A 58-year-old woman presented with translucent to skin-colored papular lesion over periorbital region, with a few lesions in zygomatic area and cheek, varying in size from 1–5 mm for the last 6 years []. Clear fluid was noticed on puncturing with a sterile needle. Skin biopsy from most represented lesion revealed unilocular cyst lined by two layers of flattened cuboidal epithelium without any evidence of decapitation in lining cells []. Dermoscopy showed whitish clod without crater on nonpolarized mode [] and yellowish globules with multiple telangiectasias in polarized mode []. Both cases were treated with topical botulinum toxin-like peptide (twice daily application). Almost complete clearance of lesions was observed in Case 2 after 6 weeks of treatment, but Case 1 could not come for follow-up.


A 2-year-old boy was brought to the outpatient department (OPD) with a painless left-sided inguinoscrotal swelling. On examination, a tense cystic swelling was felt separate from the testis with a positive traction test. A provisional diagnosis of encysted hydrocele of the cord was made, and the child was planned for herniotomy.
Intraoperatively, a firm 4 cm × 3 cm fibrofatty mass was found to be arising in the left paratesticular location, near the cord, reaching the midline in front of the pubic symphysis. The mass was densely adherent to the scrotal skin, and a gross total resection was performed only after increasing the incision significantly. Histopathology [] revealed bundles of myofibroblastic components with interspersed bundles of collagen and mature adipose tissue, consistent with the triphasic histology of fibrous hamartoma of infancy. The child had an uneventful recovery and has completed 1 year of follow-up without any features of recurrence.


A 1-year-old boy was brought to the OPD with a history of left-sided scrotal swelling since birth. On examination, he was found to have a 5 cm × 5 cm sized left-sided paratesticular mass and a discrete suprapubic nodule. His serum alpha-fetoprotein was within normal limits, and ultrasound revealed a left scrotal mass with increased vascularity. Computed tomogram was suggestive of a scrotal swelling which displaced the testis superiorly, with edematous and infiltrated subcutaneous fat at the scrotal root. Fine-needle aspiration cytology showed a small round cell tumor with focal spindling, whereas a Trucut® biopsy was consistent with the presence of spindle cells in an edematous stroma. The child was started on chemotherapy after a provisional diagnosis of rhabdomyosarcoma was made. After 8 weeks of chemotherapy (vincristine, actinomycin, and cyclophosphamide), the child was subjected to excision of mass as it showed a minimal reduction in size.
Intraoperatively, the mass was densely adhered to the skin and surrounding tissues, including the testis. Left orchidectomy with excision of the mass was done. Histopathology showed the paratesticular mass to be a cellular angiofibroma with CD34 positivity [-]. It was densely adherent but not involving the testis or cord. The suprapubic nodule revealed features of fibromatosis. The child had an uneventful postoperative course and is under follow-up without any recurrence.


A 69-year-old man was referred to the department of family medicine at Severance Hospital for chronic weakness and recurrent admissions for untreated and undiagnosed longstanding pancytopenia, which had persisted for the last 10 years. The patient had severe splenomegaly and was being treated for fungal pneumonia (aspergilloma and Pneumocystis jirovecii pneumonia) before the referral. There was past medical history of right thyroidectomy (for thyroid cancer), posterior right coronary artery stenting (due to chronic stable angina pectoris), and paroxysmal atrial fibrillation. The repeated admissions were severely crippling the patient’s quality of life. The current admission was for exacerbation of fungal pneumonia. Upon initial evaluation, the patient was afebrile, with body temperature of 36.5°C and blood pressure of 99/66 mm Hg. Heart rate was 77 beats per minute and respiratory rate was 20 per minute. The patient showed poor nutritional status, weighing 48.7 kg with a height of 169 cm (body mass index [BMI], 17.05 kg/m2). The patient appeared cachectic and exhausted by prolonged admission.
Initial laboratory studies showed pancytopenia with neutropenia (absolute neutrophil count [ANC], 150/μL; reference, >1,500/μL), hyponatremia (131 mmol/L), and increased prothrombin time (12.9 seconds) and partial thromboplastin time (41.1 seconds). C-reactive protein (40.3 mg/L) and erythrocyte sedimentation rate (59 mm/h) were also elevated. Additional routine laboratory test results are shown in . Screening for infection yielded no evidence of cytomegalovirus infection, or other causes of atypical pneumonia. Cultures of the blood and sputum were negative, but urine culture yielded 1,000 colony-forming units/mL of Gram-positive cocci. On chest X-ray, multiple nodular consolidations were observed in the left upper lung, and a chest computed tomography (CT) scan further demonstrated multiple nodular consolidations in the right upper lobe with a small amount of left pleural effusion and pericardial effusion. No enlarged lymph nodes were identified, and the enlarged spleen measured 21.4 cm.
Initial medications upon admission included aspirin, nicorandil, trimetazidine, bisoprolol, and levothyroxine for the treatment of the underlying conditions. Moreover, total parenteral nutrition was initiated to compensate for the patient’s nutritional deficit. Antibiotic therapy was commenced with trimethoprim/sulfamethoxazole, meropenem, and amphotericin B, as was used in the previous clinic. However, as the chest CT scan indicated minimal possibility of active Pneumocystis pneumonia, and polymerase chain reaction for Pneumocystis jirovecii was also negative, amphotericin B was administered as the sole antifungal agent. Additionally, prophylactic antibacterial agents were reduced to cefepime, since the fever had subsided by the time the patient was transferred to Severance Hospital.
Consultations from the departments of hematology, rheumatology, and infection were sought, and the differential diagnosis focused on the evaluation of splenomegaly, pancytopenia, and neutropenia. Peripheral blood smear revealed normochromic, normocytic anemia with a reticulocyte percentage of 0.65%. Screening test results for iron deficiency anemia indicated anemia of chronic disease, with elevated ferritin (3,308.5 ng/mL) and low transferrin (98 mg/dL) along with normal serum iron level (79 μg/dL). In addition, there was no deficiency of B12 and folate. Bone marrow biopsy revealed an average cellularity of 60%, with no signs of bone marrow failure. The detailed results can be found in , and follow-up results for complete blood counts are listed in .
Prior bone marrow biopsies had similarly failed to indicate a diagnosis, which made primary hematologic disease unlikely. Subsequently, investigations were performed for potential autoimmune causes, and these yielded positive anti-nuclear antibodies (ANA) with a titer of 320:1 and rheumatoid factor (RF) levels of 23 IU/mL. After a rheumatology consultation, further studies were performed revealing weakly-positive anti-DNA (19 IU/mL) and anti-cardiolipin immunoglobulin M antibodies (11 MPL-U/mL). Anti-beta2-glycoprotein 1 antibodies and lupus anticoagulant were both negative. Serum C3 was low (36.7 mg/dL), but C4 was normal (11.98 mg/dL). Furthermore, when the patient was evaluated for lupoid manifestations, an oral ulcer was found, but no other autoimmune features were seen, including skin rash, arthritis, muscular weakness, uveitis, and Reynaud phenomenon. Cystatin C was elevated (1.53 mg/L), and cystatin C-based estimated glomerular filtration rate (GFR) was 42.6 mL/min/1.73 m2. Although the creatinine level was normal (0.82 mg/dL), its diagnostic value was limited due to the low BMI of the patient. Considering the ongoing infection, the presence of renal failure was deemed indeterminate. Follow-up investigations showed equivocal levels of anti-DNA antibodies (10 IU/mL), therefore, the elevation of rheumatologic antibodies was tentatively considered to be a by-product of infection upon further consultation.
With other possible causes of pancytopenia ruled out, splenomegaly itself was suspected to be the cause of the pancytopenia. During the hospitalization, the pancytopenia progressively worsened, and by day 11 of hospitalization, total white cell count reached 540/μL (neutrophil 35.9%), hemoglobin 6.8 g/dL, and platelet count 57×103/μL. Moreover, onset of sepsis was suspected, with body temperature of 37.0°C, blood pressure of 86/52 mm Hg, and pulse rate of 84. After an infusion of 1.5 L of fluid did not raise the blood pressure to baseline levels, filtered red blood cells were transfused, along with norepinephrine at a rate of 4 mL/h. Given the patient’s indeterminate diagnosis and deteriorating general condition, splenectomy was considered as a curative treatment option. However, considering the poor condition of the patient, surgical splenectomy was deemed as hazardous, and partial splenic embolization was considered as an alternative. During the course of hospitalization, numerous consultations were sought but due to the failure to establish a definite diagnosis, no specific department could agree to actively transfer the patient from our department. Partial splenic embolization was undertaken on day 17 of hospitalization, using iodixanol as a contrast agent, and ultrasound guidance for arterial access. Vascular access point was right common femoral artery, and after performing celiac angiography and splenic angiography, the lower portion (70%) of the spleen was embolized with gelfoam. Intra-procedural images are shown in .
The day after embolization, there were no serious complications and a general increase in blood counts was observed; white blood cell count rose to 820/μL, hemoglobin to 10.0 g/dL, and platelet count was 45×103/μL. However, 2 days after the procedure, at 11 PM, the patient’s temperature rose to 38.5°C, followed by a rapid drop to 35.7°C in an hour accompanied by a decrease in blood pressure to 84/56 mm Hg and a pulse rate increase to 148 per minute. Septic shock was suspected; therefore, norepinephrine and fluids were infused and CT scans of the chest and abdomen were undertaken. Notably, there was no pulmonary embolism or bowel perforation, and the abdominal CT image is shown in . After 2 hours of resuscitation, increased rales were heard in the lungs, and oxygen saturation began to fall, eventually reaching 55%. Consequently, mechanical ventilation was initiated. However, given the grim prognosis, the legal guardians of the patient refused to give consent for admission to the intensive care unit for closer monitoring and treatment. The patient began to show signs of cardiac arrest at 5 AM, when cardiopulmonary resuscitation (CPR) was commenced. Nevertheless, spontaneous circulation could not be established and the patient died 60 minutes into CPR at 6 AM.
Written informed consent for publication of this image was obtained from the patient.


The patient was a 63-year-old woman with a recurrent parafalcine meningioma. She had presented originally 6 years prior with focal right lower extremity motor seizures and was found to have an approximately 4 cm bilateral parafalcine meningioma at the paracentral lobule that was eccentric to the left. Her initial resection was aborted due to sustained ST elevations before dural opening. After cardiac catheterization, evaluation, and clearance, she underwent resection 1 month later through a bicoronal approach. The tumor was heavily calcified, invading, and densely adherent to the falx and sinus, and although sinus bleeding was encountered, a Simpson Grade III resection was achieved. The sinus was preserved. Pathology revealed the WHO Grade II atypical meningioma. Notably, she was later diagnosed with coronary artery disease.
She underwent adjuvant radiotherapy (54 Gy) and later twice underwent gamma knife radiosurgery for progressive disease at 4 years and 5 years postoperatively. Six years postoperatively, she experienced worsening seizures and imaging revealed meningioma recurrence. Preoperative vascular imaging showed SSS occlusion [] and repeat surgery was recommended.
Perioperatively, a central line was placed, and precordial Doppler was used due to concern for possible AE. We opened and extended her prior bicoronal incision. After significant dissection through scar tissue and extension of craniotomy, we began resection of the tumor. During tumor resection, the falx was being coagulated and the patient became profoundly bradycardic, then asystolic []. Given that tumor invading the SSS was being resected, there was concern for AE and we copiously irrigated the field and placed the head in Trendelenburg position, followed by tamponade with wet sponges. She remained asystolic for approximately ten seconds and then became profoundly bradycardic for approximately 1 min. There was no evidence of AE on precordial Doppler or end-tidal CO2 monitoring, and the patient recovered spontaneously during medical interventions by the anesthesia team.
After discussion between the anesthesia and neurosurgery teams, AE and a cardiac etiology were ruled out and surgery resumed. By careful exploration of the tumor-falcine-sinus interface, we confirmed that the sinus was occluded by tumor and began to coagulate it again to sacrifice it to improve resection. Given the likely chronic nature of her sinus occlusion, we felt confident that this would not result in venous congestion. During repeat coagulation of the SSS and posterior falx, profound bradycardia occurred again and self-resolved upon cessation of coagulation. This was repeatedly reproducible. After sacrifice of the sinus and falx in the region of the tumor and careful dissection, we were able to achieve a Simpson Grade I resection. The remainder of the case was uncomplicated.


Seven years and three months post-transplantation (in February 2016), a 34-year-old man was admitted to the outpatient department of our hospital, complaining of decreasing appetite, weight loss, gross hematuria, fatigue, and oliguria (urinary volume was less than 200 mL).
The patient had undergone living kidney transplantation after hemodialysis for 2 mo at the age of 22 years on November 27, 2008 for ESRD. Biopsy of the patient’s native kidney was not performed, and etiology of the primary disease causing the ESRD was unclear. His mother, who was 41 years old at the time, donated her left kidney to him. The kidney graft was implanted at the right iliac fossa. The zero-point biopsy of graft showed unremarkable findings. Methylprednisolone was administered as induction therapy for a total dose of 2.5 g. Maintenance immunosuppression consisted of tacrolimus, mycophenolate mofetil (MMF), and prednisone. The target trough level of tacrolimus was 8-10 ng/mL for 1 year post-operation. The creatinine level was 6.93 mg/dL before transplantation and decreased to 0.98 mg/dL 2 wk post-operation. The patient was discharged and followed regularly at another hospital.
Three and a half years post-transplantation (in May 2012), the patient was reviewed at another hospital. The creatinine level had increased to 1.92 mg/dL and urine test was positive for proteins (3+). The patient had no other discomfort or complaints, but he refused biopsy of the kidney graft. At that time, the result of panel reactive antibody (PRA) testing was negative, ultrasonography of the kidney graft was normal, and tacrolimus trough level was 6.2 ng/mL. Methylprednisolone was administered at a total dose of 1.5 g experientially (500 mg/d for three days), but the creatinine level increased gradually. Six years post-transplantation (in November 2014), the creatinine level of the patient further increased to 5.31 mg/dL, and biopsy of the kidney graft was performed at another hospital. Histopathological examination showed T-cell mediated acute rejection (Banff 1A) and sclerosing glomerulonephritis. Ultrasound of the kidney graft also showed a mass involving the upper pole of the graft, measuring 2 cm × 3 cm × 3 cm. However, the patient declined further examination and treatment.
The patient presented no other significant findings on a previous medical history.
On admission, the patient’s body weight was 37 kg, which had reduced by approximately 20 kg in 2 years. Physical examination showed pale palpebral conjunctiva and hyponychium, and a large mass could be palpated in the right abdominal region with clearly demarcated boundaries and partial mobility.
The patient was admitted on February 2, 2016. Laboratory tests showed a hemoglobin level of 53 g/L, white blood cell count of 5.03 × 109/L, platelet count of 212 × 109/L, and creatinine level of 11.23 mg/dL.
Contrast-enhanced computed tomography (CT) of the abdomen and pelvis revealed a giant heterogeneous cystic-solid mass, measuring 10 cm × 10 cm × 15 cm, involving the upper pole of the kidney allograft. The solid lesion of the tumor was enhanced by the contrast medium, whereas the cystic part of the mass was not enhanced (Figure ). No lesion was found in the liver and both native kidneys. No abdominal and pelvic lymphadenopathy was revealed. Head CT showed no abnormalities. Malignancy of the kidney graft was suspected. The R.E.N.A.L nephrometry score[] was 11x. Based on the TNM classification[], the lesion was scored as stage II, T2bN0M0. Ultrasound-guided fine needle aspiration of the mass was not performed due to concerns of malignant tumor metastasis along the passage path of the puncture needle.


A previously healthy 65-year-old woman who had been experiencing left buttock pain radiating to the dorsum of the foot for 2 years visited my spine clinic.
She had sudden onset of left buttock pain 2 years ago; the pain slowly radiated to the dorsum of the foot and worsened over time. Prior to visiting the clinic, she underwent lumbar spine magnetic resonance imaging (MRI) and abdominal computed tomography scan for the evaluation of left buttock pain. She was managed conservatively. However, the condition did not improve. She received physiotherapy, pain killers, and epidural injections based on a presumptive diagnosis of spinal stenosis and varicose vein for 2 years in other hospitals.
The patient had a free previous medical history.
Upon presentation at the clinic, her pain was aggravated by sitting and walking for a long time. When walking 500 m or sitting on the chair, she experienced sensory loss in the dorsum of the left foot. However, she had no significant previous medical history or surgeries. Physical examination revealed no atrophy and dilated veins in both lower extremities. According to the motor examination, there was no definite weakness on both lower limbs. Hypoesthesia to light touch and pin prick was observed on the dorsum of the right foot and lateral side of the right calf. Deep tendon reflex revealed a mild decrease in ankle reflex at the left side. The results of the straight-leg-raise test, femoral nerve stretching test, Patrick test, and flexion, adduction, and internal rotation test were negative. Moreover, the range of motion of the hip joint and lumbar spine and pedal pulses were normal.
The results of the electrodiagnostic evaluations, including motor and sensory nerve conduction studies, H-reflex test, and electromyography, were normal.
A retrospective review of previous lumbar spine MRI findings revealed no significant evidence of spinal stenosis. However, a cystic mass was observed in the left L5-S1 extraforaminal space (Figure ). The lesion was indicative of an INGC because of its location along the path of the L5 spinal nerve. The patient was not aware of the cystic lesion. Thus, to confirm the nature and extent of the cystic mass, hip MRI, including high-resolution magnetic resonance neurography (MRN), was recommended. High-resolution MRN revealed an INGC arising from the articular branch of the hip joint, which extended to the lumbosacral plexus and L5 spinal nerve (Figure ). Moreover, a degenerative change in the posterior labrum was observed (Figure ). The cystic lesion had a tubular-like feature from the termination of the articular branch to the level of the sciatic notch, where crossover at the level of the sciatic nerve and/or lumbosacral plexus occurs (Figure ). However, the balloon-like feature above the crossover expanded to the far-lateral extraforaminal space at the L5-S1 level along the left L5 spinal nerve (Figures , , and ).


A 19-year-old man presented with low back pain without radicular pain in both lower extremities for 2 years.
His back pain worsened from stretching and standing for a long time. He had no history of trauma. He rated himself as 7 on a 10-point visual analogue scale. Conservative treatment, such as rest, lumbosacral brace immobilization, oral non-steroidal anti-inflammatory drugs, and physical therapy, did not relieve his back pain, which seriously affected his daily activities.
He had no relevant traumatic history.
Physical examination revealed a reduced range of motion in the lumbar spine, especially with limited lumbar extension. Tenderness was noted over and beside L2-L5 spinous processes. Bilateral straight leg raising test was negative. The sensory, motor, and tendon reflexes of both lower limbs were normal.
Lumbar dynamic radiographs showed no instability (Figure ), two-dimensional computed tomography (CT) scan showed lumbar spondylolysis at bilateral L2-L5 levels (Figure ), and lumbar magnetic resonance imaging showed no signs of lumbar disc degeneration (Figure ). Because daily activities were severely limited, surgery was recommended for the case.


A 41-year-old male from Tamil Nadu state, India, had a history of febrile illness with myalgia and dry cough for approximately 1 week; he was nonalcoholic. He was treated only with oral paracetamol for fever at a local hospital [he had no history of using any drugs causing myoclonus at presentation or in the recent past (e.g., quinolones, cephalosporins, antiviral agents such as lopinavir or ritonavir, tramadol, antidepressants)]. Upon resolution of the abovementioned symptoms by approximately day 10, he noted subtle jerky involuntary movements of the limb along with difficulty while walking. His symptoms peaked over the next 10 days when he had severe limb and truncal jerking at rest that worsened upon action. He could not walk without support. He did not complain of any headache, cognitive symptoms, speech problems or any other neurological symptoms.
On examination at presentation (20 days post fever, 10 days post onset of neurological symptoms), the patient was alert and oriented; his score on the Mini-Mental Status Examination (MMSE) was 29/30. The patient predominantly had generalized myoclonus (mostly synchronous, both positive and negative) that was most prominent in the proximal upper and lower limbs and trunk, with auditory and mantle area tactile stimulus sensitivity. Clinically, myoclonus appeared to be a subcortical-brainstem origin phenotype. The patient had gait ataxia with normal upper and lower limb coordination, motor power, deep tendon reflexes and sensory examination, as well as possible gait disturbance due to myoclonus involving the proximal lower limb and trunk ( in the online-only Data Supplement). The rest of the examination, including smell, speech, and eye movements, was within normal limits.
At this juncture, the likely pathophysiologies considered were brainstem encephalitis (in view of a predominant brainstem myoclonus-ataxia clinical syndrome) of direct viral, para/postinfectious or a primary autoimmune cause, as there was no history suggestive of other etiologies, such as drugs or hypoxic insult. Contrast MRI of the brain ( in the online-only Data Supplement), cerebrospinal fluid biochemistry and cytology were normal. Somatosensory evoked potentials (SSEPs) did not show any giant potential, and EEG did not reveal any epileptiform discharges. Detailed neuropsychology evaluation showed mild frontal dysfunction. In view of the current pandemic and a suspicious recent febrile history, a CT scan was performed on the chest, which showed right lower lobe ground glass opacities and associated interstitial thickening suggestive of a resolved viral lung infection (). Reverse transcriptase polymerase chain reaction test for COVID-19 was predictably negative due to late presentation. His other serum markers, including D-dimer, ferritin, lactate dehydrogenase, and C-reactive protein, were within normal limits. An anti-COVID-19 antibody test was performed to rule out a recent COVID-19 infection. The IgG titer was 45.2, which was strongly positive (reference > 1 implies positive for COVID-19 infection), supporting the diagnosis of a recent COVID-19 infection. In view of the latent period of approximately 10 days for the onset of the neurological symptoms following the onset of fever, the likelihood of para/post infectious brainstem encephalitis-related myoclonus-ataxia syndrome was considered [].
The patient was treated with clonazepam and levetiracetam with mild improvement in symptoms over the first 3 days of treatment with significant residual disability. He was subsequently treated with 1 g intravenous methylprednisolone (IVMP) for 5 days with significant improvement in symptoms. At discharge on day 10 of admission, the patient could walk easily without support ( in the online-only Data Supplement). At the last outpatient follow-up at 6 weeks, the patient had complete resolution of ataxia and near total resolution of myoclonus while on 0.5 mg per day of clonazepam alone (levetiracetam was tapered off following discharge), with normal scores on the MMSE and Frontal Assessment Battery. Detailed neuropsychology evaluations could not be repeated.


A 74-year-old female with a history of road traffic accident presented in the emergency room around 3 h after sustaining trauma. The patient was a rear seat passenger in a car with a history of loss of life to driver and critical head injury to non-driving front seat copassenger. The patient had bilateral lower limb, facial, and hand trauma. The patient had a history of bilateral TKR (TKA) done 2 years ago. The patient had a history of systemic hypertension on regular treatment. The patient was assessed by emergency physician and initiation of necessary measures including provisional stabilization of lower limbs, fluid replacement, and critical care monitoring of parameters done. The patient had bilateral knee injuries with crepitus, abnormal mobility, and deformity of the right knee and leg. The left knee revealed tenderness and swelling along the joint. There was no sign of neurovascular injury to lower limbs. Additional injuries along face and right hand were soft-tissue injuries. Plain film radiography showed distal femur comminuted displaced PPF right knee (, ) classified as type II in accordance with Rorabeck and Taylor criteria [] and midshaft comminuted fracture right tibia fibula (, ) classified as type III A in accordance with Felix et al. []. The left knee radiography showed undisplaced periprosthetic lower pole fracture of patella (, ) classified as type IA in accordance with Ortiguera and Berry criteria []. The floating knee scenario for the right lower limb was classified as Fraser’s type IIb and planned for surgical management for the right lower limb injury.
The patient was stabilized and on the 2nd day of injury, the patient underwent surgical reduction and fixation of distal femur fracture with distal femoral locking plate (AO Synthes) through the lateral approach and diaphyseal tibial fracture fixation with narrow locking plate (AO Synthes). Primary autologous iliac ipsilateral bone grafting to augment the healing at both fracture segments done. The left knee patellar fracture was managed conservatively in a long knee brace immobilization. Immediate post-operative period was uneventful and the patient was discharged from hospital in stable condition after 5 days of surgery.
Rehabilitation protocol was initiated early with in bed limb exercises and assisted passive range of movements exercises for the right knee and ankle from the 1st week onward. Three weeks after surgery, the patient was allowed walker support walking and rehabilitation of the left knee in a brace support continued. At 6 weeks, the patient was allowed knee mobilization exercise for both knees. The patient was monitored with clinical and radiological assessment at 6, 12, and 24 weeks. At 6 months, the patient was able to mobilize with stick support once there were clear radiologic signs of fracture consolidation. Follow-up scanogram (), radiographs of femur (, ), tibia (, ), and patella () showed good alignment. The patient walked without any walking aids () with good functional range of movements (, ) at 18 months follow-up and had recovered her previous functional status.


A 44-year-old Caucasian woman presented with sudden onset central crushing chest pain, shortness of breath, and collapse. An ECG showed anterior ST elevation across leads V2–V5 () prompting management via the primary percutaneous angioplasty pathway. Past medical history was unremarkable except for recently diagnosed asthma, treated with inhaled corticosteroid and β-agonist. The patient did not have any risk factors for ischaemic heart disease. Cardiovascular examination was unremarkable and respiratory examination revealed bi-basal crepitations, more prominent on the left. Urgent coronary angiography showed unobstructed coronary arteries, with initial coronary artery spasm that resolved with intracoronary nitrate (). Troponin-T was 772 ng/L (normal range <14 ng/L) and a chest radiograph showed extensive left-sided consolidation (). A working diagnosis of myopericarditis secondary to pneumonia was made and the patient received intravenous co-amoxiclav with supportive treatment and monitoring.
Viral swabs and urinary antigens for atypical pneumonia were negative. Serological viral and autoimmune screens for myocarditis were negative and the patient did not improve despite antibiotic treatment. Peripheral blood counts revealed a white cell count of 17.34 × 109/L (normal range 3–10.5 × 109/L) consisting of an eosinophilia of 7.23 × 109 (normal range <0.5 × 109/L). The patient denied any recent travel history, had a stable weight and no bowel symptoms. A computed tomography (CT) pulmonary angiogram was undertaken which confirmed the consolidation seen on the chest x-ray, and showed multiple small filling defects suggestive of pulmonary emboli. A bronchoalveolar lavage showed abundant polymorphonuclear leucocytes, lymphocytes, macrophages, and bronchial epithelial and squamous cells, in keeping with acute inflammation, though no evidence of organisms or eosinophilic damage. Serum troponin-T remained elevated at 1131 ng/L.
A CMR was undertaken showing extensive myocardial oedema on multi-parametric native myocardial mapping, patchy subendocardial late gadolinium enhancement (LGE) particularly in the apical segments and right ventricle, and a circumferential pericardial effusion (). These features were in keeping with a myopericarditis, but not indicating a specific underlying aetiology.
Taken together with the eosinophilia and late onset asthma, which was poorly responsive to standard inhaled treatment, but responsive to oral steroids, and CT sinus imaging revealing sinusitis and polyposis, the patient met the American College of Rheumatology diagnostic criteria for EGPA [asthma, eosinophilia (>10% of peripheral white cell count), pulmonary infiltrates, and paranasal sinus abnormalities].
The patient was treated with pulsed intravenous methylprednisolone (500 mg) once daily for 5 days and cyclophosphamide (15 mg/kg) and rapidly showed improvement clinically. She received a further five cycles of cyclophosphamide with tapering oral prednisolone and was initiated on azathioprine as a maintenance agent. The patient had a good response symptomatically, biochemically (normalized troponin-T), electrocardiographically, and radiologically.
Interval CMR imaging showed complete resolution of myocardial oedema () indicating a dramatic response to therapy. Some LGE remained in the apical segments which is likely representative of focal areas of fibrosis, but may also represent a limited area of infarct due to initial coronary vasospasm. Coronary vasculitis also remains a differential, but the response to intracoronary nitrate on angiogram would not be expected with vasculitis (). These findings suggest that fast administration of cyclophosphamide with high-dose steroids may reduce the burden of post-myocarditis fibrosis in EGPA. The patient was maintained on oral azathioprine and oral steroids were weaned off. She remains in clinical and radiological remission.


A 45-year-old female patient without a known history of chronic disease was admitted to our hospital’s neurology clinic with the complaint of widespread painful muscle contractions. The contractions were triggered by emotional stress. Contractions were progressively increased and within 1 month the patient became bed-dependent due to the spasms in lower back and both ankles. In the neurology clinic, EMG performed for etiological research, the presence of continuous MUAP activity at rest accompanied by spasm in the right lower extremity was evaluated in favor of stiff-person syndrome. Amphiphysin antibody was detected as +++ in paraneoplastic panel search in CSF. Patients’ treatment regime was arranged as 1000mg pulse methylprednisolone for 5 days, followed by methylprednisolone 64 mg/day, IVIG/5 days, diazepam 10 mg/day and baclofen 40 mg/day and patient was transferred to rehabilitation inpatient clinic.
The neurological examination of the patient on admission to rehabilitation inpatient clinic; Patient was conscious, oriented, and cooperative. Muscle strength evaluated via manual muscle test with standard technique (score from 0 to 5 /5)[]: Left pectoralis major 4/5, biceps brachii 4/5, triceps 5/5, brachialis 5/5, wrist flexors and extensors 5/5, upper right 5/5 throughout, lower right 3/5, lower left 3/5. Lower extremity selective muscle strength examination could not be performed due to spasticity. Sensory examination: Superficial and deep sense intact. The patient’s bilateral hip flexion (R: 100°, L: 95°), bilateral knee flexion (R: 135°, L: 95°), bilateral ankle dorsiflexion (R: 5°, L: 15°), right shoulder abduction (45°) and left shoulder flexion (90°), extension (40°) and abduction (90°) movements were limited. The patient had sitting balance partially and was immobile out of bed due to lumbar extensor spasticity and balance-coordination disorder. In the spasticity evaluation, in addition to the lumbar extensor muscles, there was MAS 2, Tardieu 3 spasticity in the bilateral gastrocnemius and soleus muscles, and MAS 1+ spasticitiy in the left hip flexor muscles ().
Functional status of the patients was evaluated with Funtional Independance Measure (FIM). Total score of the patient was 66. Quality of life of the patient was evaluated with SF-36. SF-36 provides a self-reported health status profile consisting of eight dimensions. Results of the patient: Physical functioning was 15%, role limitations due to physical problems was 75%, bodily pain was 22.5%, general health perceptions was 40% , vitality was 5%, social functioning was 25%, role limitations due to emotional problems was 66.7%, and mental health was 28%.
Since the patient was using 64 mg/day methylprednisolone, the patient’s bone mineral density measurement with Dual energy x-ray absorptiometry (DEXA) and laboratory tests were performed. Bone mineral density measurement was within normal range, Ca: 9,1 mg/dL, P:2,9 mg/dL, 25-OHVitD: 7,4 ng/mL, PTH: 150,9 pg/mL. 1000 mg/day calcium and 600 IU/day vitamin D supplement was given to the patient.
The patient was included in the rehabilitation program of active range of motion of shoulder, hip, knee and ankle, gastrosoleus and hip stretching (iliopsoas/hamstring), strengthening of abdominal muscles (knee to chest, isometric abdominal exercises, pelvic tilt), posture and gait retraining (symmetrical weight bearing, weight shifting, stepping, single leg standing, push off – calf rise) balance and coordination exercises (heel rise, side stepping, single leg standing, backwards walking) 5 days a week for 2 months ().
Meanwhile, the patient was screened for breast cancer with a prediagnosis of paraneoplastic stiff person due to the antibody positivity to amphiphysin. The patient was diagnosed with invasive breast carcinoma by breast ultrasound and subsequent breast biopsy. The patient underwent simple mastectomy, in consultation with general surgery, and was transferred back to our inpatient clinic. The rehabilitation program continued for another month in the same order. With the rehabilitation program, the patient was mobilized in the parallel bar at the end of the first month, and subsequently with a walker and a tripod cane in the following 2 months.
The neurological examination of the patient on discharge from rehabilitation inpatient clinic; The patient was counscious, cooperative and oriented. Muscle strength: upper right 5/5, upper left 5/5, lower right 5/5, lower left 5/5. Sensory examination: Superficial and deep sense intact. The patient had no limitation in range of motion and no spasticity was detected (). FIM total score of the patient was 88. SF-36 results of the patient: Physical functioning was 65%, role limitations due to physical problems were 0%, bodily pain was 22%, general health perceptions were 50% , vitality was 55%, social functioning was 37.5%, role limitations due to emotional problems were 0%, and mental health was 84%.
The patient’s drug doses were reduced gradually, and she was discharged with baclofen 10 mg/day and methylprednisolone 48 mg/day. Control EMG performed after discharge has been interpreted as; Compared to baseline EMG, there was no pathological spontaneous MUAP activity, and this has been interpreted as noticeably improving condition.


A 46-year-old man presented with a 4-week history of right eye (RE) ocular pain, redness and visual loss. He was diagnosed and treated for COVID-19 infection two weeks before onset of symptoms and had received home therapy of intravenous steroids for five days as a result of which he had developed steroid-induced diabetes. At presentation, visual acuity was hand motions; examination showed ciliary congestion, anterior chamber showed 2 + cells and 1 mm hypopyon and there were dense vitreous exudates []. B-scan revealed vitreous echoes and attached retina. A diagnosis of endogenous endophthalmitis was made and he underwent pars plans vitrectomy with injection of intravitreal vancomycin 1.0 mg, amikacin 300 ug, amphotericin-B 5 ug and voriconazole 100 ug. On table the vitreous exudates appeared dry with snowball like accumulations suggesting fungal infection [Fig. and ]. Thick sheets of pre-retinal exudates were seen in the inferior periphery. The vitreous biopsy samples were sent for microbiological processing for smears (Grams and KOH), and aerobic and anerobic cultures by plating on blood and chocolate agar and fungal cultures by plating on Sabouraud dextrose agar. All were negative. Oral voriconazole was continued for 6 weeks. The infection resolved rapidly with visual recovery to 6/9 six weeks later [].


A 57-year-old male, diabetic and hypertensive, was hospitalized for severe Candida septicemia, with renal infection during COVID-19 infection. Blood and urine cultures were positive for Candida
tropicalis. The patient did not complain of loss of vision but on testing, his visual acuity had dropped to counting fingers at 2 meters in his RE. LE was normal. RE showed 2 + cells and flare and 1+ vitreous cells and three well-circumscribed retinitis lesions in his RE, one involving the center of macula [Fig. and ]. He was switched from systemic fluconazole to intra-venous voriconazole 200 mg twice daily due to the superior ocular bioavailability of the latter. After two weeks, the retinitis appeared to be resolving [] but subsequently worsened [Fig. and ]. Intravitreal amphotericin-B 5 ug and voriconazole 100 ug were given. Ten days later, there was increase in the vitreous haze, but the original retinitis lesions were resolving [Fig. and ]. As he was not systemically fit to undergo surgery, intervention was deferred and the ocular condition was closely monitored. Four weeks after the intravitreal injection, the vitreous inflammation persisted but retinitis showed early signs of resolution [Fig. and ]. Systemic voriconazole was continued for the renal and ocular infection and 3 months following the intravitreal injection his visual acuity improved to 6/36 with complete resolution of the vitreous inflammation and retinitis [Fig. -]. He was advised to continue oral voriconazole for a further 4 weeks.


A 59-year-old lady presented with complaint of RE visual deterioration and nocturnal low-grade fever for 4 weeks. Symptoms had started 2 months ago during COVID-19 infection, for which systemic steroids were given for 4 weeks. Locally she had undergone Magnetic Resonance Imaging (MRI) of the whole body for her pyrexia, which had revealed abdominal abscesses and she had received systemic antibiotics for the same with no response. On examination, visual acuity was 6/9 and 6/6 in the RE and LE respectively. LE was normal. RE showed 1 + vitreous cells and a large choroidal abscess supero-temporal to the macula []. The abscess showed central activity, scarring at its edges and multiple discrete yellow miliary lesions around it [Fig. and ]. OCT revealed vitreous traction over the lesion []. Serological investigations to look for possible etiological causes which included: complete blood picture, Mantoux skin test, Quantiferon-TB gold test, Venereal disease research laboratory test, Treponema pallidum hemagglutinin assay and blood and urine cultures, were negative. Whole body Positive Emission Tomography/Computed tomography (PET/CT) scan revealed multiple hypodense lesions in the spleen, the largest being 43 millimeters in diameter, low for hypermetabolic activity. Based on the clinical appearance of the chorio-retinal lesions, a provisional diagnosis of tuberculosis was considered. After discussion with her internist, a therapeutic trial of 4-drug anti-tubercular therapy (ATT) was started, with the intention of considering vitreous biopsy in case of worsening. She was closely followed up every week and the lesions showed improvement. Six-weeks after initiating ATT the choroidal abscess and the miliary lesions had resolved significantly [Fig. and ]. The splenic abscesses had also started showing resolution. She was continued on 4-drug ATT for the first two months with the intention to continue 2-drug ATT for 10 months.


A 32-year-old man presented with 3-day onset of paracentral and triangular negative scotoma in RE infero-temporal visual field. He had recovered from COVID-19 infection 4 months prior. LE was asymptomatic. He had undergone a complete health check-up including serological investigations a month prior which were normal. RE fundus revealed a triangular deeper retinal greyish-white lesion located supero-nasal to center of macula []. OCT over the corresponding area showed disruption in the outer retinal layers [], hyper-reflective lesions in superficial retinal layers with shadowing of deeper retina [Fig. and ]. The entire inner retinal surface just inferior to foveal center showed hyper-reflectivity []. LE fundus revealed small greyish-white lesion nasal to the foveal center and multiple similar lesions inferonasal and temporal to the center []. OCT revealed a single hyper-reflective lesion in the superficial retina with underlying shadowing temporal to the center [] and hyper-reflectivity of the entire inner retinal surface []. Based on the characteristic symptoms, the fundus lesions and OCT findings he was diagnosed as post COVID-19 RE symptomatic AMN, and bilateral asymptomatic PAMM. He was placed under observation.


A 27-year-old female patient presented with central vision deterioration in LE of 10-days duration. She had recovered from COVID-19 infection two weeks prior for which she had been on oral steroids. RE was normal; left eye visual acuity was 6/18. Examination showed no signs of inflammation. Fundus examination revealed serous detachment of the macula and was confirmed by OCT []. She was observed and the symptoms resolved spontaneously a few weeks later.


A 32-year-old lady in the ICU complained of rapid loss of central vision in both eyes (one month after COVID-19 infection). She was admitted with fever and Pseudomonas sepsis while still on treatment for COVID-19 infection. She had severe anemia (hemoglobin 6.8 gm%), leukocytosis (total leucocyte count 13000/mm3) and thrombocytopenia (platelets 72,000/mm3). Vision was counting fingers at 4 meters. Fundus examination showed bilateral pre-foveal hemorrhages. Four weeks later she followed up in the outpatient department and reported no improvement. Her visual acuity was recorded as 6/18 in and 6/36 in the RE and LE respectively. Bilateral retinal hemorrhages were noted as before. The corresponding OCT showed pre-foveal location with underlying shadowing [Fig. -]. A month later her visual acuity had improved to 6/6 and 6/9 in the RE and LE respectively. The pre-foveal heme had resolved almost completely [Fig. and ] although the RE OCT showed residual paracentral pre-foveal heme and the LE OCT now revealed some intraretinal heme [Fig. and ]. She was advised to follow-up after 3 months.


A 40-year-old gentleman complained of multiple non-specific but distressing visual symptoms including severe visual blur and extreme brightness and flashes of light for 3 weeks. He was admitted in ICU with invasive systemic aspergillosis and was on intravenous voriconazole (300 mg twice daily) for 4 weeks as microbiology isolates had shown sensitivity only to voriconazole. The systemic aspergillosis had been diagnosed during his COVID-19 infection, which he had developed 6 weeks prior. History was significant for renal transplant 3 years back and diabetes mellitus for 2 months (onset after recovery from COVID-19 infection). He was also on tablet augmentin 1 gram twice daily; oral mycophenolate mofetil 360 mg twice daily; oral prednisolone 5 mg daily; tacrolimus 0.5 mg twice daily; and subcutaneous insulin. The BCVA was 6/6 BES. Color vision (using Ishihara charts), pupil response to light, anterior segment and fundus evaluation were within normal limits in both eyes each eye. Perimetry (Humphrey’s visual field analysis central 24-2 program) was normal. A review of all the medications that the patient was on was done and based on the onset of his symptoms, a possibility of voriconazole-induced visual symptoms was made. The dose of voriconazole was reduced with improvement in symptoms within a week. However, the drug had to be stepped up in view of his systemic condition of invasive aspergillosis and the patient again reported recurrence of his visual symptoms.


A 61-year-old male patient presented with diminution in vision and ocular pain in OS. He had contracted COVID and was admitted in a hospital for 14 days. He was a known diabetic, hypertensive and suffered from coronary heart disease in the past. On examination, the best-corrected visual acuity (BCVA) in OD was 20/30 and that in OS was CF 1 meter. Fundus examination of OD [] revealed subretinal exudate nasal to the disc, and a large subretinal exudate clump under the fovea in OS with vitreous exudates forming a string of pearl-like appearance. A clinical suspicion of fungal EE (OU) with subretinal abscess was made and the patient started on oral ketoconazole 200 mg BD. In spite of extensive investigations and a thorough evaluation by an internist, no systemic foci of infection could be found. Intravitreal voriconazole was administered and repeated twice at 72-h intervals. Once the lesion started reducing in size, the patient was continued on oral ketoconazole and is currently undergoing treatment.


A 55-year-old male presented with complaints of a central scotoma in OS for 15 days. He gave a history of contracting COVID-19 1½ months back with hospitalization for a month. He was diagnosed as post COVID retinitis elsewhere and subsequently treated with three doses of intravenous corticosteroid followed by a tapering schedule of oral corticosteroid. On examination, BCVA in the OD and OS was 20/20 and CF 1 feet, respectively. Fundus examination in OD [] revealed subretinal exudate superior and temporal to fovea, and a large subretinal abscess under the fovea with overlying retinal necrosis and localized vitritis in front of the lesion was noted in OS. A clinical suspicion of fungal EE was made and the patient started on oral itraconazole 200 mg BD as his LFT was deranged. No systemic focus of infection was noted, and blood and urine culture were negative. As the lesion appeared to enlarge during the follow-up visit, OS vitreous biopsy was performed and intravitreal vancomycin, ceftazidime, and voriconazole combination was administered. However, the culture from vitreous aspirate failed to yield any organism. In the follow-up visit, the patient developed ball-like vitreous exudates. Hence, intravitreal voriconazole was administered repeatedly for four times, whereas oral itraconazole was continued. The subretinal lesions in OD resolved and the size of the subretinal exudate reduced significantly. BCVA in the last follow-up was 6/6 in OD and CF 2 m in OS.


A 64-year-old male reported to us with complaints of a black dot seen in OS for 15 days. A known diabetic and hypertensive, he was diagnosed to have COVID-19 in the previous month and had been admitted for over 20 days. On examination, BCVA in OD was CF 3 m and that in OS was 20/20. Fundus examination in OD [] revealed subretinal exudate adjacent to fovea, whereas OS showed vitreous haze and few vitreous balls. The patient was started on oral itraconazole 200 mg BD and intravitreal voriconazole was administered in OS subsequently. The blood and urine culture were negative and systemic evaluation was noncontributory.


A 54-year-old male patient presented with complaints of diminution of vision in OU for 20 days. The patient was a known diabetic and was diagnosed to have COVID-19 1 month back. His BCVA was the perception of light in OD and CF close to face in OS. A hypermature cataract was seen in OD and OS was pseudophakic. Slit-lamp examination of OS revealed fibrin over IOL and 1+ cells in AC. The vitreous cavity showed dense vitritis with fluffy snowballs in the vitreous cavity precluding the view of the retina. B scan [] revealed few dot echoes in vitreous and thickened membrane echo not attached to disc s/o posterior vitreous detachment in the OS, whereas OD vitreous was clear. The patient underwent vitrectomy with silicone oil injection in OS and vitreous biopsy was sent for microbiological evaluation, which did not yield any organism. The patient was started on oral ketoconazole and was followed up closely. After 1 month of OS surgery patient also underwent OD cataract surgery. At final follow up the BCVA in OD had improved to 6/9 and OS had a visual acuity of CF 1 meter.


A 78-year-old male presented to our hospital with a recent history of acute decompensated heart failure due to severe MR, based on long-standing ischaemic heart disease which had been treated by coronary bypass and implantable cardioverter defibrillator for secondary prevention. At presentation, an auscultatory examination revealed a holosystolic murmur of a grade IV/VI was audible at the left fifth mid-clavicular line with radiation to the left axilla. No peripheral oedema was documented. The exertional dyspnoea was graded in New York Heart Association functional Class II. Six-minute walk distance was 403 m. N-terminal pro brain-type natriuretic peptide was 990 ng/L (normal < 486 ng/L). The prescribed medication was torasemide 20 mg, bisoprolol 10 mg, and amlodipine 10 mg and dabigatran 150 mg.
Transoesophageal echocardiography demonstrated an A2 segment pseudo-prolapse with an eccentric MR jet to the posterior direction, which appeared to result from mitral annular enlargement due to left atrial dilatation (volume 49 mL/m2) with the anteroposterior diameter of 38 mm, but no relevant LV cavity enlargement with the end-diastolic diameter of 52 mm and the ejection fraction of 64% (). As a result, the coaptation angle of both leaflets increased to 148°, where the angles between the mitral annular plane and leaflets reduced to 21° as to the anterior leaflet, comparing the posterior leaflet with 28°, in absence of relevant apical leaflet tethering (coaptation depth 6 mm) (). A three-dimensional colour Doppler echocardiography revealed a large MR orifice area of 0.78 cm2 with the width of 17 mm ().
Due to a prohibitive risk for redo surgery, the local multidisciplinary heart team decided to treat the patient using TMVr. In consideration of pathoanatomy of MV and a regurgitation width of 17 mm, we selected the PASCAL® Transcatheter Valve Repair System (Edwards Life Scientific, Irvine, CA, USA). The PASCAL was placed successfully between segments A2 and P2 (). The target posterior leaflet showed a thick basal part of 12.1 mm and a thin distal part of 4.7 mm with a total of 16.8 mm. The clasped length was 9.1 mm (). After PASCAL release, the MR severity was reduced to mild (); however, an acute SLDA occurred 2 min later (). The posterior leaflet was shortened to 12.3 mm (), and the device was moving back and forth instable, while the residual MR remained unchanged because the large-profile device worked like as a central spacer for the coaptation defect (). The mean transmitral gradient was 2 mmHg after PASCAL implantation. Due to the limited MV orifice area for a second PASCAL device with device width of 10 mm, we decided to stabilize the PASCAL device and both leaflets by a MitraClip XTR® (Abbott Vascular Structural Heart, Menlo Park, CA) with a device width of 4 mm. After exchanging the guide catheters, the leaflets adjacent to the PASCAL device were captured by the MitraClip XTR (), in which the residual length of the posterior leaflet was 5.5 mm after closing the clip (). The PASCAL device was stabilized (, , Video S) and the residual MR remained mild with a mean transmitral gradient of 3 mmHg (). The patient was successfully discharged 2 days after the procedure with mild MR, stable devices implanted and no post-procedural mitral stenosis with the mean gradient of 4.7 mmHg.


A 74-year-old Caucasian male with a history of remote myocardial infarction (MI) was admitted to Emergency Department (ED) with a haemodynamically stable broad complex tachycardia (BCT) of 180 b.p.m., having recently undergone an outpatient Holter for evaluation of syncopal palpitation. He reported dizziness and palpitation but no chest pain. His blood pressure was 102/78 mmHg. General clinical examination, in particular cardiovascular and respiratory examination, was normal. Twelve-lead ECG demonstrated BCT with classical findings suggestive of VT (VT-1, ), supported by its refractoriness to intravenous adenosine administered via a large cannula at the antecubital fossa. Successful administration of adenosine (6 mg, 6 mg, 12 mg) was validated by patient reporting short-living physiological side effects of flushing, chest tightness, dyspnoea, and ‘sense of doom’. Patient was initially managed with intravenous amiodarone but subsequent haemodynamic compromise with a blood pressure of 80/60 mmHg necessitated an external direct current cardioversion.
Two hours later, patient had recurrent stable VT with a different morphology (VT-2, ) whist on telemetry. Patient reported symptoms similar to those of the haemodynamically compromised VT-1. A trial of VM led to immediate VT-2 termination. In the first 12 h, the patient had recurrent episodes of VT-2, all of which terminated by VM (). Twelve hours after initiation of intravenous amiodarone, he had no further VT. He was transitioned to oral amiodarone and bisoprolol.
Routine blood tests were normal. Adjusted serum calcium was 2.39 mmol/L (2.20–2.60), serum magnesium was 0.93 mmol/L (0.7–1.0), and serum potassium was 4.7 mmol/L (3.5–5.3). His baseline ECGs showed sinus rhythm, normal axis, as well as Q waves in V1–V3 and T-wave inversion in V4–V6 (). A recent outpatient 7-day Holter revealed 1122 VT episodes during which patient experienced dizziness. Coronary angiogram demonstrated single-vessel disease with chronic total occlusion (CTO) of the left anterior descending artery (LAD) (Videos 1 and 2). Transthoracic echocardiography showed severe left ventricular (LV) systolic impairment (ejection fraction 31%) with akinetic mid-anterior and anteroseptal wall including LV apex. Cardiac magnetic resonance imaging (MRI) demonstrated transmural infarct at the mid-LAD territory implying non-viability and lack of benefit of revascularization of the LAD-CTO ().
Based on these findings, the likely diagnosis is scar-related VT. Following discussion with cardiac electrophysiologists, a VT stimulation study was deemed unnecessary given freedom from VT 12 h after admission. Prior to patient’s discharge, an implantable cardioverter-defibrillator (ICD) was inserted for secondary prevention of ventricular arrhythmias. He was followed up in the heart failure clinic and device clinic. There is no ventricular arrhythmia detected on routine ICD monitoring since ICD implantation. The patient remains clinically well to this date.


A 73-year-old Asian man with a history of myocardial infarction treated by coronary artery bypass grafting and congestive heart failure [New York Heart Association (NYHA) Class III], despite the guideline-directed medical therapy including carvedilol of 20 mg, valsartan of 160 mg, spironolactone of 50 mg, furosemide of 40 mg, and aspirin of 100 mg, was referred to our institution for therapeutic intervention in combined valvular heart diseases. Upon arrival, he presented with dyspnoea on mild exertion, while his vital signs were stable (blood pressure, 106/81 mmHg; heart rate, 72 b.p.m.; oxygen saturation, 95% on room air). Physical examination revealed a Levine IV/VI systolic murmur at the upper right sternal border and apex, as well as slight bilateral lower extremity oedema. Laboratory test results were normal except for B-type natriuretic peptide levels of 321.5 pg/mL (<18.4 pg/mL), creatinine levels of 1.17 mg/dL (<1.15 mg/dL), and albumin levels of 31 g/L (41–51 g/L). Transthoracic echocardiography (TTE) revealed severely decreased left ventricular ejection fraction of 30.3% and increased left ventricular end-diastolic volume of 237.3 mL (62–150 mL) with severe functional MR (effective regurgitant orifice area 0.41 cm2, regurgitant volume 65.8 mL), resulting in quite low forward SV (SV index to body surface area, 22.1 mL/m2) (). The aortic valve area (AVA) calculated with the continuity equation was 0.71 cm2 with a transaortic mean pressure gradient (MPG) of 22.2 mmHg. Doppler velocity index was 0.20. Pulmonary hypertension was suggested by a systolic tricuspid regurgitation pressure gradient of 42.1 mmHg. Transoesophageal echocardiography demonstrated a severe regurgitant jet with vena contracta area of 0.40 cm2 that originated from the A2-P2 portion of the mitral valve as a result of leaflet tethering (, Videos 1 and 2) and degenerative changes of the aortic valve with two-dimensional planimetric AVA of 0.80 cm2 (). Three-dimensional planimetric AVA was 0.72 cm2. Coronary angiography showed that all bypass grafts were patent.
The patient was diagnosed with classical LFLG AS, and DSE was performed to evaluate the severity of his AS. The AVA was slightly increased to 0.75 cm2 with an MPG of 24.8 mmHg and a mean transvalvular flow rate (Qmean) of 114.5 mL/s after dobutamine stress up to 20 μg/kg/min. However, the results were inconclusive because the flow reserve was absent (increase of forward SV <20%). In addition, the projected AVA at a normal transvalvular flow rate (250 mL/s) calculated by linear regression analysis was 1.06 cm2, which was unreliable due to no sufficient increase of Qmean ( and ). Multidetector computed tomography (MDCT) demonstrated the shaggy aorta () and the aortic valve calcium score using the Agatston method of 1512.3 arbitrary units (), which indicated the unlikeliness of severe AS. Although the resolution of AS could have reduced left ventricular end-diastolic pressure and MR, even multiparametric approach did not lead to the confirmation of AS severity. Therefore, our heart team decided to reassess the severity of AS after PMVR using the MitraClip system (Abbott Vascular, Lake Bluff, IL, USA), considering his high surgical risk (Society of Thoracic Surgeons Predicted Risk of Mortality, 8.856%). Two clips were successfully implanted at the centre of the A2-P2 portion, and MR was markedly reduced from severe to trivial (). There was no significant post-procedural mitral stenosis with the mean transmitral pressure gradient of 2.4 mmHg and the mitral valve orifice area of 2.60 cm2.
The patient’s symptoms were mitigated but remained (NYHA class II). Dobutamine stress echocardiography performed 10 days after PMVR demonstrated an AVA of 0.77 cm2 with an MPG of 42.1 mmHg as well as a 20% or more increase of forward SV after dobutamine infusion of 20 μg/kg/min ( and ). Thus, his LFLG AS was reassessed and categorized as true-severe AS, and we performed transcatheter aortic valve implantation (TAVI) with the 26 mm SAPIEN 3 (Edwards Lifesciences, Irvine, CA, USA) via a direct transaortic approach (). The patient was discharged after an uneventful recovery. At the 6-month follow-up, he had no cardiovascular symptoms and showed improvements in walking distance on a 6-min walk test. The follow-up TTE showed no AS and trivial MR.


A 25-year-old male initially presented with a melanoma on the left scalp with cervical and inguinal adenopathy. After biopsy confirmed metastatic disease with BRAF V600 mutation, the treatment option was debated between targeted agents and immunotherapy. In the hope of a long-term remission, it was decided to treat with immunotherapy. As ipilimumab was the only approved agent at the time, this treatment was initiated and four cycles were completed. Two years later, the patient developed a new subcutaneous nodule on his back. The biopsy confirmed a subcutaneous metastasis and the positron emission tomography (PET) scan showed an 8 mm lesion at the surface of the spleen. Given the progression of his disease, he received a treatment of pembrolizumab at a dose of 2 mg/kg every 3 weeks, for a total of 15 cycles. The best response achieved on treatment was a partial response. At his 10th cycle of pembrolizumab, the patient presented subjective morning stiffness and edema in the legs and hands, as well as pain in both knees. The patient later experienced range of motion restriction, mainly preventing him from closing his hands. Cutaneous examination revealed erythema, edema as well as cutaneous sclerosis involving metacarpal joints and upward toward the wrist as well as distal legs up to the calves. Pitting edema was prominent on the lower legs; however, Stemmer’s sign was negative which entails pinching and tenting the dorsal tissues of the foot. There was a positive prayer sign. No groove sign was noted. No calcinosis nor telangiectasias.
Laboratory tests revealed a progressive eosinophilia over 6 months, increasing from 700 cells/mm3 to 3400 cells/mm3. Skin biopsy of the second finger of the left hand and lateral malleolus of the left ankle revealed chronic subcutaneous inflammation, fibrosis of the dermis and infiltration of the fascia with mononucleated cells, confirming the diagnosis of eosinophilic fasciitis (shown in ). The use of pembrolizumab was discontinued at that time after a total of 15 cycles. Systemic steroids were offered but declined as spontaneous resolution was already underway with drug cessation. A complete resolution of symptoms and eosinophilia was reached within 4 months without corticosteroid treatment. Despite 45 weeks of exposure to pembrolizumab, the patient still managed to reach a complete remission of the immune-related adverse effect. A radiological follow-up with PET scans was undertaken after treatment discontinuation. The disease remained stable for 18 months. Then, the patient became symptomatic due to a rapidly evolving intraabdominal relapse and was started on targeted therapy with a combination of BRAF and MEK inhibitors.


A 55-year-old female presented with difficulty in walking for 15 days; on evaluation, she was found to have prolapsed intervertebral disc at L3–L4 region. The patient did not have any other neurological deficit or bladder-bowel symptoms. The patient underwent L3–L4 pedicle screw fixation in orthopedics department. The patient was on per urethral catheter for 3 days in postoperative period. After catheter removal, the patient developed difficulty in voiding urine with decreased bladder sensation with urinary retention and overflow incontinence. She had two episodes of fever with chills with lower abdominal pain, tenderness, and mild hematuria. The patient was treated conservatively, but still patient had persistent fever with increasing lower abdominal pain and distension of abdomen. General surgery opinion was taken considering acute abdomen. Ultrasonography abdomen was inconclusive. The patient underwent contrast-enhanced computed tomography (CT) scan of abdomen and pelvis in emergency department; it was showing overdistended urinary bladder with the presence of large pocket of air in bladder with air–fluid level and multiple foci of air specks in entire bladder wall with dilated gaseous bowel loops with small collection in pelvic cavity [Figures and ]. There were no free air specks in intraperitoneal cavity. On CT cystogram, there was suspicion of small amount contrast leak into the intraperitoneal pelvic collection []. Urology reference was given after above findings. On examination, the patient was febrile with pulse rate of 130 and blood pressure of 110/80 mmHg. She had lower abdominal tenderness with guarding and generalized abdominal distension. Her total leukocyte count was 13,000/mm3, hemoglobin – 9.9 g/dl, and creatinine – 0.8 mg/dl with normal electrolytes and liver function test. Per urethral catheter drained approximately 1000 ml of turbid urine. She did not have any other medical comorbidities.
The patient was started on broad-spectrum intravenous antibiotics, fluids, and blood, and urine culture was sent, hemodyanamics were monitored, and she underwent emergency exploratory laparotomy. The peritoneal cavity had seropurulent collection in pelvic region and approximately 3–4 cm diameter irregular perforation at the junction of dome and posterior wall of bladder with necrotic sloughed edges and edematous thickened entire bladder wall with the presence of whitish pus flakes attached to mucosal surfaces []. Trigone and ureteric orifices were away with normal urine jets. Bowel loops were dilated but normal, and there was no any other collection intraperitoneally. Edges of bladder perforation were debrided till fresh margin, collection fluid sent for culture, and copious wash of saline was given in pelvic cavity and intravesically. Suprapubic catheter kept through separate opening, per urethral catheter kept in situ, and bladder closed in two layers with absorbable suture. Wide bore drain kept in pelvic cavity and abdomen closure was done.
Postoperative recovery was uneventful. Pelvic fluid collection culture was positive for Escherichia coli. Drain removed after 5 days and the patient discharged after 8 days with both catheter in situ and received oral antibiotics for 2 weeks. Per urethral catheter was removed after 3 weeks after doing fluoroscopic cystogram and ruling out any leak with adequate bladder capacity. Suprapubic catheter kept clamped and after confirming successful voiding trial catheter removed after 7 days. The patient also recovered satisfactorily from her initial orthopedic procedure without any neurological deficit.


A 64-year-old female patient who underwent modified radical mastectomy for left
breast cancer was admitted to our hospital for 6 months. Physical examination showed
5 × 5-cm masses in the left breast palpable in 2 to 4 locations. The patient's
bilateral axillary and clavicular lymph nodes were not enlarged. Breast color
Doppler ultrasonography identified 2 to 4 exploration points appearing as disordered
hypoechoic nodules in the left breast. The nodules' sizes were approximately
5 × 5 × 1.2 cm3, with unclear boundaries and uneven echogenicity; the
breast imaging report and the Breast Imaging Reporting and Data System (BI-RADS)
indicated grade 4C. Mammography showed dense, disorganized, multiple nodular shadows
in the left upper quadrant of the breast. The boundaries of the nodules were
unclear, and the sizes were approximately 67 mm × 40 mm.
After being admitted to the hospital, the patient underwent mastectomy under general
anesthesia. Intraoperative frozen pathology suggested invasive ductal carcinoma of
the breast ().
Subsequently, the patient underwent modified radical mastectomy for breast cancer.
The post-operative pathological diagnosis was left breast infiltrating ductal
carcinoma, grade II (size: 6.5 × 2.5 × 2 cm3). We found no cancer
metastasis in the ipsilateral axillary lymph nodes (0/25). Immunohistochemistry
(IHC) indicated positive expression of estrogen receptor (ER) (3+) and E-cadherin
(+) and negative expression of cytokeratin 5/6 and 34βE12. Myoepithelial cell
staining of the breast duct was negative for P63, calponin, and smooth muscle actin
(SMA). Negative expression of cluster of differentiation (CD)34 and D2-40 indicated
no intravascular tumor thrombosis, and multidrug resistance testing identified
positive expression of human epidermal growth factor receptor 2 HER2 (+) and ER
(3+), negative expression of P53 and progesterone receptor (PR), and a Ki67 index of
30%. Tumor-node-metastasis (TNM) staging indicated pT3N0M0 left breast cancer.
Immediately after surgery, the patient’s chest wall and axilla were pressurized, and
negative pressure drainage was initiated. The drainage volume increased
significantly ()
during the first post-operative week, and on the eighth post-operative day, pale red
milky-white drainage fluid appeared from the axillary and chest wall drains.
Biochemical testing of the fluid indicated a triglyceride concentration of >1100
mg/L, and the patient was diagnosed with chylous leakage, which increased and then
averaged >150 mL/24 hours. The drainage did not decrease when we continued
pressurization and drainage while providing a high-protein diet (, ). On days 12 to 13
post-operatively, we injected meglumine diatrizoate (100 mL) into the patient’s
axilla. We also clamped the drain, and applied compression to the axilla and chest
wall to evenly disperse the agent. After 2 hours, we discontinued the negative
pressure, and aspirated the diatrizoate meglumine through the drain. We then
reinstituted pressure bandaging and negative pressure drainage. Fourteen days
postoperatively, we injected 10 mL of elemene along the drain, drained the fluid
after 30 minutes, then reinstituted pressure bandaging and negative pressure
drainage. The drain was removed smoothly, and after 2 days of continuous pressure
dressing, no subcutaneous fluid was seen. The patient had no subcutaneous effusion
when she subsequently underwent computed tomography (CT) 18 days after discharge
().


A 54-year-old female patient presented to our clinic with complaints of occasional pain, numbness, and paralysis of her right hand. She began to notice weakness of her left hand that had begun 2 years earlier. She had no history of trauma and no family history of amyloid neuropathy. She had a history of ovarian tumor 25 years ago and thyroid tumor 5 years ago, both of which healed after surgical resection.
Physical examination revealed a mass 5 × 3 cm in the ulnar side of her left proximal forearm shown in Figure . The lesion was firm, nonpulsatile, and tender on palpitation. She had numbness on the ulnar side of her left hand and fingers. The 2-point discrimination test revealed that 15 mm at the lateral side of the ring finger 10 mm at the little finger. She had muscle weakness with abduction and adduction of the ring finger and the little finger, but no deficit in the range of motion in the elbow. The electrophysiological study revealed a significant decrease in the motor nerve conduction velocity of the ulnar nerve from distal to the mass to proximal to the mass. MRI revealed that the ulnar nerve was swollen longitudinally, had a spindle shape, and measured 3.0 × 2.7 cm in the axial plane and 7.2 cm longitudinally shown in Figure . The swollen lesion had a relatively homogeneous isosignal intensity on T1-weighted images and had relative heterogeneous enhancement after the intravenous administration of gadolinium (Gd)-based contrast agent with the findings of flow void. Based on these findings, the differential diagnoses included a vascular malformation that surrounded and compressed the ulnar nerve. Excisional biopsy was not performed because of the risk of hemorrhage and iatrogenic nerve injury. The lesion was instead surgically explored with a longitudinal incision shown in Figure . The operative findings showed no vascular malformation; however, the ulnar nerve fascicles were swollen and degenerated. The affected lesion had changed into a yellow tissue shown in Figure . After the yellow tissue was carefully removed microscopically, approximately 7 cm defects remained between intact nerve fascicles. The resected tissue was hard and had a stick-like shape shown in Figure .
The histopathological examination showed degenerated connective tissue with diffuse eosinophilic deposition, which included calcification, ossification, and chondroid tissue shown in Figure and b. No intact nerve tissue remained. The deposit was positive for Congo red stain and appeared apple-green under polarized light, which suggested the diagnosis of amyloid neuropathy shown in Figure .
Immunohistochemical staining showed that the deposit was immunopositive for light-chain λ antibody shown in Figure . The deposit was immunonegative for amyloid A, transthyretin, and light-chain κ. Therefore, the pathological diagnosis was AL amyloidosis.
To determine the association with systemic involvement, we conducted screening examinations. Bone marrow aspiration, cerebrospinal fluid examination, echocardiography, electromyography of the legs, chest computed tomography, and MRI of the brain and legs showed negative results. Physical examination revealed no sign of macroglossia or purpura on the skin. Autonomic dysfunction, including orthostatic hypotension, was not present. The only positive results were from the blood test, which showed high serum levels of amyloid protein A (159.2 μg/mL [<8.0]).
Two months postoperatively, the patient underwent nerve transplantation for reconstruction of the ulnar nerve. The sural nerve was sacrificed from the left lower leg and transplanted to the defect of the ulnar nerve. One year postoperatively after the nerve transplantation, she had no apparent evidence of metastasis or local recurrence. There was no recovery of numbness in the ring and little finger and the muscle weakness still had no recovery.


The first patient, a 37-year-old female with normal past medical history, presented a progressive left foot drop for an 8-week duration. At the initial presentation in another outpatient clinic (in August 2017), only the patient's left foot drop with grade 3/5 power of ankle dorsiflexors was noted. Lumbar magnetic resonance imaging (MRI) revealed no nerve root compression. The nerve conduction study was unremarkable except for the absence of the F wave in the left peroneal nerve. Electromyography (EMG) examination showed only a reduction of maximal effort recruitment in the left extensor hallucis longus and anterior tibialis. The foot drop due to peripheral origin was suspected and conservatively treated. Because of the progressively worsening foot drop, she visited our department's outpatient clinic in October 2017. Neurological examination revealed a severe left foot drop with grade 1/5 strength in the foot and ankle dorsiflexion. Additionally, she had Babinski sign positive, increased muscle tone, ankle clonus, and asymmetric superficial abdominal reflex (left < right). Therefore, a cerebral MRI study was indicated and showed a right parasagittal tumor (dimension 3 × 2 × 2 cm). Afterward, she underwent a brain tumor craniotomy (December 2017) (Fig. ). The histopathological examination demonstrated a fibroblastic meningioma (Fig. ). During the 30-month follow-up, she showed nearly complete recovery and no recurrent tumor.


The second patient, a 46-year-old male, complained of a sudden onset isolated foot drop on the left side. Past medical history showed no significant diseases except for intermittent low back pain radiating to bilateral lower extremities. On the initial physical examination (February 2018) at an outpatient clinic in another hospital, the left foot drop was the sole sign. On a nerve conduction study, all parameters were normal. The needle EMG study revealed purely decreased maximal voluntary effort recruitment in the left anterior tibialis and extensor hallucis longus. Lumbar MRI showed no abnormal findings. He received a diagnosis of foot drop caused by peripheral neural lesions and physiotherapy treatment. Two months later (April 2018), he came to our outpatient clinic with a progressive sign. The neurological examination revealed a slightly increased Achilles reflex, absence of left superficial abdominal reflex, and Babinski sign on the left side which suggested a central cause of foot drop. Therefore, the patient underwent a cerebral MRI study, which suggested a right parasagittal meningioma (4 × 5 × 6 cm) (Fig. ). He was treated with brain surgery to remove the tumor. The histopathological finding determined a diagnosis of a meningothelial meningioma (Fig. ). During 18-month postoperative follow-up, the male patient regained total muscle power.


At initial presentation, an 11-year-old male patient presented in the emergency room with a 1-month history of congestion, rhinorrhea, and snoring. On physical exam, he was found to have a high arching, floppy posterior soft palate and inflamed nasal turbinates. He also exhibited left eye visual field deficits, which the patient said had been present for 2 weeks. He described the deficit as starting as a small black dot that slowly progressed to complete blackness. The patient was referred for an immediate full dilated eye exam, where the optometrist ordered an MRI of the brain and orbits. In addition, ambulatory referral to ENT was placed for evaluation of his abnormal palate and differentiation of persistent allergic rhinitis and/or bacterial sinusitis. The emergency department discharged him with cetirizine and oxymetazoline for congestion and counseled him to return if symptoms continued or acutely worsened.
Four days later, the patient got an orbit and sinus MRI that showed a large multi-spatial nasopharyngeal and nasal cavity mass involving the left sphenopalatine foramen that extended anteriorly into the nasal cavity along the turbinates reaching the left nasal passage, posteriorly to invade and replace the bony sella, laterally through the pterygomaxillary fissure, and caudally anterior to the adenoids with obliteration of the nasopharyngeal airway (Fig. ). The mass measured approximately 7 × 7 × 7 cm. CT of the facial bones also showed the large multi-spatial nasopharyngeal and nasal cavity mass with associated destructive and expansile bony changes. Due to these findings, he was subsequently admitted for inpatient evaluation. He underwent bilateral nasal endoscopy with biopsy of the left nasal mass. The left nasal cavity was noted to be involved with extensive mass extending under the inferior turbinate to the anterior aspect of the turbinate and along the length of the nasal cavity. The right nasal cavity was mostly obstructed by severe septal deviation and mass effect from the left-sided tumor. Pathology demonstrated highly vascular benign-appearing mesenchymal proliferation, most likely representing capillary hemangioma. The differential diagnosis included solitary fibrous tumor and JNA. Further evaluation confirmed that the specimen had features consistent with JNA and was secondarily validated by an outside laboratory.
One week after initial presentation, the patient underwent neuroembolization. The operation was completed without complications. Two days later, imaging still demonstrated a large, heterogeneous hypervascular nasopharyngeal mass compatible with JNA now with interval embolization of multiple left-sided feeding arteries (Fig. ). One week after embolization, the patient underwent a subtotal resection via bitemporal craniotomy with translabial and transnasal endoscopic and open-resection approach with split thickness bone graft and anterior cranial base repair. The pathology of the biopsy taken during surgery demonstrated features consistent with JNA. The following day, MRI of the brain and face demonstrated postoperative changes, and subtotal resection of the large nasopharyngeal mass with residual measuring 2.3 × 4.4 × 2.9 cm decreased from the previously measured 7.5 × 5.7 × 7.6 cm. Imaging demonstrated the cavernous portion and a small portion of the sphenoid part of the tumor was not resected.
Approximately 1 month after resection, follow-up imaging demonstrated postoperative changes to the facial bones consistent with prior partial resection of the anterior aspect of the nasopharyngeal mass with a residual 3.9 × 2.8 × 2.9 cm heterogeneous enhancing mass with extensive unchanged osseous erosion predominantly involving the sphenoid body. Given contrast timing and venous enhancement of the cavernous sinuses, involvement of the left cavernous sinus could not be definitively excluded. Follow-up endoscopic exam 2 months after resection revealed that the tumor remnant was starting to enlarge. Therefore, the patient was referred to radiation oncology to discuss treatment options. Subsequently, it was recommended the patient undergo external beam RT to the residual tumor to a dose of 3,600 cGy in 20 fractions for improved local control. The patient started his RT approximately 2 months after completing surgical resection and 3 months from initial diagnosis.
During RT, close monitoring revealed improvement in visual symptoms as the patient reported that his left eye vision had improved, noting he now saw gray instead of complete blackness. Interval MRI demonstrated likely progression of disease (Fig. ); so his prescription was increased to 5,040 cGy in 28 fractions. He completed the entirety of 5,040 cGy over 5 and a half weeks without complications or side effects.
Two months after RT completion, a follow-up brain MRI showed decreased residual JNA at the paranasal sinus region with signs of previous embolization, surgical, and radiation treatments. Discrete macrocystic foci had decreased in size since the most recent prior MRI. Close follow-up occurred every 3–4months, and MRI 6 months postcompletion of RT demonstrated a further decrease in tumor size of 1.7 × 1.3 × 1.6 cm. At 10 months, the patient was doing well with no evidence of disease progression, and follow-up visits were lengthened to every 6 months. Repeat imaging at 18 months revealed the tumor had decreased further in size now measuring 1.7 × 0.9 × 1.1 cm (Fig. ), and the patient has remained stable without signs of disease progression for over 24 months since the completion of his RT.


An 83-year-old woman abruptly presented one morning with the belief that her husband had been replaced by a nearly identical substitute. She repeatedly asked him who he was and where she could find her real husband, to the point of showing around a picture of him and calling his work office for help. During that day, the patient was able to manage her daily activities as usual, she prepared lunch and dinner, but she seemed often confused. She believed that her dead father was still alive and looked for him, she did not recognize some objects in her home, and she thought that a third person lived with them. She did not experience hallucinations or prosopagnosia. These symptoms gradually disappeared during the following day, when she was able to correctly recognize her husband. Although she was initially unable to recall what happened, the patient regained her memories of that day in the following weeks.
Her past medical history revealed hypertension, rheumatic polymyalgia, hysterectomy to remove a fibroma, and an oncological history. Three years before, she was diagnosed with non-small cell lung carcinoma and pancreatic carcinoma with liver and diaphragmatic metastasis. She underwent radiation therapy first and then chemotherapy treatments with gemcitabine (8 cycles) with good response. The follow-up visits showed no disease progression. Since few months before the focal seizure, the patient also complained of right frontal headache.
The patient was evaluated at our outpatient neurology clinic 3 days after the event and hospitalized 1 week later. When the patient was admitted to our Department, the neurological examination was normal. Neuropsychologic evaluation revealed a mild cognitive impairment characterized by selective frontal dysfunction with dysexecutive deficits and a minor involvement of language skills. The test showed no prosopagnosia or visuoperceptive impairment. A deflection of mood was also reported. EEG revealed focal theta activity on right frontal regions, and brain MRI showed the presence of a large right frontobasal meningioma with marked perilesional edema and mild compressive effect on adjacent structures (shown in Fig. ). Surgical treatment was postponed because of age, comorbidities, and patient decision. During the hospitalization, the patient was started on levetiracetam 500 mg b.i.d. and dexamethasone without seizure recurrence. In the following months after the discharge, the patient did not complain of confusion or delusional beliefs anymore, and regular follow-up visits (last in July 2020) showed a stable clinical condition.


A 44-year-old female patient, whose medical history included Crohn's disease since 2003, was admitted to our hospital for squamous cell carcinoma of the anal canal which was accidentally discovered during a consultation to control her Crohn's disease. The patient's management was delayed due to the confinement of the COVID-19 pandemic. A physical examination showed a painful mass in the external anal sphincter and extended to the gluteal muscle. The performance status was at 2–3.
Pelvic magnetic resonance imaging (MRI) showed an ulcerated anoperineal tumor process in hypo signal on T1-weighted sequences, a hyper signal on T2-weighted sequences, and intensely enhanced after injection of gadolinium. This process is locally extended in gluteal soft tissue with mesorectal nodules, cutaneous nodules of the sacral region, and bone lesions of the left greater trochanter. Total body computerized tomography was performed and no systemic involvement was noted. Colonoscopy revealed no synchronous tumor.
The case was discussed in a multidisciplinary consultation meeting. A concomitant radiochemotherapy treatment has been retained. Treatment was then initiated with combined chemoradiation therapy with Capecitabine 825 mg/m2 twice daily, 5 days per week, 2 piles of 500 mg in the morning and 2 piles in the evening for a body surface of 1.28, cisplatin 80 mg/m2 with a dose reduction of 20% given the performance status at 2, and a total dose of 80 mg every 28 days. And external radiotherapy total dose of 60 Gy, 2 Gy/fraction, and 5 fractions/week.
During the treatment, the patient presented with a 3 days history of headaches. Cerebral MRI was performed and revealed an important heterogeneous metastatic lesion in the left parietal and frontal bone extended to the adjacent soft tissue of the scalp (shown in Fig. ). Histopathology confirmed the cerebral lesion to be a poorly differentiated squamous cell carcinoma, consistent with the known primary tumor of the anal canal. The patient underwent total brain external radiotherapy, a total dose of 20 Gy, 4 Gy per fraction, and 5 fractions per week. The patient succumbed to systemic complications of the disease during her treatment.


A 60-year-old male presented to our hospital with a 12-month history of anal abscess that has been complicated by fistula. Performance status was at 1–2.
Colonoscopy found a mass within 3 cm of the anal margin; the patient underwent a dissected biopsy, a histological report identifying basaloid-type squamous cell carcinoma. Staging computed tomography scans of the chest, and abdomen showed secondary lung localization, external iliac, and left inguinal adenopathy.
Pelvic MRI showed left pelvic and inguinal metastatic lymphadenopathy without tumor wall thickening of the anal canal or mass syndrome (shown in Fig. ). Skeletal scintigraphy was also performed, and lesions were revealed in the right sacrum, pubis, and coccyx. Biopsy of lung lesion was carried out; the anatomopathological results and immunohistochemistry profile suggesting moderately differentiated squamous cell carcinoma with positive Anti P40.
Patients receive the first cure of palliative chemotherapy docetaxel, cisplatin, 5 − fluorouracil with granulocyte colony-stimulating factor, docetaxel 40 mg/m2 and, 5 fluorouracil 2,400 mg/m2 in 48 h every 2 weeks for 6 cures then evaluation. Treatment was complicated by persistent neutropenia which forced to stop the chemotherapy.
A follow-up positron emission tomography scan showed moderate anal hypermetabolism, metabolically active external iliac and left inguinal adenopathies, and nonhypermetabolic bilateral pulmonary micronodules, without other hypermetabolic lesions. Programmed death-ligand 1 (PD-L1) and microsatellite instability status studies were negative.
The case was discussed in a multidisciplinary consultation meeting. The patient was treated with concomitant radiochemotherapy including external radiotherapy a total dose of 60 Gy, 2 Gy/fraction, 5 fraction per week, capecitabine 825 mg/m2 twice daily, 5 days per week, 3 piles of 500 mg in the morning and 3 piles in the evening, and cisplatin with a total dose of 100 mg every 28 days. The patient presented a good clinical evolution with subsequent disappearance of the anal margin tumor and a 50% reduction of the left inguinal ADP. A few months after, he presented to the emergency with an epileptic seizure, confusion, and memory disorders with a 15-day history of decreased tactile sensation and motor control.
MRI was performed and showed multiple metastatic intracranial lesions above and below the tentorium. These lesions were rounded, well limited, with annular enhancement, and surrounded by edema (shown in Fig. ). At this point, total brain radiotherapy was planned however the patient succumbed to his disease before starting this therapy.


A 78-year-old man was admitted to our hospital with a left inguinal hernia. We performed laparoscopic hernia repair via a totally extraperitoneal approach (TEP) using a 3D Max® mesh (Bard, Japan). The mesh was fixed using a CapSure® (Bard, Japan) Permanent Fixation System. The hernia was a type M2 according to the groin hernia classification of the European Hernia Association []. The postoperative course was uneventful, and the patient was discharged 2 days after the surgery.
Two weeks later, he complained of an asymptomatic left inguinal bulging. Plain computed tomography (CT) revealed fluid retention with coating and no hernia recurrence (). Ultrasound echography revealed a mosaic pattern within a 5.0 × 4.0 cm cyst (). We considered the possibility of postoperative seroma; therefore, we decided to observe the patient for 1 month.
One month later, the cyst had not changed in size. The cyst was punctured, and a chocolate-like old hematoma (30 ml in volume) was aspirated. One week later, the temporally contrasting cyst had enlarged again. We inserted a Penrose drain into the cyst (), which was also ineffective. Contrast-enhanced CT revealed findings similar to those of the plain CT performed for the diagnosis of fluid retention, with no extravasation. We decided to perform surgery because the conservative treatments trialed, including conservative observation, aspiration and drainage, had been unsuccessful.
An anterior rather than a laparoscopic approach was selected. The cyst was separated from the spermatic cord () and its connecting vessels were divided (). A prophylactic onlay mesh was placed to reinforce the posterior wall of the inguinal canal, despite the absence of hernia recurrence.
The cut surface of the resected specimen contained the fascia, and the content had a mosaic-like appearance (). Pathologically, the cyst consisted of an old hematoma, chronic inflammatory infiltrates, such as lymphocytes and macrophages and fibrous tissue (). The final diagnosis was CEH. The postoperative course was uneventful, and no recurrence of CEH or inguinal hernia was observed. The treatment strategy is presented in .


A 43-year-old male with a past medical history of hypertension, cocaine abuse, and congestive heart failure presented to our hospital with worsening shortness of breath. He also reported bilateral leg swelling, orthopnea and a dry cough the week before his presentation. He otherwise denied any other significant symptoms like chest pain, palpitations, or paroxysmal nocturnal dyspnea. The patient reported that he has been sniffing and shooting cocaine for more than 10 years. He also reported smoking tobacco. However, he denied any alcohol use. His physical exam was remarkable for tachypnea with a rate of 26 breaths/min, tachycardia with a rate of 105 BPM, BP 100/70 mmHg, and oxygen saturation of 80% on room air. Heart exam showed an S3 gallop with no audible murmur. Lung exam showed bilateral basal crackles as seen in , and his lower extremities were remarkable for 2+ edema below the knees.
EKG showed sinus rhythm with evidence of LVH by voltage criteria and T wave inversion in the lateral leads as seen in .
His labs on admission were remarkable for Na 126, BNP > 5000, creatinine 1.9, BUN 34, AST 140, and ALT 66. The patient was initially placed on BIPAP and was given Lasix 80 mg IV twice daily and admitted to ICU for further management.
He was rapidly deteriorating and found to be in severe respiratory distress with worsening mental status, and the decision was made to intubate the patient. Transthoracic echocardiogram showed dilated cardiomyopathy with severely decreased global left ventricular systolic function with ejection fraction <20%. The patient was then started on a milrinone drip with significant hemodynamic improvement. He was successfully extubated and transferred to telemetry and eventually discharged with a cardiology follow-up appointment for a possible heart transplant.


A 92-year-old gentleman with a past medical history of diabetes, hypertension, CKD stage II, hyperlipidemia, benign prostatic hyperplasia, and recent right hip replacement due to osteoarthritis presented to the emergency department with several days of decreased urine output. Of note, patient is on hydrochlorothiazide at home. He reported he has not been able to urinate post the right hip arthroplasty. Other symptoms included dull, aching, non-radiating lower abdominal pain. Physical exam on presentation was unremarkable except for 1+ bilateral lower extremity pitting edema. The patient was noted to have a distended bladder on the bladder scan. His labs were remarkable for creatinine 6.4 mg/dl, BUN 143 mg/dl, sodium 120, glucose 183, TSH 1.7 uIU/ml, BNP 45 pg/ml, AST 22 u/l, ALT 13 u/l, ALK 67 u/l, total bilirubin 0.5 mg/dl, albumin 2 g/dl. A Foley catheter was placed, and the patient was admitted for further follow-up. Urinalysis was as follows: specific gravity 1.010, Ph 5, protein 30, negative for glucose ketones, leukocyte esterase and nitrites, 10 WBCs and 2 RBCs on microscopic analysis. Urine chemistry was remarkable for urine osmolality 247, urine sodium 48. The calculated fractional excretion of sodium (FeNa) was 6.6%. Renal ultrasound showed unremarkable bilateral kidneys with mildly increased echogenicity as seen in . Echocardiogram showed left ventricular ejection fraction of >75%, hyperdynamic global left ventricular systolic function, and impaired relaxation pattern of LV diastolic filling. The patient’s sodium gradually improved post foley placement and gentle IV hydration. BUN and creatinine started trending downward with appropriate urine output. He was discharged to follow-up as an outpatient.


A 40-year-old female presented to the outpatient clinic of Gastrointestinal Surgery in our hospital, with the chief complaints of persistent changes in bowel habits and hematochezia for 10 d in January 2019.
The patient complained of a history of hematochezia and considerable changes in her daily bowel habits for 10 d.
The patient had no previous medical history.
Personal and family history was not contributory.
Rectal palpation demonstrated the presence of a hard painful mass on the wall of the rectum 2 cm proximal to the dentate line in the chest-knee position.
Routine laboratory tests were unremarkable.
The patient underwent total colonoscopy which confirmed the presence of an ulcerated lesion located in the rectum 6 cm proximal to the anal verge (Figure ). B ultrasonography was advised which indicated the presence of a mass 21.1 mm × 10.0 mm in size.
Biopsy was performed during colonoscopy and histology showed adenocarcinoma.