A 67-year-old Caucasian male presented to the emergency department with progressively worsening headache that started 5 weeks prior. He described his headache as constant, sharp, localized to bilateral temporal regions with radiation to the eyes, waking him up from sleep and minimally relieved with Ibuprofen use. He denied having similar symptoms in the past. Four weeks after his headache started, he noted new left eyelid drooping with tearing, redness, double and blurry vision (). The double vision had resolved upon presentation. In addition, he also described myalgias in all four extremities for ~2 weeks, limiting him from lifting his arms above his head or getting up from a squatted position. Past medical history was notable for COPD, hypertension and 80 pack-year smoking history. Physical exam was significant for trace left ptosis, conjunctival injection; visual acuity was 20/70 in the right eye and 20/50 in the left with unremarkable appearance of the optic nerves.
Laboratory studies obtained were significant for elevated C-reactive protein: 14.4 [reference range (RR): <1.0 mg/dl] and erythrocyte sedimentation rate: 54 (RR: 0–20 mm/h). Other laboratory work including thyroid stimulating hormone, creatinine kinase, vitamin D level, antinuclear antibody, rheumatoid factor and anti-citrullinated protein antibody were unremarkable. Computed tomography (CT) of the chest showed non-calcified pulmonary nodules without any concerning features. This constellation of findings was highly suspicious for temporal arteritis associated with polymyalgia rheumatica and he was immediately started on 1000 mg of intravenous Methylprednisolone given daily for 3 days. Imaging studies including CT, magnetic resonance imaging, and magnetic resonance angiogram of head and neck were noted to be unremarkable. Bilateral temporal artery biopsy was obtained, which showed panarteritis, predominantly lymphocytes admixed with few histiocytes and occasional eosinophils. Giant cells were not seen. Elastic stain highlighted the disruption of internal elastic lamina ( and ).
Patient reported improvement in symptoms after 2 days of steroids and he was discharged on a Prednisone taper. Two weeks after discharge, he reported feeling much better with only very mild headache and no visual symptoms at all ().


A 35-year-old man from Bihar, presented to our emergency department in unconscious state, with high-grade fever and vomiting since last 5 days. His relatives gave the history of headache for last 6 months. For his persistent headache, a magnetic resonance imaging (MRI) of brain had been done at an outside hospital 10 days earlier, which showed a left parasellar-middle cranial fossa mass extending via the foramen ovale into the left infratemporal fossa and its dural based and looks most likely like an invasive meningioma (). Patient had no recent history of travel or contact with other COVID-19 patients. On examination, Glasgow Coma Scale (GCS) was E1V1M2, chest auscultation showed normal vesicular breath sounds, heart rate (HR) 127/minute, blood pressure (BP) 138/87 mm Hg, temperature 104°F, respiratory rate 36/minute, and SPO2 was 95% on room air. A plain computed tomography (CT) scan of the head under our institutional COVID-19 protocol was immediately performed, which showed the mass as well as hypodensities in both thalami and left caudate nucleus (). According to Modified Early Warning Score, this patient was classified as suspected COVID-19 severe case with a score of 12/21 points and was admitted in a dedicated COVID-19 intensive care unit (ICU). Chest radiographs on the day of admission and next day in the isolation were within the normal limits (). In view of airway protection and poor GCS, trachea was intubated with endotracheal tube of size 8 mm by wearing complete personal protective equipment (PPE) zone III protection gear and patient was put on synchronized intermittent mandatory ventilation (SIMV) mode of mechanical ventilation. As per Centers for Disease Control and Prevention (CDC) recommendations, nasopharyngeal swab was collected under recommended biosafety precaution. It was placed in viral transport medium (VTM) and sent to laboratory maintaining cold chain. CDC/WHO recommended real-time PCR was performed and ORF1b gene of SARS-CoV-2 was detected in this patient. On the day of admission, cerebrospinal fluid analysis showed increased protein and no bacterial growth, and tests for herpes simplex virus 1 and 2, and varicella zoster virus were also negative. The various laboratory parameters like Hb% of 14.4 g/dL, total leucocyte count (TLC) of 14.81 × 109/mm3, neutrophils 85%, lymphocytes 10%, and other parameters were within normal limit. His arterial blood gas (ABG) was pH: 7.51, PaO2: 131, PaCO2: 22, HCO3: 18, lactate: 1.3. Patient was managed with hydroxychloroquine 400 mg twice daily, azithromycin 500 mg once daily, and injection amoxicillin-clavulanic acid 1.2 g intravenous thrice daily, intravenous methyl prednisolone 1 g once daily, along with other standard ICU therapy. On second day, patient started showing features of raised intracranial pressure like increased BP, bradycardia, and papilledema. Patient was managed with propofol infusion and mannitol. An MRI brain was planned; however, patient had cardiopulmonary arrest and expired next day after about 36 hours of admission.


A 46-year-old Japanese man was admitted to our hospital with dizziness and
sudden-onset abdominal pain. His past medical history and family history
were unremarkable. On physical examination, blood pressure and body
temperature were 111/55 mm Hg and 37.3°C. Slight anemia was detected in the
palpebral conjunctiva. His abdomen was distended, and tenderness with
peritoneal irritation sign on the entire abdomen and a fist-sized palpable
mass in lower right abdomen were detected. The laboratory test results were
as follows: white blood cell count was 16 500/mm3, red blood cell
count was 372 × 104/µL, hemoglobin was 10.7 g/dL, hematocrit was
32.9%, creatine kinase was 478 IU/L, and C-reactive protein was 0.07 mg/dL.
A computed tomography (CT) scan showed fluid collection and a large
heterogeneous mass in the abdominal cavity ( and B). Based on a
diagnosis of intraabdominal hemorrhage from the intraabdominal mass, we
performed an emergency operation. Laparotomy revealed a 12 × 10 × 6 cm solid
tumor in the ileum with bleeding approximately 150 cm from the ligament of
Treitz, accompanied by a multitude of peritoneal metastases (). Partial
resection of the small intestine including the tumor was performed. Over 80
pieces of peritoneal metastases were individually coagulated by an electric
knife. Pathological examination showed that the tumor was composed of
spindle cells that were arranged in interlaced bundles with high cellularity
().
The number of mitoses was 12 per 50 high-power fields (HPFs; ).
Immunohistochemical staining showed that the spindle cells were diffusely
positive for KIT, CD34, and DOG1 and negative for desmin and S-100 protein
().
The Ki67 labeling index at the hot spot was 23% (). Based on the
above-mentioned findings, the tumor was diagnosed as a high-risk malignant
GIST of the small intestine. KIT mutation analysis showed that the tumor had
a mutation at exon 11 of the KIT gene. On the 14th postoperative day, an
oral administration of IM at 400 mg per day was started. The administration
of IM has been performed during 12 years without an interruption or a dose
change, because the regimen was well tolerated with no adverse events. The
patient has been followed-up for 12 years with no evidence of recurrence.
However, 12 years after surgery, follow-up CT revealed a mass 6 cm in
diameter in the abdomen (). Positron emission tomography with
18-fluorodeoxyglucose (FDG-PET) revealed no other sites of FDG uptake except
for the known tumor in the abdominal cavity. Based on a diagnosis of
recurrent GIST, tumor resection was performed. The tumor adhered to the
greater omentum but was not invasive (). The few nodules seen on
the small mesentery were also resected. The resected tumor measured 7.0 cm
in the largest diameter. At the cut surface, the tumor was solid, was
gray-white in color, and was associated with extensive hemorrhagic and
degenerative changes. Histologically, the tumor was composed of spindle
cells proliferating with high cellularity, and hemorrhagic and necrotic
tendencies were observed. The number of mitoses was 8 per 50 HPF ().
Immunohistochemical analysis showed that the spindle cells were positive for
KIT, CD34, and DOG1 and negative for desmin and S-100 protein (images not
shown). Ki67 labeling index at the hot spot was 14% (). The histological
pictures were almost identical to those of the specimen resected during the
first surgery, confirming the diagnosis of recurrent GIST. The molecular
examination indicated KIT exon 11 deletion mutations from Trp-557 and
Lys-558 in both the primary GIST and recurrent GIST. Additionally, a point
mutation was observed in the recurrent GIST in exon 17 from Asp-822 to
Lis-822. The patient is currently being administered sunitinib instead of IM
and has remained alive without any other recurrences 14 years after the
first surgery.


A 10-day-old male neonate was referred to our paediatric surgical department in the month of September 2019 with a cutaneous appendage arising from the lumbosacral region which had been discovered at birth. The neonate had been born by vaginal delivery and the mother had no history of illness, radiation exposure or drug intake during the antenatal period. In addition, there was no history of congenital anomalies in any of the family members or siblings.
Clinical examination of the new born found a 3.4 kg baby, with no dysmorphia, no anomaly of the limbs or genital organs. The lumbosacral examination found a 6-cm long-shaped soft tissue appendage arising and hanging down from the mid-sacral region, which was completely covered by skin and had no spontaneous movement ().
The mass of the appendage was f firm and was not sensitive. No bone or cartilage could be felt (). No abdominal mass or anal anomaly was detected.
A sacrococcygeal teratoma was suspected an alphafoetoprotein dosage was performed and it was normal.
Magnetic resonance imaging (MRI) of the spine showed no evidence of spinal dysraphism, suspecting the diagnosis of a true human tail ().
Surgical management was performed: a midline lozenge incision was done encircling the base of appendage. The subcutaneous lipoma was excised and there were no connection with soft tissue or sacroma as shown in the MRI ().
Microscopic examination confirmed the absence of any bony or cartilaginous structures. And showed lipoma without signs of malignancy or nerve tissue. The postoperative period was uneventful.


We present a 45 year-old lady who had initially been seen by the respiratory physicians following an admission with acute dyspnoea following influenza infection 1-year prior to her surgery. She had undergone CT scan for abnormal chest radiograph. She had previously worked as a cleaner and was an ex-smoker of 1.5 pack years with no previous asbestos exposure or underlying genetic disease such as tuberous sclerosis or alpha-1 antitrypsin deficiency. She had been followed up in the nodule clinic (a follow-up clinic run by respiratory physicians to monitor solitary pulmonary nodules) with a provisional diagnosis of chronic obstructive pulmonary disease. She had progressive dyspnoea and occasional lower respiratory tract infections treated with courses of antibiotics. Her co-morbidities included previous alcohol dependence and depression. Pre-operative pulmonary function tests demonstrated an FEV1 of 1.53 (53% of predicted), FVC of 2.52 (79% of predicted), diffusing capacity of lungs for carbon monoxide (DLCO) of 5.25 (62% of predicted) and 6 minute walking distance of 414 m. Initial CT imaging findings demonstrated severe, heterogenous right-sided bullous emphysematous changes with a basal predominance and multiple large bullae in the lower lobe () and a benign inflammatory nodule, which was 7 mm in size in the right upper zone presumably right upper lobe. There was associated hyperinflation causing mediastinal shift to the left with complete right middle lobe collapse and marked compression of the right upper and middle lobes. Due to her increasing symptoms and progressive solitary nodule () in the right upper zone she was referred for a surgical opinion. Pre-operative echocardiography did not demonstrate any right ventricular dilatation or impairment and no pulmonary hypertension. She was counselled regarding the progressive symptoms, lung function and risk of pneumothoraces and scheduled for right thoracotomy and lower lobectomy. Operative findings were that of large bullous disease affecting the right lower lobe () with subtotal destruction of the lung parenchyma of the lower lobe. The nodule was present in the apical segment of the lower lobe instead of the upper lobe as expected. Right lower lobectomy was completed un-eventfully and the specimen was sent for histology. The upper and middle lobes were hypoplastic and the post lobectomy space management was a challenge. Post-operatively recovery was complicated by prolonged post-operative air leak managed conservatively and once this eventually settled, the patient was discharged following removal of the chest drain. Histopathological analysis of the right lower lobe specimen demonstrated several large thin-walled cysts with interstitial clusters of spindle cells bordering the cyst and immuno-histological markers (increased expression of VEGF-R3, Podoplanin, LYVE-1 and PROX-1) confirming a diagnosis of LAM. The patient was seen in the thoracic surgery follow-up clinic and a CT abdomen/pelvis was organized to rule out renal angiomyolipomas, associated with LAM in tuberous sclerosis. Referrals were made to the respiratory physicians and the National LAM centre for ongoing management.


A 74-year-old woman was admitted because of right ankle pain swelling and gait impairment over the past month. She denied fever, weight loss, or night sweats. Her medical history was otherwise unremarkable. The ankle plain radiography disclosed an osteolytic lesion.
On physical examination, she was in good performance status (PS), and except for a minor swelling of the right ankle, the remaining physical signs were unremarkable. The hemogram was within normal limits, but the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were 61 mm/h and 7.45 mg/dL (reference range RR; <0-5 mg/dL) respectively. Serum calcium was 13.2 mg/dL (RR; 8.5-10.5 mg/dL) and lactate dehydrogenase was of (LDH) 683 U/L (RR; 230-460 U/L). Plain radiography of the right ankle revealed disruption of fibula’s architectural structure, compatible with an osteolytic lesion ().
Further imaging with Magnetic Resonance Imaging (MRI) demonstrated complete distortion of the architecture of distal fibular metaphysis by a pathological tissue that infiltrates the bone cortex and marrow and extends to the surrounding soft tissue. Other findings included multiple lesions, possibly attributed to metastatic neoplastic disease, on the lower half of the right tibia, fibula, talus, and metatarsal bones ().
Bone marrow (BM) biopsy, as well as neck, chest, and abdominal computed tomography, were free of disease.
Moreover, the patient underwent whole-body imaging with positron emission tomography/computed tomography (PET/CT) scan that revealed pathological uptake of 18-FDG by the whole skeleton, particularly cranial and long bones (). Many of these lesions’ sites were accompanied by soft tissue masses, particularly in the lower extremities and the maxilla (SUV max: 15). Increased 18-FDG uptake was also noted in the nasal and zygomatic bones, bilaterally (SUV max: 20), as well as in the cervical, iliac and inguinal lymph nodes (SUV max: 5.5) and regionally in BM (findings consistent with infiltrating disease).
The patient underwent a biopsy of the fibula. The histopathological examination showed diffuse infiltration of large-sized cells. Neoplastic cells expressed the B-cell associated antigens CD20, CD79a, PAX5, BCL-6, MUM-1, BCL-2 (80%) [BCL-2(124) Mouse Monoclonal Antibody -Cell Marque], SIg/CIgM(k) and C-MYC (> 40%) [c-MYC(Y69) Rabbit Monoclonal Primary Antibody-Roche]. The expression of CD3, CD4, CD8, CD5, CD23, CD30, CD10, CyclinD1 was negative. Additionally, in situ, hybridization for EBER was negative. The proliferation fraction, as detected by Ki-67 (MIB-1 antigen), was 90%. Fluorescence in situ hybridization (FISH) tests did not reveal rearrangement for C-MYC and BCL2 genes. The above histological findings were compatible with the diagnosis of DLBCL not otherwise specified, DLBCL-NOS with no germinal center B-cells (non-GCB) phenotype, and double expression of C-MYC and BCL-2 (, , , ).
Thus, the patient was diagnosed with a multifocal double expressor DE-PLB, stage IVEA according to Ann Arbor classification with International Prognostic Index (IPI) score: 5, age-adjusted IPI score: 3, and NCCN-IPI [International Prognostic Index for patients with diffuse large B-cell lymphoma) score: 7 (high risk).
During the hospitalization, the patient experienced a pathological fracture in the lower third of the right femur, which was treated surgically. However, it has aggravated her PS to 4, according to ECOG. Subsequently, the patient received prophylactic local radiotherapy (RT) with a total dose of 36cGy, in the lower third of both legs and was treated with 2 cycles R-CNOP (Rituximab- Cyclophosphamide, Mitoxantrone, Vincristine, and Prednisone). Unfortunately, she experienced septic shock during the neutropenic phase after the 2nd cycle of R-CNOP and succumbed to multiorgan failure.


A 32-year-old Caucasian male presented to the Ophthalmology Service at the Rocky Mountain
Regional Veterans Affairs Medical Center for evaluation of several months of bilateral eye
redness and blurry vison. Review of systems was notable for simultaneous onset of diffuse
erythema, tenderness, induration, and pruritus of a large black ink tattoo over the right
arm and chest (). This
tattoo was inked 1 year prior to presentation. He had 2 other tattoos completed 10 years
before, which were unaffected ().
At the time of initial presentation, ophthalmological examination with slit lamp revealed
anterior chamber inflammation and iris synechiae. On optical coherence tomography, there was
evidence of macular edema (). Skin examination was significant for inflammation, induration, and scant
desquamation in a pattern that closely matched the borders of the tattoo. Lungs were clear
to auscultation. The rest of the history and physical examination was unremarkable.
No clinical or serological evidence for other uveitis-associated diseases was elicited,
including infections, sarcoidosis, or spondylarthritis. Comprehensive metabolic panel,
complete blood count, urinalysis, thyroid stimulating hormone, free T4, ferritin, creatine
phosphokinase, and aldolase tests were within normal limits. Erythrocyte sedimentation rate
was 13 mm/h, and serum angiotensin-converting enzyme concentration was 86 U/L (14-82).
C-reactive protein, HLA-B27, antinuclear antibody, antineutrophil cytoplasmic antibody
(including cytoplasmic, perinuclear, and atypical ANCA), lysozyme, QuantiFERON, HIV,
hepatitis B and C serologies, rheumatoid factor, anticyclic citrullinated peptide
antibodies, and computed tomography of the chest were all within normal limits. Punch
biopsies of the affected skin were obtained. Histological examination revealed granulomatous
inflammation with associated tattoo ink deposition consistent with foreign body-type
granulomatous reaction ().
Melan A immunostain highlighted scattered single junctional benign melanocytes with control
samples staining appropriately.
The patient was initially treated with topical ocular glucocorticoids without significant
improvement. He then required oral methylprednisolone 24 mg daily, tapered to 4 mg daily
over 6 days. This agent led to rapid resolution of the inflammatory tattoo changes, but not
of the macular and optic disc edema. A sub-tenon’s triamcinolone injection to both eyes
resolved his ocular manifestation; however, tapering of his systemic glucocorticoids caused
his tattoo manifestations to reappear. Adalimumab at 40 mg subcutaneously every other week
satisfactorily terminated all of his symptoms. Unfortunately, after 3 months of therapy,
patient developed an injection site reaction. Certolizumab 200 mg SQ every 2 weeks was
instituted. A follow-up examination 4 months later revealed minimal, if any, subtle
inflammation in both eyes, mild worsening of the macular edema in his left eye, and visual
acuity of 20/20 by Snellen chart.


A 50-year-old male presented with a 1-month history of low-grade fever, myalgia, and breathlessness on exertion. On physical examination, his blood pressure was 136/80 mmHg and pulse rate was 108/min and regular. Electrocardiography showed normal sinus rhythm with mild ST-T changes. The patient was planned for echocardiography followed by coronary angiography (CAG) if needed.
2D transthoracic echocardiogram was done using a 3.0 MHz transducer and a Vivid S5 cardiac ultrasound system (GE Healthcare, Milwaukee, WI, USA). Parasternal long-axis view was taken, which showed normal motion of the left ventricle with no abnormality in the left atrium and the right ventricle []. Then, apical four-chamber view was taken, which revealed a large atrial myxoma in the right atrium occupying most of the right atrium and moving toward the tricuspid valve [ and ]. It was a heterogeneous mobile pedunculated mass. For further confirmation, transesophageal echocardiography was done, which confirmed the presence of a large (21 mm × 43 mm) myxoma in the right atrium [ and ].
Management was planned for surgical excision of the myxoma. Before surgery, CAG was done to find any concomitant CAD. CAG was done by right radial artery approach, and multiple views (right anterior oblique caudal, left anterior oblique caudal, and anteroposterior cranial) were taken for both left and right coronary systems. CAG showed single-vessel disease comprising 100% occlusion of the left anterior descending coronary artery with mild plaquing in the left circumflex coronary artery [Figures and and Videos -].
Cardiac surgery opinion was taken for further management, and the patient was planned for coronary artery bypass grafting (CABG) with myxoma removal. During surgery, CABG was done and right atrial myxoma measuring 5 cm × 3 cm × 2 cm was excised [Figures and ].


A 70-year-old gentleman presented with a painless swelling in the right thigh for 7 months, which was spontaneous. He had a history of femur shaft fracture, for which open femur nailing was done 10 years ago. Postoperatively, he had uneventful wound healing and fracture union. He has no recollection of any complications following the surgery and was able to walk full-weight-bearing without any aid. Clinically, he had a large diffuse swelling on the anterolateral aspect of the right thigh which was around 10 cm × 8 cm. The swelling was firm, non-tender, and non-pulsatile, with ill-defined margins. The presence of a longitudinal scar along the entire length of the lateral aspect of the thigh was noted, which had healed by primary intention (). The right hip and knee movements were normal. Routine hematological tests were done, including erythrocyte sedimentation rate and C-reactive protein. All the blood reports were normal.
X-rays of the femur were done in anteroposterior and lateral views () which showed an irregular, hypertrophic cortical reaction with the bony remodeling in the proximal femur and an excavated lateral femoral cortex with a broken intramedullary nail in situ.
Magnetic resonance imaging (MRI) of the right thigh was done, which showed a large, well defined, and heterogenous soft-tissue mass on the anterolateral aspect (T1 and T2 images). Post-contrast images showed a heterogeneous and patchy uptake (). These findings were consistent with a soft-tissue tumor. We, however, did not perform a computed tomography (CT) scan for this patient.
After the MRI, we decided to do a closed needle biopsy along the previous surgical scar under local anesthesia in the operating theatre. The biopsy report was inconclusive, demonstrating fibrinous blood material and granulation tissue suggestive of a chronic hematoma.
As the patient was symptomatic, we decided to plan a surgical excision of the lesion. Under epidural anesthesia, in the supine position. The skin incision was taken along the previous scar on the lateral aspect of the thigh. Granulation tissue and fibrosed muscles overlying the mass were carefully separated. We noticed a mass adherent to the lateral aspect of the femur extending intramedullary up to the implant. Using a cautery, we separated the mass from the bone extending up to the intramedullary nail. The excised specimen measured 24 cm in length and 15 cm in breadth. An intraoperative frozen section analysis was done that revealed a chronic inflammatory reaction and no evidence of sarcoma. The defect after excision of the mass was filled with frozen allograft. The excised specimen was solid with a fibrotic wall; on gross examination, after dissecting the specimen, a mop was found ( and ).
The sample was sent for histological study which revealed fibrous strands, clots, hemolyzed pigments of red blood cells inflammatory cells, and multiple fiber strands. The foreign material was studied under polarized light () and confirmed the diagnosis of gossypiboma by demonstrating cotton fibers. The specimen was reported as an accumulation of blood products and their degraded components and not a tumor.
The patient had an uneventful surgical procedure and was mobilized and rehabilitation was started on day 1 postoperatively.


A 22-year-old female present with a lemon-sized painless swelling of the palm, with a history of smaller swelling in the same region 6 years ago, for which 4 years, ago surgical intervention in the form of excisional biopsy was carried out at a hospital in Bihar. Histopathological examination confirmed the diagnosis with giant cell tumor of flexor tendon sheath, and the patient remained asymptomatic till 8 months. After 8 month of surgery, small peanut size swelling had recurred. The swelling was slowly increasing in size, and over the past 3 years, the patient developed pain in this swelling associated stiffness in the hand functions. Physical examination revealed local swelling of 5 cm ×5 cm, which is nodular, non-tender, firm, non-adherent to overlying skin, and moved on flexion of fingers (). The range of movement of proximal interphalangeal joint and distal interphalangeal joint was restricted with flexion contracture of fingers which had developed. The patient did not have any other complaint or constitutional symptoms such as night sweats, fever, or weight loss. Blood investigations were normal with the non-reactive status of Rh factor, anti-CCP, HIV, and HbsAg.
The patient was investigated with a plain radiograph (), which showed soft-tissue shadow of the mass and scalloping of underling metacarpal bone over the volar cortical margin. Magnetic resonance imaging was done, which demonstrates encapsulated mass over flexor tendon sheath. Excision biopsy was performed by surgical removal (), two nodular mass measuring 6×5×3 and 2.5×2.0×1.5 was removed. Both masses sent for histopathological examination ().
HPE section shows fibroblastic proliferation with the present of scattered inflammatory cell infiltration with a multinucleated giant cell. No evidence of significant atypia. No evidence of mitosis/necrosis. A diagnosis of GCTTS was finally made.
The recovery following surgery was uneventful. There was no local tenderness, and the patient had an increased range of motion of finger with only restricted terminally (). During 12-month follow-up period, there was no evidence of local tumor recurrence on clinical and ultrasonographic examination.


A 75-year-old male weighing 50 kg and having a height of 165 cm was scheduled to undergo right upper lobectomy for the treatment of non-small cell lung cancer. His significant medical history was chronic obstructive pulmonary disease (COPD) and was a 55-pack-year smoker. The preoperative pulmonary function test showed a moderate obstructive pattern with a forced expiratory volume of 1.64 L (61% of predicted) in one second. The chest computerized tomography revealed subsegmental atelectasis in bilateral lower lobes and right middle lobe, emphysema with bullae in bilateral lungs (), and scanty right pleural effusion. An electrocardiogram (ECG) performed before the surgery showed right bundle branch block, and transthoracic echocardiography revealed normal left ventricle (LV) global systolic function (ejection fraction [EF] = 58%) and abnormal relaxation of LV filling pattern.
The patient received 0.2 mg of glycopyrrolate intramuscularly as a premedication. On arrival in the operating room, intraoperative monitoring was performed including ECG, non-invasive blood pressure, pulse oximetry, bispectral index, and capnography. The immediate preoperative vital signs of the patient were as follows: systolic/diastolic blood pressure of 112/74 mmHg, a heart rate of 90 beats/min, and Oxygen saturation (SpO2) of 96%. After preoxygenation with 100% oxygen, general anesthesia was induced with intravenous 70 mg of propofol, 20 mg of lidocaine, and continuous infusion of remifentanil. After confirming adequate mask ventilation, 60 mg of succinylcholine was given to facilitate passage of a double-lumen endotracheal tube (DLT), after which neuromuscular blockade was maintained with intermittent boluses of intravenous rocuronium. The trachea was intubated with a 37 Fr. left-side DLT (Mallinckrodt™, Covidien Inc., Ireland) under direct laryngoscopy. The DLT position was confirmed by chest auscultation and fiberoptic bronchoscopy. A left radial artery catheter and a central venous catheter were placed via the right internal jugular vein. Arterial blood gas analysis (ABGA) during two-lung ventilation (FiO2 0.6/end-tidal CO2 concentration [EtCO2], 34 mmHg) revealed pH 7.369, PaCO2 40.6 mmHg, PaO2 256.3 mmHg, and SaO2 99.8%. The patient was placed in the left lateral decubitus position for the planned video-assisted thoracoscopic surgery (VATS), and DLT positioning was again confirmed with fiberoptic bronchoscopy.
General anesthesia was maintained with balanced anesthesia using oxygen-air-sevoflurane (1–2 vol%) and continuous infusion of remifentanil. After endotracheal intubation, 40 mg of rocuronium was administered and an additional dose of 10 mg was administered twice until the event described below occurred. Mechanical ventilation during OLV was initiated using pressure-controlled ventilation-volume guaranteed mode with a tidal volume of 300 ml and a respiratory rate of 14 breaths/min. After about 30 min of procedure, VATS was converted to thoracotomy due to surgical site adhesion. Peak airway pressure (PAP) was 14 cmH2O during two-lung ventilation. After OLV, the PAP was 25 cmH2O initially and gradually increased to 35 cmH2O within 10 min. SpO2 gradually decreased from 97% to 80% during the next 5 min. As a rescue measure, two-lung ventilation was performed for several minutes and SpO2 increased to 96%. After reapplication of the OLV, SpO2 gradually decreased from 98% to 70%. Inspired oxygen was increased from 60% to 100%, and two lung ventilation was reinstituted. Oxygen saturation increased to 95% for approximately 5 min. Systolic blood pressure decreased to 70 mmHg; subsequently, 100 µg of phenylephrine was administered twice and infused continuously. However, blood pressure was maintained as 85/60 mmHg. The ABGA (FiO2 1.0, EtCO2 23 mmHg) was checked and the outcomes were pH 7.223, PaCO2 60.9 mmHg, PaO2 61.9 mmHg, and SaO2 85.6%. Dopamine infusion (10 µg/kg/min) was started and systolic blood pressure was maintained above 100 mmHg. With intermittent suction of the DLT, oxygen insufflation into the non-dependent lung and dopamine administration, SpO2 was maintained between 85–90% during OLV. Subsequently, the PAP was noted to be about 35 cmH2O (maximum 37 cmH2O). We did not apply positive end-expiratory pressure to the dependent lung because of the high PAP. Nearly 2 h after the operation, systolic blood pressure suddenly dropped below 80 mmHg and fell below 50 mmHg within 1 min, SpO2 decreased from 90% to 70%, and EtCO2 decreased to 17–18 mmHg. Almost immediately, the arterial waveform disappeared and asystole was revealed on ECG. Two-lung ventilation was reinstituted and the surgical site was temporarily closed using dressing films. The patient was placed in the supine position and resuscitated with atropine and epinephrine, and the surgeon started closed cardiac compression. At the same time, we asked for help in applying ECMO. About 17 min later, recovery of spontaneous circulation achieved. Nearly at the same time, veno-arterial (VA) ECMO was also started via the right common femoral artery and common femoral vein. On auscultation, lung sound of the left lung field was decreased markedly. Tension pneumothorax of the dependent left lung was suspected. Portable chest X-ray revealed tension pneumothorax of the left lung () and a chest tube was inserted immediately. Follow-up chest X-ray showed re-expansion of both the lungs (). The patient was returned to the left lateral decubitus position, and the right upper lobectomy was performed after the right lung was selectively collapsed. At this time, the left lung was ventilated with a tidal volume of 250 ml and a respiratory rate of 13 breaths/min, and PAP was about 35 cmH2O. After completion of the surgical procedure, the DLT was replaced with a single lumen endotracheal tube of 7.5 mm internal diameter, and the patient was hemodynamically stable. He was transferred to the intensive care unit while maintaining VA-ECMO.
Immediate postoperative echocardiography revealed moderate LV global and severe right ventricle (RV) free wall motion abnormality and decreased LV systolic function (EF = 40%). On the 10th day, transthoracic echocardiography showed normal LV global wall motion but still severe RV free wall motion abnormality was apparant. On the 14th day, echocardiography revealed normal RV free wall motion. Finally, ECMO was weaned off and the patient’s trachea was extubated.


A 72-year-old Chinese man with chronic nuchal pain complained of progressive difficulty in lifting the head over the last 2 years. He also developed difficulty walking due to the loss of horizontal gaze. Past history was notable for hypertension under control. The patient reported no history of trauma and no known neurological deficits. Prior workup by an orthopedic surgeon and a neurologist excluded the diagnosis of any cranial, neurological or autoimmune diseases. A muscle biopsy from the left trapezius muscle demonstrated nonspecific myopathic features. Cervical collar, oral non-steroidal anti-inflammatory medication and exercise rehabilitation were ineffective in correcting his posture for the past 1 year. The patient then sought chiropractic care for his condition.
Upon examination, the patient ambulated with a cane to maintain balance. Gaze was down at the floor, instead of forward. Pronounced head drop with neck flexion caused the chin to rest on the chest in standing or sitting. The center of gravity plumb line (COG PL, red dashed line) is considered a virtual gravity line of the entire body (). Measurements of cervical range of motion (ROM) showed restriction of active motions, where active versus passive extension ROM (normal range: 70°) was 10°/54°, and active versus passive rotation ROM (normal range: 90° to both sides) was 58°/72° each side. The head was able to be passively raised up by hands and the neck deformity resolved when lying supine. Pain intensity of the neck was rated 3-4/10 on an 11-point numeric pain rating scale, where 0 means no pain and 10 means the worst imaginable pain. Motor strength measurement of the cervical extensors with a handheld dynamometer was graded at 4+/5. The patient could maintain the head up with extreme effort only for a couple of minutes. EOS® radiographies ( and ) revealed reverse lordosis (CobbC2-C7 −16°), cervical disc space narrowing with grade 1 anterolisthesis at C3/4 and C4/5 levels (red arrows), and C5-C6 ankylosis (hollow arrow). COG-C7 sagittal vertical axis (SVACOG-C7) ⩾30 mm (red solid line) is regarded as occiput-trunk discordance and SVAC2-C7 ⩾40 mm (purple solid line) is considered to be cervical sagittal imbalance. Needle electromyography revealed myopathic changes in the cervical muscles. Clinical pictures and histological findings were consistent with INEM associated with cervical spondylosis.
The chiropractic regimen consisted of upper thoracic spine manipulation, electrical muscle stimulation (EMS), cervical extension exercises and cervical collar. The splenius capitis, semispinalis capitis, semispinalis cervicis, and trapezius are the key muscles for cervical extension. In order to correct dropped head posture and relieve neck pain, these muscles need to be strengthened specifically. In the presence of instability at C3/4 and C4/5 levels, cervical manipulation was contraindicated. An upper thoracic manipulation was cautiously delivered instead. An inflatable air pump cervical collar was prescribed to maintain neck posture and to relieve neural compression when patient was at home. Greater functional range of active cervical motion was obtained after 2 weeks of treatment 5 times per week. Subsequently, in addition to manipulative therapy, EMS of the neck extensors and cervical extension exercises for muscle strengthening were added in each treatment session. Treatments were delivered 3 times weekly for further 3 months. Dropped head state was almost corrected and neck pain was fully resolved near the completion of treatment. The patient resumed normal daily activities and continued monthly follow-ups. At the 6-month follow-up, he regained upright posture of the head and global sagittal balance (). Repeat standing full-spine EOS® ( and ) depicted substantial improving of most of the radiographic parameters except SVAC7-S1. The C7 plumb line (white dashed line) should fall within 30 mm, either anterior or posterior, to the posterosuperior endplate of the S1. His SVAC7-S1 moved posteriorly (from −37 to −66 mm), indicating negative sagittal balance.


The first time M.S. came at our Department, she was a 21-year old female patient that had her left clavicle broken during her delivery. Her left arm appeared bigger and darker in color than contralateral one since early age. When she was 4-year old, she underwent an arteriography, which demonstrated the presence of an AVM affecting the proximal third of the left omerus where a muscular perforator of the omeral artery was directly connected to the left omeral vein with no interposing capillary network. Furthermore, an Rx showed initial sign of omeral bone erosion. Selective arterial embolization was then performed. When she was 7-year old, a second super-selective arterial embolization was performed, and bone-cement was implanted in the omeral bone to prevent spontaneous rupture. She was diagnosed with Albrigth syndrome when at 11-year old a CT scan demonstrated fibrous dysplasia of both femours and left tibial bone. Hand involvement became evident when she was 12-year old: she complained of pain at the left 5th digit and ulnar edge of forearm along with fever (). In the following three years, she was subjected to serial selective arterial embolization. When she was 17-year old, selective arterial embolization of two massive fistulas at the level of the elbow was performed and was complicated by left cephalic vein thrombophlebitis. The following year, severe fever, swelling and pain to the left upper limb were symptoms of bacterial dermoipodermitis, followed by septic shock and massive hemorrhage coming from the dorsum of the left hand (). Applying a compressing garment left in place for two months stopped hemorrhage, and proper antibiotic administration plus resuscitation measures were able to prevent septic shock from creating further complications. The resulting wound was left to heal for secondary intention with a resulting retracting scar (). During the following three years numerous lymphatic fistulas and infections occurred at her left upper limb, furthermore her forth left-hand digit had to be amputated. Eventually we lost the patients during follow-up ().


A 63-year-old female presented with a one-month history of left shoulder and arm weakness. She denied any history of numbness, paresthesia, pain, trauma, stretch injuries, or constitutional symptoms. Examination of her left shoulder showed marked atrophy of the C5 musculature, especially the deltoid, biceps. The strength of wrist extensor in both sides was normal. Passive range of motion was unrestricted in all planes, which means no evidence of capsular tightness. Medical Research Council grade strength of deltoid 1/5, biceps 1/5, triceps 4/5. () Other neurologic function was normal. Magnetic resonance imaging (MRI) of left shoulder showed no obvious evidence of a rotator cuff tear. MRI of the cervical spine indicated multilevel spondylotic changes, both C4–5 level and C5–6 level were included. While the C4–5 level was the most severe segment. The axial MRI of C5–6 level revealed that the space on both sides of neural foramina were acceptable. MRI T2-weighted imaging and CT myelography axial imaging at the C4–5 level showing large right paracentral disc herniation without myelomalacia. There was direct compression of the right anterior horn of the spinal cord on axial images. What is noteworthy was that the left neural foramen seemed to be narrower than the right one. () Electromyography (EMG) changes of denervation were most prominent in the left deltoid and biceps, while the thoracic paraspinal muscles and lower limb muscles were not involved obviously. Neurology consultation excluded amyotrophic lateral sclerosis (ALS) and other neurology-related diseases.
This atypical case is different from the CSA prior reported study, but large right paracentral disc herniation in C4–5 level was diagnosed clearly. We speculated that there was some relationship between disc herniation in C4–5 level and clinical symptoms to some extent. After obtaining informed consent, the patient underwent anterior cervical discectomy and fusion technique in C4–5 level. Six weeks postoperatively, the patient’s biceps recovered some strength. Physical examination demonstrated elbow flexion of grade 4/5, deltoid function 2/5, and external rotation 1/5. Twelve weeks postoperatively, patient’s symptoms obviously recovered. Physical examination demonstrated elbow flexion of grade 5/5, deltoid function 3/5, and external rotation 3/5. Atrophy of the deltoid and biceps showed notable improvement. Contour of biceps was clearly visible when compared to preoperation. ()
MRI of the cervical spine at 12 weeks after operation revealed the compression of the spinal cord was removed, and the compressed dural sac notably recovered. Both neural foramens were apparently enlarged than pre-operation. ()
The patient was pleased with her functional improvement, and was now able to perform activities of daily living including feeding and personal hygiene.


A 54-year-old woman who developed chest pain and dyspnea, without any cardiovascular risk factors and a family history of coronary heart disease, was admitted to our hospital with the diagnosis of acute myocardial infarction. A physical examination showed a body temperature of 36.5°C, pulse rate of 84 beats/minute, respiratory rate of 20 breaths/minute, and blood pressure of 149/104 mmHg (1 mmHg =0.133 kPa). Coarse breathing sounds and moist rales were heard in both lungs. A cardiac examination was unremarkable. An electrocardiogram (ECG) showed sinus rhythm and ST-segment elevation in leads II, III, and aVF (). Laboratory tests showed a creatine kinase-MB (CK-MB) level of 70.00 ng/mL (reference range, 0–4.3 ng/mL), myoglobin level of 759.00 ng/mL (reference range, 0–107 ng/mL), and cardiac troponin I (cTNI) level of 7.43 ng/mL (reference range, 0–0.05 ng/mL). The patient was diagnosed with acute inferior ST-elevation myocardial infarction (STEMI). After obtaining informed consent, the patient underwent diagnostic coronary angiography (CAG). CAG showed an SCA arising from the left sinus of Valsalva, without an RCA from the right sinus of Valsalva. Additionally, there was severe stenosis, with up to 95% in the mid-distal left anterior descending (LAD) artery, and a normal left circumflex artery. The proximal LAD gave rise to the right ventricular branch and the distal LAD artery continued to be the posterior descending artery ().
A 3.0 × 29-mm drug-eluting stent was deployed in the mid-distal LAD artery. Percutaneous coronary intervention (PCI) was successful, without any perioperative complications. The patient was managed with antiplatelets, anticoagulants, coronary artery dilators, lipid-lowering agents, and symptomatically. One week later, the patient was discharged from the hospital.


A 67-year-old man who had a history of hypertension and diabetes for 6 years, without a family history of coronary heart disease, presented with complaints of chest pain and shortness of breath for 2 hours. A physical examination showed a body temperature of 36.0°C, pulse rate of 72 beats/minute, respiratory rate of 19 breaths/minute, blood pressure of 162/98 mmHg, and moist rales was heard in both lungs. An ECG showed sinus rhythm and ST elevation in leads V1 to V4 (). Laboratory tests showed a CK-MB level of 25.70 ng/mL and a cTNI level of 7.16 ng/mL. The diagnosis of acute extensive anterior STEMI was made. CAG showed total occlusion of the proximal LAD artery with thrombus burden, no major stenosis of the left circumflex artery, and an invisible RCA. The distal LAD artery gave rise to the right ventricular branch and posterior descending branch ().
After obtaining consent from the family, we proceeded to primary PCI, thrombus aspiration was performed, and a 4.0 × 32-mm drug-eluting stent was implanted in the proximal LAD artery. The procedure was successful. The patient’s vital signs were stable during the operation, without any complications. This patient was also managed with antiplatelets, anticoagulants, coronary artery dilators, lipid-lowering agents, and symptomatically. Six days later, the patient was discharged from the hospital.


A 14-year-old boy presented at our pediatric emergency department with a 3-day history of
unilateral frontal pulsatile headache, nausea, vomiting, poor appetite, but without fever at
admission. The pain had not responded to oral pain medication. A magnetic resonance imaging
(MRI) was performed and showed no sign of intracranial tumor or ischemia. However, the
patient was wearing fixed orthodontic appliances which caused artifacts in the area of the
temporal lobes. The patient was admitted for observation. On the next day, the headache had
improved, yet, on neurological examination, just before discharge was planned, the patient
suddenly showed oral automatisms and started fiddling with his clothes.
The electroencephalogram (EEG) showed a focal cerebral dysfunction over the right
hemisphere with a maximum over the temporal lobe. No signs of meningism were present, but
the patient became more sensitive to light.
After lumbar puncture, which revealed clear, non-hemorrhagic cerebrospinal fluid (CSF) with
282 cells/µL (70% lymphocytes), treatment with intravenous acyclovir (60 mg/kg/day) and
ceftriaxone (85 mg/kg/day) for suspected encephalitis was started immediately, and
antiepileptic treatment with oxcarbazepine was initiated.
Over the next few hours, the patient became somnolent and was transferred to the pediatric
intensive care unit (PICU) where he had to be intubated. Despite antiviral medication,
mechanical ventilation and deep analgesic sedation, the cranial computed tomography (CT)
scan showed a progressive brain edema of the right temporal lobe as well as multiple foci of
hemorrhage. The polymerase chain reaction (PCR) was positive for herpes simplex virus type 1
(HSV-1, virus concentration: 7.03 × 103 copies/mL, altona Diagnostics, Hamburg,
Germany) and human herpes virus 7 (HHV-7, virus concentration: ct: 35.5, in-house PCR).
Therapy was extended by foscarnet (120 mg/kg/day) and dexamethasone. Because of persistent
EEG abnormalities, lacosamide was added to the antiepileptic therapy. Finally, the patient
could be weaned from mechanical ventilation after 2 weeks.
One month after admission, repeated lumbar puncture showed 28 cells/µL, proved negative for
HSV-1 and showed a very low HHV-7 concentration (ct: 37.1). Acute treatment of acyclovir and
foscarnet was discontinued, and oral prophylactic acyclovir (16 mg/kg/day) was started. MRI
showed bilateral asymmetric signal alterations in both temporal lobes and the frontobasal
region (), in the insular
cortex and cingulate gyrus on the right side and mild brain atrophy. During the following
weeks, the EEG and the patient’s clinical condition improved gradually.
Neurologically, the patient showed a reduced vigilance but was fully orientated. His speech
was slow, he suffered from amnestic aphasia, showed tongue fasciculations, as well as
dysdiadochokinesia of the left side. After intensive neurorehabilitation of 7 weeks, the
patient could continue his daily life activities. An EEG 5 months after the acute infection
under antiepileptic treatment only showed a diffuse slowing.
Immunological and genetic testing excluded an underlying immunodeficiency of UNC93B, TLR-3,
the innate immunity and T-cells. Oral prophylactic acyclovir was continued until these
results proved negative 9 months after diagnosis. One year after the diagnosis, the patient
was attending regular school again, but achieved less well results compared to the time
before the encephalitis, he was seizure-free, and the EEG was normal, while the patient was
still under antiepileptic treatment.


A 67-year-old man with a body mass index of 28.7 kg/m2 had experienced hip pain for more than 5 years. He had developed both aseptic necrosis of the femoral head and hip arthritis and therefore agreed to undergo THA with ideal positioning of the prosthesis (). The prosthetic femoral stem was a No. 12 CORAIL Stem (Johnson & Johnson Medical Devices, New Brunswick, NJ, USA). The Dorr femoral bone classification was type A, and the T-score of bone mineral density was −1.7. The patient underwent rehabilitation from partial to full weight bearing in 1 to 5 days. PFF occurred by a fall about 2 months after THA, and the patient subsequently underwent three failed open reduction with internal fixation (ORIF) procedures. The timeline of the failed procedures is shown in . The PFF was classified as a Vancouver type B1 fracture (). The first ORIF involved the use of a locking plate with cable system and was performed 3 days after the fracture. Implant failure occurred upon partial weight bearing, and the patient reported lateral hip pain 2 days after the first ORIF procedure (). The second ORIF procedure involved multiple cables at the proximal end and was performed 2 days after the first failure (). The patient recovered his activities of daily living, but an internal plate fracture occurred 3 months after the second ORIF procedure (). The third ORIF procedure involved a locking plate and cable system and was performed 2 days after the second fracture (). The patient’s rehabilitation involved delayed weight bearing after 2 weeks of bed rest. Ultimately, we found that the internal failure had been caused by proximal cable cut-out in which the cable had cut into the bone and stopped because the stem was metal on the medial side. Additionally, malunion and hypertrophic osteogenesis were found at the fracture site (). At 12 months after the third ORIF procedure, the patient had a Harris hip score of 69 and a Medical Outcomes Study 36-Item Short Form Survey score of 75 ().


An infant girl was born to a 25-year-old woman at 39 weeks gestation. The baby weighed 2.5 kg and had an Apgar score of 9/10. The baby was noted to have jaundice on day one with a serum bilirubin level of 290 mmol/L. There was a drop in hemoglobin within one day from 20.3 g/dL to 17.0 g/dL with a high reticulocyte count (9.3%) recorded. There was no other cause to suggest neonatal jaundice, such as intrauterine infections and glucose-6-phosphate dehydrogenase deficiency. An urgent peripheral blood film was sent and showed hemolysis with numerous spherocytes and the presence of nucleated RBCs and polychromasia. The baby’s blood group was B rhesus (RhD) positive. Direct Coombs test was positive with IgG specificity. Red cell elution studies of infant blood identified the presence of anti-E and anti-Jka antibodies. Her red cells phenotyping showed DCEce (R1R2) Jka+Jkb-, which was similar to the father.
Antenatally, the mother had a threatened miscarriage at 13 weeks. She was discharged well without any complications or requiring any blood transfusion. Her blood group was B Rh-positive, and her antibody screening at that time was negative. The pregnancy progressed well without any complications. Post-delivery, her hemoglobin level was 12.0 g/dL with positive antibody screening. In the postnatal period, antibody identification was done and alloantibodies to Jka and E antigen were found. The mother’s RBC phenotyping was Jka-Jkb+ and E-e+. Maternal anti-E and the anti-Jka antibody titer were determined as 1:512 and 1:32, respectively.
Intravenous immunoglobulin and intensive phototherapy were started for the baby since bilirubin levels were increasing. Simultaneously, we requested fresh whole blood with both antigens negative (E and Jka) in anticipation for a possible need for an exchange transfusion from the blood bank. The possibilities for anti E or anti-Jka to cause severe jaundice is rare, but based on one case report, the chances to develop severe HDFN cannot be ignored. HDFN due to anti-Jka is rare and can cause persistent anemia in the infant. Fortunately, the baby’s two-hourly serum bilirubin level showed a decreasing trend, and she did not require exchange transfusion and was discharged well on day nine. The daily blood investigations are shown in .


A 64-year-old woman presented to our emergency department with progressive shortness of breath, dry cough, and fever. She had a contact history with a confirmed COVID-19 patient. She was otherwise healthy with no known comorbidities and was not being treated with any medication. Her physical examination on admission revealed tachypnea, bilateral intercostal retraction, and hypoxia (peripheral oxygen saturation was 88% in room air). A chest X-ray showed bilateral peripheral opacities suggesting interstitial inflammatory lung disease without cardiomegaly. Her baseline electrocardiogram (ECG) () showed a normal sinus rhythm of 94 bpm with QT interval and Fridericia’s corrected QT interval (QTc) of 380 and 441 ms (475 ms with Bazett’s formula), respectively. Her initial complete blood count showed a normal hemoglobin level and white blood cell count (14.0 g/dL and 4500 cell/µL, respectively), but low absolute lymphocyte of 1000 cell/µL, and mild thrombocytopenia of 136 000 cell/µL (). SARS-CoV-2 infection was later confirmed by qualitative reverse transcription polymerase chain reaction test of the nasopharyngeal and oropharyngeal specimens, and diagnosis of COVID-19 pneumonia was established. Initial treatments were oral chloroquine phosphate 500 mg BID, intravenous (IV) meropenem 1 g TID, IV ciprofloxacin 400 mg BID, and subcutaneous unfractionated heparin (UFH) 5000 IU BID as pulmonary embolism prophylaxis.
On the fifth day of hospitalization, her respiratory condition deteriorated (). She required intensive care, invasive mechanical ventilation, and continuous ECG monitoring. Her blood tests showed a total white cell count of 9800 cell/µL, a low absolute lymphocyte count of 490 cell/µL with an increased neutrophil percentage of 91%, low serum potassium of 3.0 mEq/L, low serum calcium of 3.65 mEq/L, and serum procalcitonin of 0.1 ng/mL. IV potassium and calcium were administered for serum electrolyte correction. Continuous ECG monitoring did not yield any significant changes from the baseline ECG.
The patient’s overall condition in the ICU was stable until two sudden episodes of malignant arrhythmias ensued within 24 hours apart, which were on the day 13 of illness (day 9 of admission and antibiotic treatment). The first arrhythmia was TdP (), which was preceded by sinus tachycardia () with Fridericia QTc of 292 ms (353 ms with Bazett). We performed cardiopulmonary resuscitation (CPR) as soon as TdP was documented and prepared the defibrillator. It was not long before the rhythm spontaneously turned to asystole, then CPR was continued. After 2 minutes of CPR, the patient was on return of spontaneous circulation with sinus tachycardia and evident T-wave alternans (). Intravenous magnesium sulfate and potassium were given, along with termination of chloroquine phosphate administration. The serum electrolytes upon the episode of TdP showed relatively normal values (Na 146 mEq/L, K 3.6 mEq/L, Ca 4.53 mEq/L, Mg 1.9 mEq/L), but with increased serum troponin I level of 0.42 ng/mL. The blood samples were taken after CPR. The second episode of arrhythmia was a fatal pulseless ventricular tachycardia which occured within 20 hours from the onset of TdP. Unfortunately, even after vigorous resuscitation the patient could not be saved. The final blood examination before she succumbed to the disease showed the following: lymphopenia (290 cell/µL), and signs of multiorgan failure, including acute kidney injury (increased serum creatinine 1.33 mg/dL and urea 75.6 mg/dL), liver injury (serum alanine aminotransferase 100 IU/L), coagulopathy (serum D-dimer 11.22 mg/L), and increased proinflammatory markers (serum ferritin 1237 ng/mL, serum procalcitonin 32.4 ng/mL, and serum C-reactive protein 0.85 mg/dL).


A 6-year-old girl was admitted for a hard and painless swelling of the right gluteal region and the right elbow. She had no particular medical or family history, particularly of any tumor or renal dysfunction. There were no particular functional signs apart from the mechanical discomfort caused by the swelling. Examination of the lower limbs and skin at the swelling were normal but extension of the right elbow was limited. Blood tests did not reveal anything in particular (calcemia, phosphoremia, alkaline phosphatase and parathormone were normal, there was no inflammatory sign and kidney function was normal too). Pelvis plain radiographs and right elbow showed calcified masses of extra-articular projection (a and b) without any joint or bone lesion abnormality. Right gluteal mass benefited from computed tomography (CT) scan, which revealed a polylobed and extra-articular calcified lesion without joint or bone abnormality but it contained liquid components with liquid–liquid levels (). This gluteal mass was resected due to mechanical and esthetic complaints, appearing hard and whitish peroperatively. Pathological examination revealed a cystic subcutaneous lesion consisting of central granular or amorphous material, calcified, surrounded by a macrophage reaction with multinucleated giant cells and mononuclear inflammatory elements; associated with numerous osteoid deposits scattered in amorphous layers with surrounding non-inflammatory fibrous tissue, related to TC (). Evolution was favorable with no sign of recurrence at 30 months of quarterly clinical follow-up for the gluteal lesion while the elbow lesion left in place did not evolve in terms of volume.


An 8-year-old girl was admitted with a swelling of the left ankle extended to the middle third of the leg evolving for >6 months, without any medical or family history of note. The swelling was hard and fixed, painless and did not affect walking. There were no local inflammatory signs or deterioration of the general condition. Calcemia, phosphoremia, alkaline phosphatase and parathormone were normal like creatinine and urea.
Plain radiograph showed a calcified, multi-lobed mass in the extra-articular projection of the ankle and lower third of the leg (). Absence of joint or bone abnormality was confirmed on CT scan (). Surgical management was chosen due to the esthetic complaints linked to tumoral location at the ankle, revealed a whitish mass with hard and muddy appearance (). Pathology examination revealed calcified amorphous material, surrounded by a macrophage reaction with multinucleated giant cells and mononuclear inflammatory elements; associated with numerous osteoid deposits scattered in amorphous layers with surrounding non-inflammatory fibrous tissue (). The evolution was favorable with no sign of recurrence after 24 months of quarterly clinical follow-up.


A 68-year-old Asian man presented with numerous progressive itchy papules on the legs, torso, and upper extremities for 2 years. He had sought treatment at a different hospital where he was treated with antihistamines, topical corticosteroids, and a short course of systemic steroids, but without improvement.
He also had various medical conditions, notably hypertension, coronary artery disease, hypertrophic cardiomyopathy, and gouty arthritis. Not long before the reported admission, he had been admitted for an extensive pulmonary embolism causing deep vein thrombosis. His current medications were aspirin, clopidogrel, carvedilol, nifedipine, simvastatin, omeprazole, colchicine, and warfarin. He also had a 10-year history of alcohol consumption and a 40-year history of tobacco smoking. However, there was no family history of skin diseases, including leprosy.
Skin examination revealed multiple, hyperpigmented papules with some central erosion and crusts distributed on the abdomen and extremities (shown in Fig. ). The hair, nails, mucous membranes, and lymph nodes were normal. Neurological examination revealed normal pinprick sensations, no muscle weakness, and no nerve enlargement. The differential diagnoses were prurigo nodularis, lymphomatoid papulosis, perforating disorders, and papulonecrotic tuberculid.
Two skin biopsies on the right arm were performed. The first specimen obtained from a lesion with an erythematous papule revealed normal epidermis and keratin. The dermis exhibited a diffuse foamy histiocytic infiltrate with globi formations and the appearance of a Grenz zone (shown in Fig. ). Fite's staining showed a strongly positive result for numerous bacilli (shown in Fig. ). The second section obtained from a hyperkeratotic papule exhibited compact orthokeratosis with mild irregular acanthosis of the epidermis (shown in Fig. ). Diffuse fusiform and foamy histiocytic infiltrate with several globi formations was observed in the dermis. The histiocytes were arranged in a whorled pattern at the upper to the middle dermis (shown in Fig. ). The Grenz zone was not detected in this section. Fite's staining also showed a strongly positive result for bacilli (shown in Fig. ).
The patient was administered with a modified WHO-recommended multidrug therapy regimen (rifampicin, dapsone, and clofazimine) for 24 months. After 6 months of treatment, his skin lesions and itching symptoms were improved, in addition to the absence of leprosy reactions.


We report on a 28-year-old male patient with no past medical history. He was brought to the emergency department of Weill Cornell affiliated Hamad General Hospital with mild confusion. He complained of severe headache of 2 days duration associated with photophobia. He denied any neck stiffness, blurry vision, weakness, or numbness. His symptoms were preceded by a productive cough of yellow sputum associated with fever, chills, and chest discomfort for 1 week, no loss of consciousness or dizziness. A review of systems was unremarkable. He has a history of sick contact with patients having flu as he lives in a camp; he is not sexually active.
Examination revealed an average built man, conscious, oriented with short attention spans. He was looking sick with tachycardia (119 bpm) and tachypnea (28 breaths per minute) with shallow breathing maintaining SpO2 95% on 5-L oxygen.
Additionally, he had a nasal voice tone. His throat was congested with non-exudative enlarged tonsils and no lymphadenopathy. Oral temperature was 40.6°C, blood pressure 141/88 mm Hg.
His pupils were isocoric and reactive with a normal funduscopic exam, but with horizontal nystagmus. The neurological exam was remarkable for lower motor neuron right facial palsy, absent gag reflex, and right hypoglossal nerve weakness. His power and sensations were intact. However, with generalized, exaggerated deep tendon reflexes, and up going plantar reflexes on the left side. There was no neck rigidity; Kernig's and Budinski's signs were negative. The chest examination was unremarkable. Other physical examinations were insignificant.
His laboratory investigations were remarkable for neutrophilic leukocytosis, elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST), and mild hyponatremia (Table ).
Chest X-ray (CXR) showed increased broncho-vascular marking with no apparent infiltration. Plain computed tomography of the head was un-remarkable, CT pulmonary angiography to rule out pulmonary embolism was negative; however, a small area of consolidation was noted on the superior segment of the left lower lobe (Fig. ).
Given the history of fever and multiple neurological deficits, meningoencephalitis was suspected. Hence, a lumbar puncture was performed. The aspirated cerebrospinal fluid (CSF) looked clear; WBC 9 (0–5) with lymphocyte 92%, red blood cells 12, the protein and CSF glucose were normal at 0.34 g/L (0.15–0.45 g/L) and 4.67 mmol/L, respectively (Table ). Gram stain and culture were negative. Viral PCR and initial tuberculosis workup, including AFB smear and the PCR were unrevealing. Since admission, the patient was started on empirical antibiotics, antiviral, and steroids, managed as a case of possible bacterial or viral meningitis.
MRI and MRA of the head were done and showed multiple acute-subacute lacunar infarctions and distal stenosis, suggesting a possible vasculitis (Fig. , ). Hence, autoimmune workup was also sent and was also unrevealing (antinuclear antibodies, antinuclear cytoplasmic antibodies, complement levels).
While awaiting the workup, the result of oropharyngeal swab PCR revealed the presence of MP bacteria. After excluding other plausible etiologies for his presentation, considering that the neurological symptoms and signs followed the respiratory symptoms, MP with CNS vasculitis was deemed the most likely diagnosis. The patient continued Macrolide antibiotics and pulse steroids. His attention improved at discharge, and 1 month after discharge, he was free of any neurological deficits. Four months after discharge, he is followed up in our clinic and is doing fine.


A 62-year-old woman sought consultation at a dental hospital for a planned dental implant in the left mandibular first and second molars. A panoramic radiograph showed an edentulous region in the left posterior mandible and haziness of the right maxillary sinus (), suggesting maxillary sinusitis. However, CBCT covered only the mandible, the planned region for the dental implant. Detailed radiographic information on the right maxillary sinus was not obtained. Implantation of the left mandibular molar was performed, and prosthetic treatment was successful.
Four years after the implant therapy of the left mandible, the right maxillary second premolar and second molar extracted due to severe tooth mobility (). The panoramic image still showed similar haziness in the right maxillary sinus (), implying a chronic and static inflammatory status. Medium-FOV CBCT (169×119 mm, spatial resolution 0.2 mm, Asahi Alphard Vega, Kyoto, Japan) showed a faint calcified material in the upper region of the right maxillary sinus (). A fungus ball was strongly suspected due to the intralesional calcification within the sinus opacification. The patient was recommended to receive paranasal sinus (PNS) CT (spatial resolution: 0.3 mm, Somatom Definition Edge, Siemens, Erlangen, Germany) including the ostiomeatal complex. The PNS CT showed heterogeneous, complete opacification with calcified materials in the right maxillary sinus on non-enhanced coronal images (). Enhanced axial images presented sclerosis of the surrounding wall of the right maxillary sinus and nodular () and punctuate () calcified materials. These calcified materials presented in the middle and upper regions of the maxillary sinus. CT images also revealed sclerosis of the surrounding bony wall, bony erosion of the medial wall of the right maxillary sinus, and soft tissue protruding into the ostiomeatal complex (mass effect).
Endoscopic sinus surgery under general anesthesia revealed that the right maxillary sinus was filled with a brownish clay-like material, which was removed by saline irrigation and suctioning (). A histopathologic examination showed fungal hyphae with acute angle branching and septation (hematoxylin and eosin stain, ×400, ). These hyphae were highlighted by the Gomori methenamine silver stain (×400, ). These findings were morphologically consistent with Aspergillus infection. The patient remained disease-free during a 3-year follow-up period.


A 40-year-old woman sought consultation at a dental hospital for the treatment of right upper first molar pain. The periapical view () showed partial pulpal treatment status. She was in the process of receiving endodontic treatment at a private practice. Due to the suspicion of tooth fracture, CBCT with a small FOV (102×102 mm, spatial resolution: 0.1 mm) was performed. A definite tooth fracture line in the right upper first molar was not seen. However, an opacification of the adjacent right maxillary sinus was partially and incidentally observed on parasagittal CBCT (). The primary working diagnosis was chronic maxillary sinusitis. Calcified materials in the upper region of the maxillary sinus were not observed because of the limited FOV of the CBCT, precluding the confirmation of the working diagnosis. Endodontic treatment was successfully completed. One year later, she visited the hospital's emergency room with severe pain around the right upper first molar. She also complained of nasal obstruction, right facial pain, and rhinorrhea. The PNS CT showed heterogeneous opacification, sclerosis of the surrounding bony wall, bony erosion of the medial wall of the right maxillary sinus, mass extension into the right nasal cavity, and mucosal thickening in the right ethmoidal sinus (). The CT image also showed calcified materials more distinctly on the enhanced CT image than on the non-enhanced CT image in the center and upper region of maxillary sinus on the coronal () and axial () images. These punctate and nodular calcifications were located in the middle and upper regions of the right maxillary sinus. The patient underwent endoscopic sinus surgery. Histopathologic findings showed a fungus ball with an intraluminal growth pattern and bundles of hyphae (). The patient remained disease-free during a 9-year follow-up period.


A 56-year-old Caucasian man with no known past cardiac or neurological history presented to the emergency department with symptoms of confusion, aphasia, and left-sided weakness that started on waking up from sleep. His wife also noted left-sided facial droop and ataxia. He reportedly had increased somnolence, poor appetite, and lethargy for a few days. On presentation, he had a blood pressure of 148/105 mmHg, heart rate of 102 beats per min, rectal temperature of 97.9°F (36.6°C), respiratory rate of 16 breaths per min, and oxygen saturation 98% on room air. On physical examination, he appeared confused, pupils were reactive to light, but there was saccadic eye movement. Motor strength was reduced in the left upper and lower extremities. Computed tomography (CT) and magnetic resonance imaging (MRI) of the head revealed no acute intracranial pathology. In addition, there was no pathology on CT angiography of head-and-neck vessels. Chest X-ray, however, revealed pulmonary congestion [], and ST-segment depression, as well as QTc interval prolongation, was noted on the 12-lead electrocardiogram []. Serum troponin I was 0.99 ng/ml on admission and rose to a peak of 2.3 ng/m. Urine drug screen was positive for Δ-9-tetrahydrocannabinol (THC) and negative for cocaine, opioids, amphetamines, barbiturates, and benzodiazepines. Blood alcohol and ammonia levels were below reference range. Blood glucose on presentation and thyroid function tests were within normal limits. Transthoracic echocardiogram with intravenous ultrasound-enhancing agent showed a mildly dilated LV cavity with severe hypokinesis of the basal and mid-segments and markedly reduced ejection fraction. The apical segments of the LV, however, showed hyperdynamic motion [Figure , and ]. Coronary angiography showed no obstructive coronary artery disease [ and ]. On further questioning, the patient denied any recent emotional triggers but admitted to heavy marijuana use for several days before this presentation. Cardiac MRI performed 2 days after admission revealed an LV ejection fraction of 36% and hypokinesis of the basal and mid-ventricular segments [Figure , and ]. No myocardial-enhancing lesions were noted on late gadolinium images. All neurologic and cardiac symptoms resolved after 3 days of treatment. The patient did not return for scheduled postdischarge echocardiography although he was doing well 2 weeks following hospital discharge on a follow-up visit.


The authors present the case of an 82-year-old man presented to the ED with a progressive paraparesis that started a month before admission. His past medical history was unremarkable.
Neurological examination revealed a symmetric paraparesis (muscle power grade 4/5) below the T5 spinal cord segment. Babinski reflex and ankle clonus were present and both touch, pain, thermal and tactile sensations were preserved.
Spinal magnetic resonance imaging (MRI) () showed an hyperintense contrast-enhancing abnormal mass at the level of T6 which occupied the left side of the spinal canal and compressed the spinal cord.
Further investigation revealed multiple metastatic lesions and prostate cancer as the probable primary neoplastic site.
The patient underwent a T5-T7 laminectomy and complete removal of epidural tumoral mass.
On Day 2 post-op, the patient developed a right-sided BSS (right leg monoplegia and ipsilateral tactile, epicritic and proprioceptive hyposthesia below T5 and thermal and pain left-sided anesthesia).
Postoperative MRI () revealed a de novo T2 hyperintensity, possibly due to retraction of the thecal sac during surgery and consequently spinal cord lesion.
No hydrosyringomyelia or other complications were visible.
The patient remained in the ICU for 3 days in order to maintain vasopressor-induced high blood pressure and adequate spinal cord perfusion.
Patient was referred to PT and started his motor rehabilitation program on Day 3 post-op.
Prior to discharge, patient’s strength was grade 1/5 on the right leg and 4/5 on the left leg; he had proprioceptive impairment on both feet and hyposthesia below T5.
Three months after discharge, the patient had partially recovered from the motor deficit on his lower right limb, having a motor strength grade 2/5.
Neurological exam was otherwise unremarkable, having made a full recovery from the sensory deficit and motor deficit on his lower left limb (present preoperatively).
MRI done at this time showed a reduction in the T2 hyperintensity seen in both previous post-op MR scans ().


We present a 42-year-old female with a history of hypothalamic glioma and resultant obstructive hydrocephalus that had been subjected to multiple surgeries since her childhood due to CSF shunt malfunction. Following her last VPS implantation, symptoms of high intracranial pressure (ICP) notably improved but ventricle enlargement remained almost unchanged on computed tomography (CT) [-]. In addition, a coiled distal catheter was found on the abdominal X-ray, which was misinterpreted, probably due to patient obesity, as being in the correct position inside the peritoneal cavity [].
In the present admission, 2 months after the latest VPS placement, the patient complained of severe headache, vomiting, and gait disturbance. An urgent cranial CT demonstrated hydrocephalus in addition to a large low-density subdural collection over the right hemisphere with a minor right interhemispheric component [-]. Macroscopic integrity of the whole shunt system was checked on plain radiographs, but because of a suspected dislocation of the peritoneal tip, a CT scan of the abdomen was performed. This revealed multiple loops of the distal catheter and CSF fluid accumulation at the subcutaneous space []. Valve reservoir pumping demonstrated rapid reexpansion and the CSF was easily tapped. CSF Gram stain and culture revealed no microorganisms. Blood count and chemistries were also normal.
The paradox of finding a subdural accumulation (typically associated with VPS overdrainage) and hydrocephalus in a patient with distal VPS malposition generated perplexity and uncertainty for us regarding the most appropriate surgical strategy. Draining the subdural accumulation was considered in addition to repositioning the peritoneal catheter. Nevertheless, the delayed development of the subdural collection following several weeks of hydrocephalus in a patient with shunt malfunction led us to consider that both abnormal fluid accumulations might be related to the blocked CSF flow. Thus, we finally recommended VPS revision alone. We first performed a minilaparotomy, which revealed a pseudocyst encompassing the distal end of the catheter. Once adequate CSF outflow was verified, the fibrous capsule was partially resected, and the catheter repositioned intraperitoneally. Following surgery, all symptoms resolved, and postoperative CT performed on day 4 showed resolution of both hydrocephalus and subdural CSF accumulation [-]. Moreover, postoperative abdominal X-ray confirmed correct placement of the distal peritoneal catheter []. After the 2-month follow-up, the clinical and radiological courses remain satisfactory [].
We wish to highlight both the time frame of the development and resolution of the subdural accumulation, as well as the successful surgical strategy chosen. CSF accumulation occurred in a delayed fashion following several weeks of ventriculomegaly, and it was completely resolved by the 4th postoperative day after only VPS revision, which points to a shift of excessive CSF from the ventricles to the subdural compartment as the underlying mechanism for subdural fluid accumulation in our patient.


The patient complained of general malaise.
A 69-year-old man was referred to our facility with a diagnosis of recurrent HCC. He had undergone right anterior sectionectomy for two tumors in segment 8 at another hospital 10 mo previously. The pathological diagnosis of the two tumors was moderately differentiated HCC and poorly differentiated HCC, respectively, without vascular invasion. The pathological stage was stage III according to the Union for International Cancer Control 8th edition.
The patient had undergone appendectomy for appendicitis at 27 years of age.
The patient’s father had experienced lung cancer, and his sister had suffered from breast cancer.
On physical examination, the patient had a temperature of 36.6 °C, heart rate of 76 bpm, respiratory rate of 16 breaths/min, blood pressure of 143/86 mmHg, and oxygen saturation in room air of 98%. The patient’s weight was 59 kg. He had no jaundice or anemia in the bulbar conjunctiva. There was an operative scar for an inverted L-shaped incision on the abdomen from the previous liver resection. No ascites and encephalopathy were detected.
The preoperative liver functional reserve was good. Laboratory data revealed serum albumin of 3.5 g/dL, total bilirubin of 0.9 mg/dL, prothrombin time of 93%, and indocyanine green retention rate at 15 min of 5.2%. The Child–Pugh score/ classification was 5/A and the albumin-bilirubin (ALBI) score/modified ALBI grade was -2.19/2b. The alpha fetoprotein value was within the normal range, while the protein-induced vitamin K absence or antagonist II value was elevated at 998 mAU/mL.
A computed tomography scan of the abdomen demonstrated a heterogeneous contrast-enhanced mass of 10 cm in size in segment 7, which had rapidly increased in 5 mo (Figure and ). The magnetic resonance imaging (MRI) images at 5 mo before the second operation are shown in Figure (A: T1 image; B: T2 image). There was no evidence of the recurrent tumor on these MRI images. A positron emission tomography examination showed elevated standardized uptake volume in the sternum and slight uptake in the liver (Figure and ). The patient was diagnosed as recurrent HCC in segment 7 of the liver with metastasis in the sternum.


An 82-year-old female patient was admitted to our emergency department because of hematemesis with a high-grade suspicion of upper gastrointestinal bleeding. Laboratory analysis revealed decreased hemoglobin (7.6 g/dL) and elevated infection signs (leukocyte count 27 × 109/L, C-reactive protein 15 mg/dL). Initial physical examination was notable for a soft abdomen with diffuse tenderness but without voluntary guarding. Due to beginning septic shock with increasing hemodynamic instability and loss of vigilance, the patient was referred to our intensive care unit. After need for intubation, a gastroscopy was performed. There was no endoscopic evidence for an upper gastrointestinal bleeding. However, endoscopy showed spontaneous penetration of the gallbladder (shown in Fig. ) and revealed plenty gallstones in the duodenal bulb (shown in Fig. ). Subsequent computed tomography confirmed the endoscopic findings demonstrating chronic cholecystitis with pneumobilia and gallbladder penetration in the duodenal bulb with entry of gallstones in the intestine (shown in Fig. ). Further, it revealed a reflective intestinal atony and a dilated stomach filled with contrast medium. Based on the endoscopic and CT scan findings, Bouveret syndrome due to penetration of gallstones in the duodenal bulb was diagnosed. On account of chronic cholecystitis and sepsis, open cholecystectomy and gallstone salvage from the duodenum were performed. Biliary enteric fistula was not found during surgery. Patient could be discharged after several days from the hospital.


A 25-year-old gentleman presented with complaints of blurred vision in the right eye (RE) after a history of blunt trauma with a cricket ball seven days prior. He had been started on anti-glaucoma drops and topical steroids by a local physician. His corrected distance visual acuity (CDVA) was 20/800 in the RE and 20/20 in the left eye (LE). The intraocular pressure on applanation tonometry was 17 and 16 mm Hg in the RE and LE, respectively. On ocular examination, a resolving hyphema and anterior chamber reaction were noted in the RE. Funduscopy revealed a subretinal bleed at the posterior pole and inferiorly with a resolving vitreous hemorrhage []. There was no evidence of a rhegma or dialysis after a dilated indirect ophthalmoscopy with scleral indentation. The optical coherence scan (OCT) of the RE macula showed extensive subretinal scarring with gross disruption of the photoreceptor layer and decreased retinal thickness []. The LE examination was within normal limits.
The patient was explained about the guarded vision prognosis and asked to review in a fortnight. On follow-up at three weeks, fundus examination revealed a thick epiretinal membrane, glial condensation with a taut posterior hyaloid face and a macular TRD []. An OCT scan revealed a thick preretinal membrane bridging the disc and macula with a pucker like concave configuration [, below]. A thorough fundus examination again did not reveal any breaks or dialysis.
In view of the above development, a vitrectomy with membrane peeling and silicone oil infusion (for a longer tamponade) was done for the RE, following which the vision improved to 20/120 one-month post-surgery. There were poor outer retinal integrity and RPE clumping and scarring evident on both clinically and on the OCT scan []. An intraoperative peripheral retinal evaluation also did not reveal any predisposing breaks or dialysis.
Silicone oil removal was done 6 months later, following which the vision remained stable at 20/120 and the clinical findings remained status quo [].


A 27-year-old male presented with an occupational injury from his left eye. He was a worker in a seafood shop and injured from his left eye while he was trying to open a wooden box containing mussels. A nail which he was trying to pull out from the box was suddenly broken and shot his left eye. His visual acuity (VA) at presentation was 20/20 in the right eye and 20/40 in the left eye. Slit-lamp examination revealed a metallic foreign body (FB) which was partially penetrated the globe 3 mm from the limbus at 9–10 o'clock quadrants []. Anterior chamber (AC) depth was normal; no AC reaction was observed. Pupillary irregularity and mild posterior subcapsular lens opacity were detected. Central retina and optic disc were normal; peripheral retina could not be evaluated due to the discomfort of patient. Orbital tomography demonstrated a 25 × 2 mm hyperdense FB penetrated to the globe obliquely from the nasal sclera []. His systemic evaluation was unremarkable.
Repair of open globe injury with the removal of intraocular FB was performed 6 h after the trauma, as soon as laboratory and systemic evaluations was completed and the interval between the last oral food intake was suitable for general anesthesia, by an experienced surgeon (BY).
Topical vancomycin (50 mg/ml) and ceftazidime (100 mg/ml) fortified drops per hour; prednisolone acetate 1%, 8 times a day; cyclopentolate 1%, 3 times a day; preservative-free artificial tears per hour, and 400 mg/day oral moxifloxacin were administrated postoperatively. Twelve hours after the surgery, the patient suffered from pain in his operated eye. Ocular examination revealed 2 mm hypopyon and pupillary membrane formation with a decrease in VA to the hand movement level []. No leakage was observed from the operation area. Hyperecogenic opacities compatible with vitritis were seen on B-mode ultrasonography. The clinical situation was considered as endophthalmitis. Vitreous samples were taken and sent to the laboratory for culture followed by intravitreal vancomycin 1 mg/0.1 ml, ceftazidime 2 mg/0.1 ml, and dexamethasone 0.4 mg/0.1 ml injections. On the first day after intravitreal injections, ocular pain resolved, hypopyon regressed to 0.5 mm, and VA increased to counting fingers. Fundus examination revealed white discoloration of the retina, intravitreal hemorrhage, and membrane formation. Two days later intravitreal vancomycine, ceftazidime, and dexamethasone injections were repeated. Topical and systemic medications were continued as the same regimen.
On the third day of vitreous samples culture, bacterial growth was detected. Gram staining of the colonies showed gram-positive bacillus. The identification of the colonies was determined in MALDI-TOF MS (Bruker Daltonik GmbH, Bremen, Germany) and it was identified as A. sulphurea with a score of >2.
VA increased to 20/32 in the left eye and intravitreal hemorrhage resolved 10 days after the trauma. Since the clinical findings improved, repetition of intravitreal injections or vitrectomy was not needed. Topical medication had been discontinued gradually within 1 month and oral antibiotic had been discontinued 10 days after the trauma.
Three months after the ocular injury, VA was 20/25. Scleromalacia in the penetration area of the FB, mild posterior subcapsular lens opacity was seen on slit-lamp examination []. Fundus examination revealed hyperpigmented and hypopigmented retinal pigment epithelial changes.


A 20-year-old female with a 2-year history of systemic lupus erythematosus (SLE) presented with complaints of painless progressive decrease in vision in her right eye of 5 months duration. She had been diagnosed with SLE 5 years back, and had additionally developed lupus nephritis and pulmonary artery thrombosis, for which she was on treatment in the form of systemic corticosteroids, immunosuppressive medication mycophenolate mofetil at a dosage of 2 g a day (divided), tablet hydroxychloroquine 400 mg a day and an anticoagulant. Her systemic condition was well controlled, according to her rheumatologist. A year earlier, she had undergone treatment for SLE retinopathy with intravitreal ranibizumab and pan-retinal photocoagulation in both eyes, elsewhere. She had undergone a carotid doppler test at that stage, which had been reported to be within normal limits.
Her best corrected visual acuity was 20/20 with a normal intro-ocular pressures and an anterior segment exam. Fundus evaluation revealed a rhegmatogenous retinal detachment in the right eye. Left eye revealed a healthy disc with no disc pulsations, a healthy macula on direct examination with a 78 D lens, and clinically normal retinal vessels with no active neovascularization noted at the disc or elsewhere. Trace old vitreous hemorrhage inferiorly with peripheral laser scars and regressed neovascularization was noted in the temporal periphery. An FFA [ and ], multicolor imaging, optical coherence tomography (SD-OCT), and SD-OCT angiography (OCTA) (Spectralis, Heidelberg, Germany) was performed. Two interesting features were noted.
Firstly, the FFA was unremarkable till the peak phase. At 27 s an increase in arteriolar fluorescence in all the four major arterioles, with a simultaneous decrease in venular fluorescence without a change in vessel caliber was seen. Fluorescence increased in the venules at 29 s, with a reduction in arterioles. This cycle repeated at 43 s. Peripheral areas of nonperfusion with areas of leakage were seen suggestive of neovascularization.
Secondly, the multicolor image of the left eye [] showed an undulating retinal surface infero-temporal to the disc, apparent in the blue and green channel, absent in the infrared. Corresponding changes were seen on the SD-OCT [] as an area of inner retinal thinning, on the enface OCT image as dark patches, on the OCTA [] as a flow void in the superficial and deep capillary plexus and on the FFA as a subtle ill-defined hypofluorescence in the early phase, persisting into the mid and late phase of the angiogram.
No conjunctival blanching was noted when the patient was examined earlier or after the fluorescein angiography. The patient was re-evaluated by the rheumatologist who advised no additional treatment. The right eye retinal detachment was managed surgically and the left eye was treated with additional laser photocoagulation.


The index case was a 10-year-old girl who presented with complaints of nausea and acute pain abdomen. She was afebrile and hemodynamically stable with tenderness in the right iliac fossa. An abdominal X-ray was normal, ultrasonogram showed dilated bowel loops with sluggish peristalsis. She had no premorbid or respiratory illness, had 97% oxygen saturation on room air. Laboratory values showed leukocytosis with neutrophilia, lymphopenia (16,870 per mm3 – 92% neutrophils, 5.9% lymphocytes). SARS-CoV2 nasopharyngeal swab RT-PCR was sent in the background of a COVID-19 afflicted family member and a negative SARS-CoV2 rapid antigen test (ICMR approved). This was positive and concurrent assessment of chest radiograph was suggestive of bilateral basal infiltrates (). D-dimer was high (1,496 ng/mL), fibrinogen was high normal (480 mg/dL), CRP was high (32 mg/dL), but procalcitonin (6 ng/mL) and ferritin (186 ng/mL) were normal.
Explorative laparotomy done on an emergent basis showed extensive gangrenous small bowel of 60 cm length in the region of the distal jejunum and proximal ileum. The small bowel had herniated into a transmesenteric defect near the mid-ileum and was obstructed (). The gangrenous segment was excised, and an end to end anastomosis done. The colon was normal with no features of malrotation. The child was started on low-dose, low-molecular weight heparin, as the subsequent values of D-dimer (1,060 ng/mL) also remained high postoperatively. The biopsy revealed that the lumen of the venules from the gangrenous segment was partially obliterated by platelet and fibrin thrombi (). Her blood and tissue culture were sterile. Nasopharyngeal swab RT-PCR done on postoperative day 7 was also positive. She needed minimal oxygen postoperatively and gradually recovered without any specific antiviral therapy.


A 20-year-old otherwise healthy female patient was reported to the institutional department of endodontics with the chief complaint of pain and swelling in the left upper front tooth for the past 2 weeks. Her history was suggestive of trauma to the face about 7 years back. On intraoral clinical examination, soft tissue swelling between tooth number (#) 21 and 22, mesial tilt of crown of #22 [], and tenderness on percussion of #22 were observed. #22 was reported to be nonvital whereas #21 was vital, on vitality examination. Intraoral periapical and occlusal X-ray showed large pear-shaped unilocular radiolucency on the lateral root aspect of #21, 22 with sclerotic borders [ and , respectively]. The patient was referred to the department of periodontology for consultation; on clinical evaluation, periodontal probing depth was 2-3 mm with respect to (w.r.t.) #21, 22 as well as in rest of the dentition. Fine needle aspiration performed for swelling w.r.t. #21,22 showed blood mixed yellow color fluid which, on Papanicolaou, smear revealed intermixed inflammatory cells predominately neutrophil and lymphocytes and with numerous red blood cells (RBCs), suggestive of chronic inflammatory lesion. On the basis of above, clinical findings including fluid aspirate analysis provisional diagnosis of RC was made. The patient was advised to proceed for root canal treatment (RCT); if the lesion does not respond to endodontic therapy, then surgical intervention may be planned. Root canal preparation was completed as per the standard endodontic protocol w.r.t. #22; however, clinically, the swelling remained static, and even on radiographical evaluation, the lesion did not show any changes till preobturation w.r.t #22 [ and , respectively] suggested that cyst is of self-sustaining type (true RC). Therefore, the patient was informed in detail regarding single stage management of lesion by root canal obturation w.r.t #22 followed by surgical enucleation of lesion's associated anticipated residual bone defect (RBD) management by amalgamation of platelet-rich fibrin (PRF), demineralized freeze-dried bone allograft (DFDBA) and ostIN™ bone graft with its pros and cons in comparison to the non-graft technique. The patient submitted signed consent in support of periodontist advice.
After Phase I therapy, all routine investigations advised were reported to be within normal perimeter. Root canal obturation was done in #22 utilizing lateral condensation technique. Immediately, under local anesthesia, crevicular [] and vertical releasing incision were given w.r.t #21–23 and mesial line angle of #21, respectively, followed by full-thickness flap reflection []. Following blunt dissection till the apical extent of the lesion in the vestibule, complete enucleation of the cyst (≥15 mm × 18 mm) was carried out with the help of surgical curettes []. Enucleated cystic growth was preserved in 10% formalin solution and sent for histological evaluation. RBD was thoroughly debrided []; adjacent root surfaces were planned followed by the placement of amalgamation of PRF, DFDBA, and OstIN™ bone graft []. During the surgical separation of cystic lining from the labial flap, mucosal perforation occurred near mucogingival junction that was approximated, and flap was sutured with 4-0 silk and radiovisual graph taken w.r.t #21 and 22 [] showed RBD duly filled with bone graft material. Postoperative instructions were given to the patient, and the patient reported on the 3rd week for the postoperative checkup.
Hematoxylin and eosin-stained microphotograph section under × 10 showed that cystic cavity lined by the nonkeratinized epithelium of variable thickness with arcadian pattern. In some area pseudostratified hyperplastic epithelium with underlining neutrophilic infiltration was observed. Underlying connective tissue stroma was moderately collagenous with numerous small endothelial cells line blood vessels with engorged RBCs, suggestive of RC [].
Surgical site healed uneventfully, sutures were removed, but mucosal fenestration was observed w.r.t #22 [] on 3 weeks postsurgical follow-up. The patient was informed regarding the same and signed consent was taken to repair the same with PRF in conjunction with coronally advanced mucosal flap (CAF). Under local anesthesia, fenestration site was thoroughly refreshed followed by irrigation with normal saline. Autologous Choukroun's PRF was prepared. Partial thickness incision was given with releasing incision w.r.t #22 for tension-free displacement of trapezoidal CAF. PRF was secured at defect site and CAF was secured utilizing 4-0 vicryl suture [ and -, respectively]. Postsurgical instructions were given to the patient. Eight days postoperatively, mucosal fenestration site healed uneventfully; at 3-month postoperatively, complete repair of mucosal fenestration was observed which remain static till 9-month postoperative [-, respectively]. RBD regeneration reevaluated on radiovisual graphs at 3-month postsurgically showed radiopacity in the treated RBD site due to the stability of grafted materials and was distinguished from adjacent bone site []. Complete elimination of radiopacity of the grafted materials was observed because of uniform homogenization (uniform radiopacity) of healed treated RBD, which was not distinguishable from the adjacent bone at 9-month postoperatively []. No complication was observed till the last follow-up.