scar formation at the distal portion of the incision site (area receiving no intra-op vCPM) was treated with sub-dermal 0.5 ml triamcinolone (Kenalog-10) injection. By post-op Day 76, scar thickness was reduced with patient demonstrating improved grip strength. Collective improvement in active-ROM values for all right-hand digits equaled 34.8% (58.3% start of OT ROM; 93.1% OT discharge ROM). Patient was now able to extend digits to independently bathe, groom and dress herself using her right extremity (Fig. ). At 1 year post-surgery, the surgical scar remained smooth without density or contracture. Patient has experienced no treatment-related adverse events and shown no regression of rehabilitated-ROM.


A 55-year-old male with a history of multiple myeloma (MM), previous stem cell transplant and recurrence of disease presented to the hospital. He had recently started treatment of relapsed MM with carfilzomib and had developed intermittent fevers 2 days before presentation. He also complained of dyspnea and a productive cough, which had been present for 3 days before the onset of fever. On admission examination, he was febrile, tachypneic, and tachycardic but alert and fully oriented with a normal blood pressure. He had decreased breath sounds in the right lung base, without rales or wheezing, and the rest of his examination was unremarkable. His initial laboratory analysis was notable for pancytopenia with a white blood cell count of 1.2 × 109/l, hemoglobin of 53 g/l and platelets of 4.0 × 109/l. He was admitted to the hospital and treated with cefepime and azithromycin for presumed pneumonia; further home medications continued during admission included acyclovir, allopurinol, fluconazole and pantoprazole. Shortly after admission, he developed new-onset hypoxia and hypotension with altered mental status. He was transferred to the medical intensive care unit, where laboratory analysis revealed a lactic acid of 6.1 mMol/l and an initial arterial blood gas (ABG) returned a pH of 7.40, carbon dioxide partial pressure (PaCO2) of 3.3 kPa, PaO2 of 11.3 kPa, and measured O2sat of 94%. During an intubation procedure, the patient was treated with topical endobronchial lidocaine (4% gel applied with tongue blade) as well as intravenous etomidate and succinylcholine. Roughly 2 h post-intubation, he became increasingly hypoxic while on 100% fraction of inspired oxygen (FiO2). A repeat ABG was notably brownish in color (Fig. a) and returned a pH of 7.21, PaCO2 of 3.3 kPa, PaO2 of 55.1 kPa, and measured O2sat of 49%. Co-oximetry was requested given the divergence in PaO2 and O2sat, which revealed a methemoglobin level of 53%. Intravenous methylthioninium chloride (a dose of 1% solution at 1 mg/kg) was delivered and subsequent ABGs, at 30 min and 1 h post administration, showed methemoglobin levels of 12 and 9%, respectively, with return of O2sat to > 90% and bright red coloration to the ABG sample (Fig. b). Figure shows a detailed timeline of these events. Unfortunately, despite recovering from acute methemoglobinemia, the patient ultimately succumbed to septic shock secondary to bacteremia with Rothia mucilaginosa.


During routine upper limb dissection for undergraduate students in the department of Anatomy at North DMC Medical College, Delhi, we found an additional unusual supply to the dorsum of both hands by the LABCN in a 68-year-old male cadaver.
On dorsum of the right hand, the first digit and lateral half of second digit were supplied by the LABCN, medial side of second digit and lateral side of third digit were supplied by SBRN and medial side of third digit, fourth and fifth digits were supplied by DBUN (, , ).
However, on dorsum of the left hand, only the lateral side of the first digit was supplied by LABCN. The medial side of first digit, the second and third digits as well as the lateral side of fourth digit received branches from SBRN, medial side of fourth digit and the fifth digit were supplied by DBUN (, , ).


A 68-year-old woman was well healthy and underwent phacoemulsification and IOL implantation in the right eye at a local clinic in March 2012. Postoperative vision decreased, and she visited to our clinic 1 month later. Biomicroscopy revealed corneal edema with a vision of 20/200 in the right eye. Then, an uneventful n-DSAEK was smoothly performed in her right eye 4 months later. A donor corneoscleral button was mounted on an artificial anterior chamber and dissected with automated microkeratome (Moria, Inc, France). After 8-mm trephination, a thin lenticule was placed on Busin glide and pulled into anterior chamber by forceps, where it was unfolded and attached to the recipient cornea by air bubble for 10 min. The final air was left as the graft size at the end of surgery. Postoperatively, the lenticule was well attached to the cornea. Topical 0.1% betamethasone was prescribed four times daily and was tapered to twice daily 2 months later. Postoperative vision improved to 20/40. Nine months after surgery, a 3-mm circumscribed opacification was seen in the anterior surface of the IOL within the pupil region []. The opacification was characterized by fine and white granular deposits. The vision of the right eye slightly decreased to 20/50. However, the opacification did not increase and her vision was 20/50 during the 3-year follow-up.


A 61-year-old man with diabetes mellitus underwent uneventful phacoemulsification and implantation of IOL (AcrySof SA60AT; Alcon Surgery) in the right eye in December 2013. Later, he presented with proliferative diabetic retinopathy, retinal detachment, and vitreous hemorrhage with a vision of hand motion in the right eye. PPV and silicone oil tamponade were performed in November 2014. Postoperative course was smooth and vision was 20/120. Removal of silicone oil and intravitreal air injection was performed in March 2016, and postoperative vision was 20/100. However, whitish granular deposits were observed in the anterior surface of the IOL confined to the pupillary zone 1 month after surgery and vision decreased to 20/120 []. The opacification and his vision were stationary in the 9-month follow-up.
Anterior segment optical coherence tomography (AS-OCT; Cirrus HD-OCT; Carl Zeiss Meditec Co. Ltd.; Tokyo, Japan) revealed hyperreflective opacity in the anterior surface of the IOLs in the two cases [Figure and ].


A 46-year-old man with a past history of old inferior myocardial infarction underwent a 24-h 12-lead Holter electrocardiography (ECG) as a regular medical checkup for his cardiac function. His records demonstrated VPCs of 30 000 beats per day, and the dominant VPCs showed left bundle branch block morphology with a superior axis, positive lead I, and a precordial R-wave transition between V1 and V2 (Figure A). His chest X-ray revealed an increased cardiac silhouette with a cardiothoracic ratio of 61% and pulmonary congestion. Echocardiography demonstrated decreased LV ejection fraction (LVEF) of 40% with hypokinesis of the inferior wall.
Electrophysiological analysis and RFCA targeting the VPCs were performed using a 3-dimensional electro-anatomical mapping system (CARTO UNIVU; Biosense-Webster, Diamond Bar, CA, USA). We first performed pace-mapping in the RV using an ablation catheter (ThermoCool; Biosense-Webster) (Figure B). A good pace-map (PASO 0.894) was achieved at the basal septum of the RV, but no prepotential preceding the surface QRS was recorded. Further, we approached the LV using an ablation catheter inserted into the LV by trans-septal approach and a Pentaray catheter (Biosense-Webster) by trans-aortic approach (Figure C). A perfect pace-map (PASO 0.978) was achieved at the basal septum of the LV with a prepotential preceding the surface QRS at 45 ms using the Pentaray catheter. RF energy (40°C, 30W) was applied at this site, which resulted in reduced numbers of the targeted VPCs without complete elimination.
Further, we examined ICE (Sound Star; Biosense-Webster) together with the RA angiography (Figure A), which demonstrated that the perfect pace-mapping site was located on the LV side of the AVS (Figure B). Owing to unsuccessful ablation using the LV approach with trans-septal and trans-aortic, the search for ablation site was changed to the RA. The ablation catheter in the RA recorded a prepotential preceding the surface QRS at 26 ms, and QS pattern was recorded by unipolar lead of the ablation catheter during the VPCs. Moreover, the ablation catheter recorded both of the A and V waves, in which A/V ratio was 0.31 during the sinus beats (Figure C). The better contact force was obtained on the RA side, 22 g, than that at the LV side, 4 g. After tagging the His-bundle potential by the ablation catheter, the RF energy was applied to this site on the RA side of the AVS (40°C, 30W). With appearance of JR at a cycle length of 600 ms during RFCA (Figure D), the targeted VPCs were completely eliminated without causing atrioventricular block.
One year and 10 months after the session, he underwent a 24-h Holter ECG and echocardiography again. The Holter ECG-demonstrated VPCs were decreased to 5900 beats per day, and the echocardiography-demonstrated LVEF was improved to 45%.


A 77-year-old female came to the hospital with complaints of lower abdominal pain localized particularly in the left iliac fossa. On initial examination, she was febrile (100.4°F). The abdomen was distended with ill-defined palpable mass in the left lower abdomen. The pelvic examination showed a spontaneous malodorous discharge in the vagina and cervical os. She had leukocytosis (14,500/mm3) and raised erythrocyte sedimentation rate (ESR) (40 mm/h).
She underwent contrast-enhanced computed tomography (CECT) scan which revealed a large collection adjacent to the sigmoid colon. The collection was seen abutting the uterus with air-fluid level within the uterine cavity []. Based on CT findings, possibility of sigmoid diverticular abscess and colouterine fistula was considered. The patient underwent abscess drainage, hysterectomy, and colostomy. About 2 cm defect was noted in the posterior uterine wall communicating with the abscess and sigmoid colon. The patient improved clinically following surgery.


A 73-year-old female patient came to the outpatient department with complaints of lower abdominal pain, blood in stools, and whitish discharge through vagina for 10 days. On examination patient's vitals were stable. The patient underwent a CECT scan abdomen which revealed irregular wall thickening involving the rectosigmoid region for a length of ~ 7 cm, with wall thickness of ~ 18 mm. There was loss of fat plane between the uterus and the thickened rectosigmoid colon with air pockets within the endometrial cavity []. Mesocolic fat and perirectal fat stranding was also seen with multiple adjacent subcentimetric lymph nodes. Based on CT findings, possibility of rectosigmoid malignancy and colouterine fistula was considered. The sigmoidoscopy and biopsy of the lesion revealed infiltrating moderately differentiated adenocarcinoma of colon. The en bloc resection of the uterus and sigmoid colon with colostomy was performed on the patient and adjuvant chemotherapy started.


A 73-year-old male patient visited Pusan National University Hospital with the chief complaint of a mass touching the left orbital rim that had been present for a month. The patient did not complain of other symptoms such as tenderness and had no trauma history.
According the medical history of the patient, he had brow ptosis and lagophthalmos symptoms due to facial paralysis that occurred after otitis media surgery performed 30 years previously (). The CT findings showed a honeycombed osseous lesion in the left lateral orbital rim, and a benign bone tumor was suspected (). A biopsy was performed by applying a direct incision after local anesthesia of the lesion for a histological diagnosis, and bleeding continued for several days after the biopsy. The histological examination showed multiple dilated vascular spaces between pre-existing bony trabeculae in a low-power view, and vascular spaces surrounded by endothelial cells in a high-power view. Eventually, intraosseous hemangioma was diagnosed histologically ().
To fully resect the mass, the orbital floor and zygoma were exposed through a subciliary incision under general anesthesia, and then the tumor was completely eliminated through sawing, curettage, and burring. Bleeding control was performed using electrocautery (Cutanplast, Mascia Brunelli, Milano, Italy and Surgicel, Ethicon, Somerville, NJ, USA) and the bony defect that occurred after the elimination of the tumor was reconstructed by performing a seventh rib bone graft. In the final histological diagnosis, the disease was confirmed as intraosseous hemangioma originating from the zygomatic bone, and follow-up observation has so far been conducted for 10 months after surgery without recurrence or symptoms ().


A 24-year-old, 17-week pregnant female (G2P1L1), married for 5 years, presented with bleeding per vagina for 3 days. She also complained of huge mass coming out of vagina, difficulty in walking, and pain in abdomen and lower back. There was no history of fever, weight loss, trauma, bowel or bladder disturbance, and use of any contraceptive. Her menstrual history and past history were unremarkable. Local examination showed a large pedunculated, well-circumscribed, ulcerated mass coming out of the vagina.
Ultrasound of abdomen showed bulky anteverted uterus, measuring 9.6 cm × 7.6 cm × 5.4 cm. Prominent heterogeneous endometrium (25 mm) with few small echogenic foci and small pockets of collection were favoring retained products of conception. Furthermore, there was a large solid mass measuring 11.4 cm × 11.3 cm × 9.95 cm in the cervical region, protruding into and outside the vagina. On magnetic resonance imaging, the mass exhibits hyperintense signal on T2 and hypointense on T1 with multiple specks of T1 hyperintensity within, suggestive of pedunculated prolapsed fibroid [].
A clinical diagnosis of spontaneous incomplete abortion with prolapsed cervical fibroid was made, considering that pedunculated mass was excised and uterine curettage was done. Histology of curettage material revealed chorionic villi and trophoblastic tissue. On gross examination, mass was soft to firm and external surface shows congestion. Cut surface was a solid, homogeneous gray-white mass with glistening appearance []. On microscopy, the tumor composed of admixture of loose fibroareolar tissue with numerous variable-sized vessels and round-to-stellate reticulum cells on myxoid background. Surface was partly lined by stratified squamous epithelium of vagina with areas of ulceration, hemorrhage, and mixed inflammatory cell infiltrate [Figure and ]. On immunohistochemistry, tumor was positive for ER and vimentin [Figure and ] and negative for PR and S-100.


A 46-year-old Chinese man presented to presented to Reproduction Center of Yokohama City University Medical Center complaining of infertility for 10 years with the following characteristics: testis volume of 12 and 15 mL on the left and right, respectively; not definitively palpable bilateral vas deferens; semen volume of 0.5 mL; azoospermia; normal serum gonadotropin; and luteinizing hormone and follicle-stimulating hormone levels of 9.8 and 10.8 U/mL, respectively. His karyotype was 46,XY. A Y-chromosome microdeletion test showed b1/b3 deletion (AZFc partial deletion). Based on these findings, azoospermia owing to CBAVD or nonobstructive azoospermia due to AZFc partial deletion was suspected. After genetic counseling and obtaining informed consent from the patient and his wife, testicular sperm extraction was performed. The right epididymis body and tail were defective; only the head part was confirmed. The ductus epididymis in the remaining epididymis was expanded, and the vas deferens of both sides was also completely absent. Motile intratesticular spermatozoa were successfully extracted from the seminiferous tubule. On histopathology, spermatogenesis was confirmed, and a few spermatozoa were found in almost every seminiferous tubule. The mean Johnsen score count was 8.3 (). The frozen extracted sperm have been used for intracytoplasmic sperm injection (ICSI), which was unsuccessful.


A 52-year-old man came in emergency with a history of road traffic accident (RTA). He was unable to move his all four limbs and not able to pass urine also. With the old history, he was suffering with ankylosing spondylitis of cervical spine. During RTA, he was going on the motorcycle and suddenly stacked with divider on the road. Because of his helmet, he did not get a head injury, but his cervical spine had absorbed the total trauma force during fall. He was feeling difficulty to take breath. He gave a complete history of incidence by his own but unable to move his limbs and body below the level of neck with abnormal sensations of pin-prick in his body below neck. On general examination, he was in hypotension with bradycardia, suggestive of spinal shock.
After all postspine trauma safety measures such as cervical collar, spine board, fluid management and airway management, plain radiographs done. Plain radiography of cervical spine [] revealed cervical spine C4–C5 level fracture with total displacement with forward bending of cervical spine. Chalkstick fracture of cervical spine was final diagnosis.
After plain radiography, we were planning for magnetic resonance imaging (MRI) to find out severity of cervical cord injury, suddenly, the patient clinical condition course deteriorated and he became unconscious with very low blood pressure. Fiberoptic intubation done and ventilation started. Unfortunately, after all lifesaving attempts, patient died due to cardiac arrest in emergency within 40 min.


A 64-year-old female patient had been diagnosed with left VGN 4 years before her admission to our clinic and had been treated with carbamazepine, and gabapentin, which are effective on neuropathic pain. Ganglion blockade with radiofrequency ablation (RFA) had been used twice; as a result, the patient had benefited from these procedures for a short time. However, on her admission, she had an electricity-shock-like intolerable pain beginning from the left ear and extending to the larynx. She stated that talking and chewing triggered the pain. The case of the current study described the pain she had as almost the same as the other patients of VGN reported to have in the relevant literature. In other words, no other characteristics of pain caused by choroid plexus compression were described by our patient compared to typical pain described by VGN patients. Moreover, she had neuralgia-related sleepiness, weight loss, and depression. On her cranial magnetic resonance imaging (MRI) [], there was an image suspected as a vascular decompression. The patient underwent an MVD operation and her pain relieved in postoperative period. When the images of MRI [] were analyzed retrospectively, we noticed that choroid plexus could be observed on the images of MRI although it was shown in grey.
MVD was applied to the 9th and 10th cranial nerves of the patient with the left retrosigmoid lateral suboccipital craniotomy on prone position under microscope. A significant posterior inferior cerebellar artery (PICA) compression was not observed from anterior on the 9th and 10th cranial nerves in intraoperative observation; on the other hand, choroid plexus tissue causing compression on root entry zones [] was identified and it was resected. Afterward, root entry zone compression was seen to disappear, and a clear change of the color of the root entry zones of the 9th and the 10th cranial nerves was observed []. Despite the absence of a significant vascular compression, PICA, and the 9th and the 10th cranial nerves were separated with a Teflon sponge. In the postoperative period, the patient had no pain, which was reported to exist before the operation, related to VGN. No complications were detected in the postoperative course. She had no pain or any other complaints at the end of the 6th month after the surgery.


The patient was a 49-year-old male civil servant who was married and a secondary school graduate. The patient presented to our outpatient clinic with symptoms of insomnia, loss of appetite, behavior change, suspicion, thought about being harmed by others, and forgetfulness which had continued for about two months. The patient was admitted to our service for diagnosis and treatment.
On the day of admission to hospital, in his first psychiatric examination his consciousness was clear, the place-time-person orientation was full, but his self-care was poor. He had euthymic mood and his affection was limited. A memory pathology was not considered. His attention was observed as normal. No perceptual pathology was observed. His intelligence seemed normal. He had a circumstantial, sometimes tangential process of thinking. He had delusions of persecution in his thought content. No suicidal thoughts were observed. He was assessed as to have no insight, and a distorted ability to judge and evaluate reality.
No pathology was detected in routine examinations that were requested on the day of admission. The patient was immediately started on quetiapine 200 mg/day because of his active psychotic symptoms. The patient had confusion during his first night of hospitalization, he was agitated and said that he wanted to go home and attempted to jump out of the window. Upon which, the patient was restrained and a zuclopenthixol 50 mg/mL intramuscular (IM) injection was administered to provide sedation for that night. The patient could not be sedated, and thus was given chlorpromazine 75 mg IM, haloperidol 15 mg IM, and clonazepam 2 mg tablets, respectively, at one-hour intervals for 3 hours.
The treatment was reevaluated on the second day of admission, and was arranged as olanzapine 20 mg/day, and a 10-mg haloperidol IM injection was applied due to his agitation.
The patient’s temperature was 39°C in the morning of the 3rd day. Recurrent oral fever measurements were also detected above 39°C. His blood pressure varied; the systolic blood pressure ranged from 80 to 160 mm Hg. Although he was inclined to sleep, he responded to verbal stimulants. His extrapyramidal symptoms were evaluated using the Extrapyramidal Symptom Rating Scale and no rigidity was detected. According to this scale, his rigidity subscale score was 0. Increases in his biochemical parameters were detected in laboratory investigations. In the follow-up, the patient’s aspartate aminotransferase (AST) and creatinine phosphokinase (CPK) were high at 993 U/L and 38247 U/L, respectively, and his white blood cells (WBC) were 12.6 K/uL, normal prothrombin time was INR: 1.22 IU, and his activated partial thromboplastin time (aPTT) was 36.5 sec. Infectious Diseases and Neurology departments were consulted. Cranial computerized tomography (CT), magnetic resonance imaging (MRI), and EEG were within normal limits. Encephalitis, meningitis, and possible neurologic and infectious diseases were excluded.
NMS was diagnosed upon observing altered consciousness (confusion, somnolence), elevation of fever, sweating, blood pressure variability, CPK and AST elevation, and leukocytosis in his examination.
Follow-up of the patient began in the intensive care unit (ICU). The patient’s fever subsided after 8 days of intensive hydration in the ICU and his blood values returned to normal limits. His medication, doses, and symptoms as time progressed are presented in .


A 21-year-old female presented to us with decreased vision in the right eye that was revealed during a recent eye examination. Visual acuity recorded was 6/60 in the right eye and 6/6 in the left eye. On examination, ocular alignment showed 30-degree exotropia in the right eye; ocular movements were full in all direction of gaze. Anterior segment examination was unremarkable in both eyes. Fundus examination of the right eye showed a yellowish-white raised spheroidal lesion approximately 1 disc in diameter at the macula with surrounding subretinal exudates (Fig. ). Retinal arteries and veins dipping into the lesion were observed. The temporal and infero-temporal periphery showed retinal vessel telangiectasia with subretinal exudation. Fundus examination of the left eye was unremarkable. Fundus fluorescein angiography showed hypofluorescence of the subfoveal lesion in early and mid-phase which became hyperfluorescent with minimal leakage in late phase (Fig. ). Retinal-retinal anastomosis was demonstrated within the nodule. Peripheral images showed telangiectatic vessels, capillary nonperfusion, and leakage. Optical coherence tomography showed a hyperreflective subfoveal lesion with posterior shadowing and elevation of the overlying retinal layers (Fig. ). The height of the lesion was approximately 1,000 μm.
The patient underwent laser photocoagulation in the peripheral retinal areas of capillary nonperfusion and telangiectatic vessels. Additionally, an intravitreal injection of 1.25 mg of bevacizumab was given. She underwent additional laser treatment elsewhere before following up with us 4 weeks later, when examination showed laser scars surrounding the lesion at the macula. The lesion appeared less vascular and the exudates seemed to have decreased (Fig. ). The peripheral vessels and subretinal exudation also showed regression (Fig. ). However, there was no evident visual improvement. A second dose of 1.25 mg of Intravitreal Bevacizumab was given. Follow-up examination at 8 weeks showed a further decrease in vascularity and subretinal exudates and a reduction in the size of the macular lesion (Fig. ). Thereafter, the patient was lost to follow-up and only returned 5 months later when examination showed that the macular lesion appeared more fibrotic (Fig. ) with increased subretinal exudates. She declined any further intervention.


A 57-year-old man presented with a progressive visual disturbance over a period of 3 weeks. His medical history was unremarkable. At presentation, the patient exhibited depressed visual acuity on the left and defects of the temporal visual field. Ophthalmological examination found intact extraocular movements. Other neurological deficits were not noted. Cranial computed tomography scans revealed an isodense mass at the tip of the left middle fossa, 2 × 2 cm in maximal dimension, extending into the orbital apex, and accompanying bony erosions in the medial sphenoid ridge []. On magnetic resonance imaging, the tumor appeared isointense both on T1- and T2-weighted sequences and intensely enhanced on contrast examination [Figure –]. The left optic nerve was considerably compressed by the tumor at the orbital apex []. The patient underwent a microsurgical tumor resection. A frontotemporal craniotomy followed by drilling of the sphenoid ridge revealed a dura-based, capsulized tumor []. It was elastic, hard, entirely located epidurally, and moderately vascular []. A meningo-orbital artery was found to pass through the orbitomeningeal foramina and supply the tumor from the upper surface. With the internal debulking maneuver using cavitron ultrasonic surgical aspirator (CUSA), eventually, a gross total resection was achieved. Part of the dura mater at tumor attachment appeared intact and was only given electrical coagulation. Microscopically, the tumor comprised spindle-shaped cells, lacking findings of atypia or necrosis []. Immunohistochemical stains were positive for bcl2, CD34, CD99, and STAT6 [Figure –], whereas negative for S100 and epithelial membrane antigen. The MIB-1 index was 10% []. These were consistent with HP of World Health Organization grade II. Postoperatively, the patient's visual disturbance improved. Systemic11 C-methionine positron emission tomography/CT scans did not reveal any abnormal accumulation. Immediate adjuvant radiotherapy was not administered. The patient has been under close observation without local recurrence or distant metastasis for 14 months


A 60-year-old male presented with progressive weakness in the right (3/5) greater than the left (4/5) lower extremities. The thoracic magnetic resonance imaging (MRI) revealed an extradural tumor at the D-6-7 level that was hyperintense on both T1 and T2-weighted images and enhanced with contrast []. The lesion was also continuous with the epidural fat and extended several levels cephalad and caudad to D-6-7 []. Further, the axial T2-W MRI showed tumor growing through the left D-6-7 neural foramen where it mimicked a schwannoma.
During the D-6-7 laminectomy, the tumor was found to extend from dorsal to the dura and into the left neural foramen. Although it first appeared to be a schwannoma, its vascular areas containing well-encapsulated fat were consistent with a fat angiolipoma. Histopathology confirmed this diagnosis, documenting multiple small blood vessels and intervening areas of fat. The postoperative MRI showed no evidence of residual tumor, and the patient regained normal function within five postoperative weeks.


A 47-year-old Caucasian woman with a history of migraine headaches (last headache approximately 8 months ago), methamphetamine abuse (approximately 8 months of sobriety), and depression currently treated with sertraline presented with sudden onset of bilateral frontal-occipital headache. The headache started while playing cards with her friends 4 days before admission. She described the headache similar to her typical migraine, pulsating in character, with photophobia, and nausea. However, it was different due to severity of pain and periodic exacerbations at least 2–3 times a day up to 10/10 in intensity with gradual relief to 4/10 in the interim. The pain was worsened by neck flexion but not Valsalva maneuvers. She had two different emergency room visits in the past 4 days due to this pain and received oral opioids along with a combination of intravenous prochlorperazine, ketorolac, and diphenhydramine. These initially alleviated the pain, but the pain returned. She was admitted to our neurology floor. Her neurological examination including fundus examination was unremarkable. She had two computed tomography (CT) scans of the head that were reported by radiology as unremarkable. Magnetic resonance imaging (MRI) of her brain showed a small T2/fluid-attenuated inversion recovery hypointense nonenhancing lesion in the right occipital lobe with blooming artifact []. MRI venogram was negative.
She was treated with promethazine, ketorolac, and diphenhydramine for acute headache. She was also started on topiramate (25 mg twice a day) and valproic acid (500 mg twice a day) for chemoprophylaxis given the frequency of the headaches. Two days after admission, she began to experience visual disturbances of people and objects seeming distant and distorted suggestive of “Alice in Wonderland” phenomenon with worsening nausea and vomiting. These were thought to be a migrainous aura. She received two doses 1 mg of intravenous DHE 8 h apart. Shortly thereafter, she became somnolent and developed a new onset left-sided homonymous hemianopia. A stat CT scan of the head showed right frontoparietal and left parietooccipital parenchymal hemorrhages []. Digital subtraction angiography (DSA) was performed which showed moderate-to-severe vasospasm in bilateral middle cerebral artery (MCA), anterior cerebral artery (ACA), and posterior cerebral artery (PCA) territories [].
A lumbar puncture was performed to rule a vasculitic process. Cerebrospinal fluid biochemical analysis showed protein 47 mg/dl, glucose 71 mg/dl, white blood cell (WBC) 8 mcL with a lymphocytic predominance and red blood cell (RBC) 3000/mcL. Systemic markers for inflammation, vasculitis, and autoimmune panel were negative. She was suspected of having RCVS. Five days into admission, she developed new right-sided hemiparesis and ataxia. MRI brain demonstrated acute ischemic infarctions in the right cerebellum, left ACA, and bilateral PCA distributions with no change in the size of her previous hemorrhages []. Repeat lumbar puncture showed normalization of previously elevated protein 45 mg/dl, glucose 59 mg/dl, WBC 3/mcL, and RBC 55/mcL.
A repeat DSA showed vasculopathy of bilateral PCA along with left MCA and ACA territories. Intra-arterial verapamil was administered without much improvement of vasospasm. Her RCVS management included tight regulation of systolic blood pressure between 140 and 160 mmHg along with maintaining euvolemia. She was also started on oral verapamil and initially given a short course of prednisone which was discontinued after 4 doses. She continued to improve and was eventually discharged home with outpatient rehabilitation services after 13 days.


A 17-year-old male presented with one month history of right-sided abdominal swelling and discomfort with no other associated gastrointestinal symptoms. General examination findings were normal. Examination of the abdomen revealed a round mobile palpable mass in right iliac fossa; there was no abdominal distension or clinical evidence of ascites. Bowel sounds were normal. The rest of the systemic physical examination (including a testicular examination) was unremarkable.
Complete blood count and biochemistry profiles were within normal range. C-reactive protein was slightly elevated (22.5 mg/L). Tumour markers (alpha-fetoprotein and b-HCG) were normal. Contrast-enhanced computed tomography scan of the chest, abdomen and pelvis revealed a well-defined soft tissue mass with mixed enhancement measuring 8 × 10 × 8 cm, lying medial to the ascending colon and extending anteriorly to the anterior abdominal wall and posteriorly to the psoas muscle (). There was no evidence of pulmonary metastatic disease. Ultrasound-guided core biopsy from the mass confirmed a grade 2 synovial sarcoma associated with positive immunoreactivity for CD 99, TLE-1 and EMA and negative for CD34.
The patient underwent a laparotomy and resection of the mass. A ureteric stent (JJ stent) was inserted prior to commencing the laparotomy in order to allow identification of the right ureter. The right colon was mobilised laterally. The tumour were removed en-bloc () and submitted for final histopathology examination. A primary ileocolic anastomosis (side-to-side) was performed using the gastrointestinal anastomosis and transverse anastomosis stapling devices (Barcelona technique). The Postoperative course was uneventful and the patient was discharged at seven days. The stent was removed on postoperative day 28. The histology of the tumour (R0 complete resection) revealed a monomorphic spindle cell sarcoma with a predominant fascicular architecture and appearances consistent with a synovial sarcoma (Federation Nationale des Centres de Lutte Contre le Cancer grade 3) (). The patient has been commenced on Doxifos (a combination of doxorubicin and ifosfamide) adjuvant chemotherapy.


A 40-year-old female patient presented with a slow growing, painless swelling of 6–7 years’ duration on the right side of the face intraorally and extraorally. Habit history revealed smoking of 10 cigarettes per day for 7 years. Intraoral examination revealed a diffuse hard swelling measuring about 5 cm × 6 cm on the maxillary right posterior region, extending from the midline of the palate, from mesial aspect of 14 to the distal aspect of 18. Orthopantamograph and occlusal radiograph showed extensive bone loss and missing 16. The computed tomography at the level of the maxilla revealed a radiodense mass extending from the 14 region up to the maxillary tuberosity and also extension of the tumor mass into the maxillary antrum. A volume-rendered computed tomography showed erosion of the palatine bone on the right side of the maxilla []. Grossly, the tumor mass was yellowish cream in color with a reddish tinge, firm in consistency with an irregular surface texture. The cut surface was yellowish white with a few hemorrhagic foci at the periphery.


A 64-year-old woman underwent chest computed tomography (CT) after opacification was detected on chest X-ray during a routine health check. CT revealed a 22 mm ground-glass nodule (GGN) in segment S4 of the right lung, but the nodule was monitored without intervention. She was referred to our department when another routine chest X-ray in 2016 showed enlargement of the GGN. Chest CT revealed a 42 mm irregular part-solid GGN with well-defined margins adjacent to the interlobar region in the area where the right S4 GGN was detected two years earlier (Fig a). The right lung showed a new 26 mm solid nodule with pleural indentation in S6 (Fig b) and a new 20 mm GGN in S10 (Fig c) with no hilar or mediastinal lymphadenopathy.
The patient had no remarkable past medical or occupational history and no history of smoking. Adenocarcinoma was diagnosed based on transbronchial biopsy of the S4 GGN and S6 nodule. Positron emission tomography and head magnetic resonance imaging were performed to detect systemic metastases, and revealed no findings suggestive of extrapulmonary metastasis. These results could indicate triple lung cancer (cT2aN0M0) or ipsilateral pulmonary metastasis (cT4N0M0, with the T4 nodule being an ipsilateral metastasis in a different lobe). Blood counts and biochemical tests showed no abnormal findings. Preoperative tumor marker levels were: carcinoembryonic antigen 8.1 ng/mL, stage-specific embryonic antigen-1 37 U/mL, squamous cell carcinoma antigen < 0.5 mg/mL, pro-gastrin-releasing peptide 55.4 pg./mL, and neuron-specific enolase 17.1 ng/mL.
Right middle and lower lobectomy with hilar and mediastinal lymph node dissection was performed at the Department of Thoracic and Cardiovascular Surgery at our hospital. In accordance with World Health Organization (WHO) Classification, the S4 tumor (Fig a) was subclassified as invasive adenocarcinoma, the S6 tumor (Fig b) as minimally invasive adenocarcinoma of the acinar and papillary type, and the S10 tumor (Fig c) as minimally invasive adenocarcinoma. We considered the possibility of using this classification (a modification of the WHO classification), as our diagnostic criteria for primary lung adenocarcinoma, so we screened for EGFR using specimens from each of the three tumors. Four EGFR mutations were detected, and no three tumors had the same mutations (Table ). ALK fusion genes were not detected in any of the tumors by immunohistochemical (IHC) analysis. Each tumor had different EGFR mutations and each was classified as a primary tumor. Tumors were staged individually according to the WHO Classification as pT2aN0M0 (stage IB S4 tumor), pT1bN0M0 (stage IA S6 tumor), and pT1aN0M0 (stage IA S10 tumor). Adjuvant chemotherapy was deemed necessary for the stage IB tumor according to postoperative treatment guidelines; oral tegafur/uracil was initiated. The cancer has not recurred 21 months after resection. Written informed consent for this publication was obtained from the patient.


A 68-year-old female presented with a history of painless haematuria associated with passage of clots for one month. She was catheterised following an episode of acute urinary retention 3 weeks back. She had a history of diabetes and hypertension. There was no abdominal mass on palpation. The haemoglobin level was 11.2g/dL. Other haematological and biochemical parameters were within the normal limits. Urine cytology had negative results regarding malignant cells. Spiral computed tomography scan of abdomen and pelvis with urogram revealed a large heterogeneously enhancing infiltrative lesion with specks of calcification in the pelvicalyceal system of the left kidney infiltrating into the left renal cortex and upper half of the ureter with hydronephrosis and hydroureter ().
Left nephroureterectomy was performed with a preoperative diagnosis of transitional cell carcinoma.
Gross pathology; resected nephrectomy specimen measuring 12 cm × 5 cm × 4 cm with attached ureter measuring 10 cm. External surface of the kidney was covered with perinephric pad of fat and appeared smooth and nonadherent. Cut surface of the kidney showed a polypoidal whitish solid homogeneous growth in the pelvic region measuring 10 cm × 4.5 cm × 3 cm extending to the renal parenchyma. The corticomedullary differentiation was retained in the adjacent renal parenchyma. The tumor also involved the ureter with marked dilatation, irregular nodularities on the surface of upper ureter, wall thickening and intraluminal extension ().
The resected end of the ureter, renal capsule and vessels were free of tumor.
Microscopy showed a neoplasm composed predominantly of sheets and poorly formed fascicles of pleomorphic spindle cells with vesicular nuclei and nucleoli.
Extensive foci of osteosarcomatous differentiation was noted with abundant osteoid matrix production and areas of mineralised osteoid ().
6-8 mitotic figures/high power field with atypical mitosis, tumour giant cells, foci of necrosis, calcification and hyalinisation were also noted. The tumour involved renal parenchyma and ureter with osteosarcomatous differentiation at both sites. The focal epithelial component was formed by islands of urothelial carcinoma with carcinoma in situ in the urothelium of renal pelvis (, ).
Immunohistochemistry was performed and epithelial elements were found to have strongly positive results for cytokeratin and negative for vimentin. The sarcomatous component was found to have positive results for vimentin (, ).
A pathological diagnosis of sarcomatoid carcinoma of renal pelvis with osteosarcomatous differentiation with involvement of the ureter and renal parenchyma was given. The resected end of the ureter, renal capsule and vessels were free of tumor. The postoperative period was uneventful and the patient was discharged 8 days after the operation. Ten months later the patient was receiving regular clinical follow-up and there was no evidence of local or metastatic disease.


A 57-year-old female patient (height 5’2” and body weight 55 kg) without any known comorbidity and any known drug allergy was posted for elective thyroidectomy for a colloid goiter. Computed tomography of the neck region showed the huge thyroid swelling compressing the airways []. She was induced with injection propofol 120 mg intravenously followed by direct laryngoscopy and endotracheal intubation with a bougie. After successful intubation confirmed by capnography and bilateral air entry, she was connected to anesthesia machine. She was hemodynamically stable at this point and adequately ventilated. For adequate skeletal muscle relaxation for surgery, injection atracurium 30 mg intravenously was administered slowly, approximately 2 min after she developed profound hypotension (50/32 mmHg) and tachycardia (153/min regular). It was associated with high airway pressure, acute desaturation, and hematuria. She was started on adrenaline infusion and ventilated with 100% oxygen. With the suspicion of an acute anaphylaxis, blood for MC tryptase (MCT) was sent 45 min after the above episode. She was treated with bronchodilator nebulization and hydrocortisone. Operative procedure was postponed, and she was transferred to Intensive Care Unit (ICU) for further management. In ICU, the patient was brought in completely unresponsive state. She was ventilated in assist-control mode. She was reviewed by a team of experts including intensivists, nephrologist, hematologist-oncologist, immunologist, and neurologist. Magnetic resonance imaging of brain revealed bilateral watershed infarct []. Initial MCT was >200 ng/ml. Bone marrow study revealed huge number of MCs scattered throughout the field []. A working diagnosis of systemic mastocytosis was made. Serial MCT monitoring was started. The patient was started on high-dose steroids and antihistaminics. Repeat MCT at 6 h was >200 ng/ml as well. She needed hemodialysis for acute renal failure. Gradually, adrenaline infusion was tapered off. Ventilator demands started getting reduced. MCT value at 24 h was 161 ng/ml. Because of anticipated requirement of prolonged airway protection, elective tracheostomy was planned. Provocative incremental intradermal test of lignocaine done before tracheostomy revealed hypersensitivity to lignocaine as well. Therefore, tracheostomy was carried out under inhalational anesthetic sevoflurane and injection ketamine. MCT was repeated after 7 days which showed >200 ng/ml value. With intensive management, patient's neurological condition improved remarkably albeit with a residual weakness in proximal muscles of extremities. Renal parameters and lung functions were normalized. Steroid doses and antihistaminics were tapered. During ICU stay, she had nosocomial infections which were treated by appropriate antibiotic as per culture sensitivity and after allergic testing.


A 63-year-old male presented to the outpatient department with complaints of cough
with sputum for the past 4 years. His history revealed hospital admission elsewhere
for lung disease 3 years ago, when chest computed tomography (CT) examination and
fiberoptic bronchoscopy showed an abnormality in the left upper lobe (). However, there was
no evidence of malignancy. The patient had no history of fever, dyspnea, hemoptysis,
dysphagia, loss of appetite or weight loss. On general examination, there was
absence of pallor, cyanosis, clubbing, edema and peripheral lymphadenopathy. All
laboratory test results were in the normal range except the neuron-specific enolase
level, which was increased to 30.27 ng/mL. Furthermore, chest CT was performed and
showed a tightly endobronchial soft tissue with calcification located at the left
hilum and total atelectasis of the left upper lung, which was enlarged compared with
3 and 4 years ago (). Also, a large mass was visible blocking the left upper lobe
under bronchoscopy. Although biopsy was successful, pathological examination of the
small specimen showed only histological inflammation and squamous metaplasia (). In view of the
cytomorphological features suspicious for squamous cell carcinoma and the
radiological features, we performed a second, interventional bronchoscopy with snare
electrocautery to focus on the protrusive lesion in the left upper bronchial stem.
The protrusive lesion was removed completely, despite a little bleeding (). To prevent
recurrence of the neoplasm, the mass root was cauterized with argon plasma
coagulation (APC). No complications related to interventional bronchoscopy were
observed. Final pathological evaluation of the entire mass was not identical to the
initial diagnosis and confirmed the mass as a hamartoma (). No additional treatment was
required, and the patient was discharged and followed at the outpatient clinic. Most
importantly, chest CT examination after 2 months showed complete recovery of the
abnormality in the left upper lobe (). The patient’s condition remained stable for at least
the following 12 months after interventional therapy.


A 68-year-old man who underwent CABG surgery 3 months earlier was admitted with a precipitous worsening of dyspnoea, bilateral leg oedema, and desaturation (82%) on room air.
His past medical history included an inferior wall non-ST elevation myocardial infarction, diabetes mellitus type II, peripheral vascular disease, hypertension, and dyslipidaemia. Three-vessel CABG was performed after his non-ST elevation myocardial infarction. Pre-operation assessment including transthoracic echocardiography and heart catheterization demonstrated no evidence of pulmonary hypertension (PH); pulmonary function testing did not show significant lung disease.
On admission, electrocardiogram showed new incomplete right bundle branch block and inverted T waves in V1–6. Laboratory results were notable for troponin T 0.032 ng/mL. Transthoracic echocardiography demonstrated a new finding of a dilated and hypokinetic right ventricle with a ‘D-shaped’ left ventricle and elevated systolic pulmonary artery pressure (62 mmHg) (Figure
). Pulmonary function testing was normal; computed tomography angiography (CTA) of the chest ruled out pulmonary embolism.
The patient was treated with diuretics with improvement of symptoms and referred to an outpatient pulmonologist and cardiologist for further assessment. These recommendations were not followed.
A year and a half later, he was admitted for decompensated congestive heart failure, primarily right-sided, with oedema, to the point of anasarca. Cardiac CTA showed no evidence of constrictive pericarditis or new coronary artery or graft disease. Pulmonary ventilation/perfusion scan showed no perfusion defect as evidence of pulmonary embolism. Other causes for PAH such as human immunodeficiency virus, hepatitis, and rheumatic disease were ruled out. Right heart catheterization confirmed severe PH with a mean pulmonary arterial pressure of 38 mmHg (66/24 mmHg absolute), right atrial mean pressure 17 mmHg, RV systolic pressure 70/5 mmHg, and cardiac output 5 L/s, with peripheral vascular resistance 5.4 Wood units, pulmonary wedge pressure 11 mmHg, and the left ventricular end-diastolic pressure 12 mmHg.
After ruling out all other PH groups, it was concluded that the patient suffered from Group 1 PAH (idiopathic PAH). Treatment was commenced with sildenafil citrate 20 mg, three times daily. The patient responded well to treatment and was discharged from the hospital to continue outpatient treatment and follow-up. However, the patient was again lost to follow-up and eventually passed away while hospitalized in a different hospital.


A 62-year-old female patient presented with a sharp decrease in vision in her right eye (OD). Her best-corrected visual acuity (BCVA) was 20/1500 in the OD and 20/20 in the left eye (OS), intraocular pressure was 13 mmHg, and anterior segment was normal in both eyes. No pathological history of interest was elicited such as trauma or metabolic diseases such as diabetes, hypothyroidism, or others. Dilated fundoscopy showed a small operculum attached to the avulsed vessel that may have resulted from a slight retinal tear, but we could not evaluate the posterior pole due to vitreous hemorrhage in OD. The OS fundus was normal. Ocular ultrasound evidenced concordant dense opacity with vitreous hemorrhage [] and an attached retina in OD.
At 4 weeks of follow-up, there was a progressive recovery with BCVA of 20/25. In the fundoscopy, there was an evidence of a mobile and avulsed peripheral vessel in the temporal sector [] associated with hemorrhagic remnants on the retinal surface [–]. In the following 8 weeks, the vitreous hemorrhage resolved with visual recovery to 20/20. The patient refused to undergo a surgical treatment, so the vessel was photocoagulated peripherally.
At 8 months of follow-up, the patient had recurrence of vitreous hemorrhage and peripheral vascular avulsion associated with bleeding persisted, so she was treated again with photocoagulation due to her refusal to undergo surgery []. Eighteen months later, the vitreous hemorrhage recurred again associated to the lesion, similar to what was observed on the optical coherence tomography where the cross-section of the avulsed vessels was seen []; therefore, it was decided to perform a 23G pars plana vitrectomy and treat the lesion with endolaser. The patient recovered 20/20 vision in OD without further complications [].


A 65-year-old gentleman was brought in via ambulance as a resuscitation call through the Accident and Emergency (A&E) department. He reported symptoms of difficulty breathing, facial swelling (), and voice of a nasal quality. He was discharged 3 days prior from a Cardiothoracic Unit of another hospital following an elective left upper lobectomy for a suspicious lesion. He was sent home with dihydrocodeine, having never taken any opioid-based medications prior to this. He suffered from hypertension and took amlodipine. He was a non-smoker and had not had any lung problems prior to this. There was no significant family history of note.
The paramedics initially treated him as an allergic reaction to dihydrocodeine. He was given 200 mg of hydrocortisone and 10 mg of chlorphenamine with no effect. However, on arrival to A&E, he was noticed to have widespread crepitus extending from his peri-orbital muscles down to mid-torso. His airway was patent with a high-pitched voice. He was tachypnoeic at 30 breaths per minute and was saturating at 86% on room air (94% on 15 L of oxygen). He was tachycardic at 130 and hypertensive at 168/72. Lung and heart sounds were inaudible due to background crepitus. He was otherwise apyrexic and not complaining of any pain.
Routine blood tests (full blood count, liver function tests, urea and electrolytes and clotting) were normal in A&E and prior to discharge from the Cardiothoracic Unit. CT scan revealed a pleuro-cutaneous fistula at the site of a recently sited chest drain, with extensive emphysema and a pneumothorax, maximum distance of 7 cm from mediastinum to chest wall ( and ).
Due to respiratory compromise, the patient required urgent draining prior to transfer to a Cardiothoracic Unit. We had deliberated the use of surgical thoracostomy but due to the long distance between skin and chest wall (10 cm) as well as underlying distorted anatomy, it was felt that an ultrasound-guided intercostal Seldinger drain would be safer. The range of ultrasound imaging was, however, limited due to interference from the subcutaneous emphysema. Discussions were held with Consultant Radiologists and Consultant Cardiothoracic Surgeons, and it was felt that the procedure could not be delayed due to potential risks to the patient. The two options available were opening up the old drain site or placement of a new drain (blindly) into the safe triangle. We opted for the latter after discussions with the patient and secured the drain after two attempts. The patient was admitted to the Intensive Care Unit and managed conservatively. He was seen by a Cardiothoracic Surgeon and was transferred the following day for ongoing management. He remains an inpatient and continued to be managed conservatively.


A 47-year-old woman who was a lifelong non-smoker was referred to the pulmonary clinic for non-productive cough and exertional dyspnoea for the past 6 months. She worked as a manager in a trading company. Her medical, social, family, medication and travel histories were non-contributory. She had initially consulted another institution for similar symptoms 6 months prior. Full blood count (FBC) then showed mildly raised absolute eosinophil count of 0.98×109/L (differential eosinophil count 13.6%). Chest radiograph was normal (). Spirometry was normal with no bronchodilator response and the flow-volume loops were also normal. She did not have symptoms of allergic rhinitis or gastro-oesophageal reflux disease or atopy. She was treated for possible asthma with budesonide 160 µg and formoterol 4.5 µg combination turbuhaler, two puffs twice daily. In view of her lack of response to treatment, she was referred for further evaluation at our centre. Further history obtained during her visit to our clinic revealed that she had no fever, weight loss or night sweats. Clinical examination showed no clubbing or cervical lymphadenopathy.