A 58-year-old man presented to the Second Hospital of Jilin University (Changchun, Jilin, China) after suffering lower abdominal pain for 2 months. No obvious abnormalities were identified on physical examination. Concentrations of the serum tumor markers, carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), and carbohydrate antigen19-9 (CA19-9) were within their respective normal ranges. Colonoscopy performed at the patient’s local hospital revealed a circumferential tumor located 50 cm from the anal verge, and biopsy revealed a moderately differentiated adenocarcinoma. During hospitalization, abdominal and pelvic computed tomography (CT) indicated thickening of the left transverse colonic wall with associated stenosis (). The patient then underwent laparoscopic-assisted radical left hemicolectomy. Postoperative pathology revealed moderately differentiated adenocarcinoma with a minor component of mucinous adenocarcinoma (). Although the tumor had invaded all layers of the colonic wall, none of the lymph nodes were positive; therefore, the tumor/node/metastasis (TNM) staging was T3N0M0. Immunohistochemical analysis demonstrated that the tumor was BRAF V600E mutation-negative, but CDX2-, MLH1-, MSH2-, MSH6-, and PMS2-positive (). The patient subsequently received six cycles of XELOX (capecitabine [XELODA; Roche, Shanghai, China] and oxaliplatin (Oxaliplatin; Hengrui, Jiangsu, China) chemotherapy and was discharged from the hospital. He attended regular follow-up examinations every 2 to 4 months, thereafter.
No obvious abnormalities were identified during 2 years of regular follow-up examinations, until gastroscopy indicated an area of rough mucosa (diameter: 2.0 cm) with a central concavity and erosion, on the lesser curvature. Endoscopic ultrasonography showed thickened mucosa. Concentrations of the serum tumor markers, CEA, AFP, and CA19-9 were within their respective normal ranges. According to the pathological and immunohistochemical findings, CDX2-negative signet-ring cell carcinoma was diagnosed. The patient then underwent gastrectomy and D2 lymphadenectomy (D2 radical gastrectomy). Postoperative pathology demonstrated a signet-ring cell carcinoma of the diffuse-type in Lauren’s classification (). The tumor was confined to the mucosa, and none of the lymph nodes were positive; therefore, the TNM staging was T1aN0M0. Immunohistochemical analysis demonstrated that the tumor was CDX2-negative, but alcian blue/periodic acid-Schiff (AB/PAS)-, MUC5ac- (), MLH1-, MSH2-, MSH6-, and PMS2-positive. The patient received no other treatment but attended regular follow-up examinations every few months. After 2 years, the patient remained well.


A 65-year-old man presented to our hospital complaining of loose stool for 5 days and hematochezia for 1 day. No obvious abnormalities were identified on physical examination. The concentrations of the serum tumor markers, CEA, AFP, and CA19-9, were within their respective normal ranges. Colonoscopy performed at his local hospital revealed a hyperplastic tumor located 10 cm from the anal verge in addition to scattered polyps across the entire colorectum. Pathologic examination indicated that the hyperplastic tumor was a moderately differentiated adenocarcinoma. One of the polyps was a high-grade dysplasia located 80 cm from the anal verge, and the other polyps were adenomas. CT imaging showed thickening of the rectal wall (). The patient underwent endoscopic mucosal resection (EMR) to treat the adenomas. After recovery, he underwent laparoscopic-assisted radical rectal resection (Dixon procedure) and radical right hemicolectomy. Postoperative pathology revealed a moderately differentiated rectal adenocarcinoma with a component of mucinous adenocarcinoma and a moderately differentiated colonic adenocarcinoma (). The rectal tumor invaded all layers of the wall, and perirectal lymph nodes were positive (2/14); therefore, the TNM staging was T3N1M0. The colon cancer invaded the submucosa, and none of the lymph nodes was positive; therefore, the TNM staging was T1N0M0. Immunohistochemical analysis demonstrated that the tumor was BRAF V600E mutation-negative, but CDX2-, MLH1-, MSH2-, MSH6-, and PMS2-positive (). The patient subsequently received six cycles of XELOX chemotherapy and was discharged from the hospital. He attended regular follow-up examinations every 3 to 6 months. One year later, he underwent repeat EMR for the colorectal polyps, which were identified as adenomas by pathologic examination.
No further abnormalities were detected during follow-up until gastroscopy conducted 2 years after the colorectal surgery indicated an ulcer (1.4 cm × 0.7 cm) on the anterior wall of the gastric antrum and a protuberant lesion (0.6 cm × 0.6 cm) on the gastric fundus. The CA 50 concentration was 146.73 U/mL (normal range: 0–20 U/mL). Furthermore, colonoscopy indicated multiple colorectal polyps, and high-frequency electrocoagulation combined with argon plasma coagulation was performed during the colonoscopy procedure to remove the polyps. Pathological analysis suggested a malignancy of the gastric antrum, and the patient then underwent D2 radical gastrectomy and local resection of the gastric fundus neoplasm. Postoperative pathology demonstrated low- and high-grade intraepithelial neoplasms with intestinal metaplasia on the gastric antrum and a low-risk gastrointestinal stromal tumor (GIST) with a karyokinesis count of <5/50 in high-power field evaluation of the gastric fundus (). Immunohistochemical analysis revealed that that the tumor was cluster of differentiation (CD)117-, CD34-, and DOG1-positive (), but desmin-, smooth muscle actin (SMA)-, neuron-specific enolase (NSE)-, and S-100-negative, with Ki67 <1%. Six months later, colonoscopy indicated two rectal polyps, which were treated by high-frequency electrocoagulation combined with argon plasma coagulation. Seventeen months after the gastric surgery, the patient had recovered well.
The details and immunohistochemical analysis results for both cases are shown in
to .


An apparent healthy, afebrile, nonsmoker 31-year-old female individual presented to the emergency department at 11:45 PM, with alleged history of consumption of poisonous ssubstance, at about 11:30 PM at her residence. She was managed as case of poisoning, routine blood investigation showed hemoglobin (Hb)-9.7 gm/dl, total leukocyte count 20.000 cells/cu. mm, sodium (Na+)-136 mmol/L, potassium (K+)-3.08 mmol/L, random blood glucose 291 mg/dl, serum urea-31 mg/dl, pO2 35.2 mmHg, pCO2 33.0 mmHg, and pH 7.133, however, with best treatment modalities, she was declared dead at 12:55AM, the following morning. Being a COVID-19 pandemic, a nasopharyngeal swab test[] was conducted before shifting the body to mortuary. She was labeled as COVID-19 because of a positive test result by RT-PCR for SARS-CoV-2. She had no history of contact or travel history to the high-risk zone of COVID-19. Autopsy was done in infection isolation autopsy rooms, by health personnel using personal protective equipment in accordance, with guidelines of the Indian Government.[]
On autopsy, body was wrapped in a double airproof plastic zipped bag, she was average built, 161 cm in length, rigor mortis was present on the whole body, and post mortem staining was involving the back area, except the areas of contact with the surface. No external injuries were found. Internally, on the opening stomach, the mucosa was found to be congested and grayish material adherent to it with garlic odor. The solid organs comprising liver, spleen, and kidneys, were found to be congested. On gross examination, lungs are enlarged, heavy, boggy, edematous [] and showed a mosaic-like [], pattern of pale fields and slightly dark purple discoloration [], with marked fluid retention which oozed out on compression [], as compared to the aluminium phosphide poisoning lung. The right lung weighed 870 g and the left lung weighed 760 g and the combined lung weight was 1630 g. The whole of the laryngeal-tracheal lumen was filled with frothy fluid. All major parenchymal organs including both lungs were dissected out and were submerged in buffered 10% formalin solution and sampled for histopathological examination, and in supersaturated salt solution for chemical examination for final cause of death.
In addition, pieces of the lungs, liver, spleen, kidney, brain, peritoneal fluid, vitreous humor, blood, and tissues from the aerodigestive tract, were collected for virological study for detection of SARS-CoV-2 RNA by RTPCR. The viral RNA was isolated from various specimens by spin column technique (Q1Amp Viral RNA extraction kit). The highly pure RNA so obtained was subjected to amplification by RTPCR (biorad CFX-96). The NIV Pune (AB1 Thermofischer) screening and confirmatory assay were used for the amplification targeting E-gene, ORFI gene, and RNA dependent RNA polymerase (RdRP) gene.[] CT value ≤36 was considered significant, and results are displayed below mentioned .
Lower cycle threshold (Ct) values indicate higher viral loads.
Routine histological stains were performed on formalin-fixed samples following standard protocols, and the findings are summarized in, below mentioned .
None of health professionals involved in the autopsy of this case developed COVID-19.


A 15-year-old female youth league basketball player had a history of one year of right ankle pain and recurrent swellings without any obvious trauma other than sports practice. She had had many physiotherapy sessions with almost no benefit. Physical examination revealed swelling on the posterior ankle with painful palpation with a positive posterior impingement test. Range of motion was full -although plantar flexion was painful- and neurovascular examination normal. Patient’s complaint of recurrent swellings, inefficiency of prolonged physical therapy, and the physical examination finding of swelling on the posterior ankle were findings that are not expected in posterior ankle impingement caused by only repetitive trauma, overuse or os trigonum. A written informed consent was obtained from the legal guardian of the patient.
The MRI revealed os trigonum posterior to talus and a soft tissue mass of benign appearance with the size of 21x25x8 mm, with clear margins and no signs of invasion or extension to neighboring tissues with mild contrast signal (Figure 1). Endoscopic benign soft tissue tumor excisional biopsy was planned.
The surgical procedure was performed under general anesthesia in prone position. The right lower extremity was prepped and dressed sterile; a pneumatic tourniquet of 250 mmHg pressure was applied to the thigh. Hindfoot endoscopy was performed via posterolateral and posteromedial portals. Diffuse bursitis was observed in the precalcaneal region. Once the inflamed pre-Achilles bursa was debrided with shaver and radiofrequency device, os trigonum and a tan-reddish colored soft tissue lesion sized 3x2.5 cm located just medially to FHL tendon was noticed. Both os trigonum and the soft tissue mass were irritating and impinging on FHL tendon (Figure 2a). The soft tissue mass was carefully detached from surrounding adhesions and punch biopsy materials were taken from the lesion. The materials were sent for histopathologic examination (Figure 3). The remaining soft tissue lesion was then completely removed with shaver and punch until no macroscopic residual tissue was left. Under radiographic guidance with the C-arm, a narrow tissue separator was inserted into the endoscopy area. The mobile and unstable os trigonum was released and resected out of the posterior ankle (Figure 2b and Figure 4). Tenosynovectomy of the degenerated and inflamed FHL tendon was performed with shaver and radiofrequency device (Figure 2c). The endoscopy was ended with closure of the portals and sterile dressing. Elastic bandage was applied to the ankle, no complications were encountered, and the patient was discharged on the same day of surgery.
Early range of motion exercises and proprioceptive physiotherapy with partial weight bearing with a pair of Canadian crutches were initiated at the third postoperative day. The histopathologic examination revealed the lesion to be a TGTC. The patient returned to basketball at the third postoperative month. She had no complaints on the last follow-up at the first postoperative year, and MRI revealed no recurrence of the tumor (Figure 5).


A 55-year-old man presented with a 12-month history of persistent headache, global memory decline, partial anosmia, and infrequent “vacant” episodes of 5–30 min duration; described as transient states of altered awareness without involuntary movements. Attacks were usually followed by a state of somnolence or disorientation. His past medical history was unremarkable, and his only medication was a H2-receptor antagonist. Family history included epilepsy in his two siblings. Initial examination revealed only partial alopecia of eyelashes and brows which had manifested 6 months prior to presentation. The initial set of investigations were non-diagnostic and included brain magnetic resonance imaging (MRI) and 24 h ambulatory electroencephalogram (EEG) which did not capture a typical ictus.
Over the subsequent months, the vacant episodes increased in frequency and became associated with a peculiar gustatory perception, confabulations and involuntary paroxysmal jerky movements. Additionally, neuropsychiatric disturbances manifested including personality/affective changes with persistent suicidal ideation and deliberate self-harm that progressed rapidly. His partner also described classical rapid eye movement sleep disorder (RBD) around this time. A repeat ambulatory 24-h EEG revealed seizure activity stemming from a temporal lobe focus associated with a typical ictus. Voltage-gated potassium channel (VGKC) complex antibodies were found to be strongly positive (410 pmol/L; normal range 0–69) with subtyping being available later. Subtyping was not performed on this sample. Surveillance body computed tomography did not reveal an occult neoplasm. Management for presumed anti-VGKC complex encephalitis was commenced including pulsed methylprednisolone (500 mg daily for 5 days) followed by a slow tail. Lamotrigine was initiated and up-titrated to maximal dose to manage focal unaware seizures, although response remained partial. Neuropsychiatric disturbances were also intractable, and so subsequently he had a trial of rituximab with no response.
Over 53 months after initial presentation, the clinical spectrum of breakthrough focal unaware seizures, progressive myoclonic jerks, cognitive and affective dysfunction was extended to an extrapyramidal syndrome. Mobility declined precipitously over a 6-month period to the point that the patient was unable to walk and became reliant upon a wheelchair. He developed an asymmetrical resting hand tremor and severe postural imbalance over the subsequent 6 months. Neurological examination revealed normal ocular movements and limb tone, but bradykinesia with atypical festinant and slow gait. Metoclopramide prescribed for dizziness and nausea was promptly discontinued. A dopamine transporter (DaT) scan demonstrated a bilateral reduction in tracer uptake in both putamina, which was more marked on the left with some reduction in the head of the left caudate nucleus (Fig. ). Repeat anti-VGKC complex antibody level was 147 pmol/L, but leucine-rich glioma inactivated 1 (LGI1) and contactin-associated protein-like 2 (CASPR2) were negative. Brain MRI performed 90 months after initial presentation demonstrated early frontotemporal atrophy with no white matter change or other abnormality (Fig. ). His Addenbrooke's cognitive examination revealed significant decline in visuospatial attention, memory, and attention domains (70/100). Neither a course of rituximab nor dopaminergic treatment was effective. With a clinical pattern suggestive of a frontotemporal dementia (FTD), genetic testing was undertaken including FUS, GRN, MAPT, and PRNP, but no recognised disease-causing variant was identified.


An 80-year-old woman was diagnosed with right breast cancer and multiple lung metastases at a previous institute a few months after she had noticed a right breast lump with progressive skin invasion. Chemotherapy was provided for 4 years. However, she was referred to our institute in December 2017 because the breast tumor progressed despite systemic treatment. She had a right breast lump with 15 cm of skin ulceration as well as bleeding, fungation, and odor at presentation (Fig. ). Breast biopsy revealed invasive ductal carcinoma, and immunohistochemistry of the tumor confirmed the following findings: HER2 1+, estrogen receptor-negative, progesterone receptor-negative, and Ki-67 = 40%. Computed tomography revealed a right breast tumor with skin ulceration, bilateral axillary lymph node metastases (Fig. ), and multiple lung metastases. The results of blood tests indicated slight anemia and mild elevation of white blood cell counts, and the levels of carcinoembryonic antigen reached 603 ng/mL. The symptoms of the breast tumor, such as bleeding, odor, and pain, impaired her QoL, and the Eastern Cooperative Oncology Group performance score was 0. Additionally, it was difficult for the patient to change bandages and clean the lesion by herself. The aim of treatment at this time was to alleviate intolerable symptoms considering her age and desire to survive without bleeding and odor from the breast tumor.
Mohs' paste was applied to the bleeding tumor, and subsequently reduced-dose bevacizumab and paclitaxel were administered, relieving the patient's bleeding and odor. The size of the tumor decreased after 3 months, resulting in a partial response. Six months after the administration of bevacizumab and paclitaxel, tumor regrowth was observed, leading to the diagnosis of disease progression even though the primary tumor was smaller than its initial size at presentation (Fig. ).
After disease progression, radiotherapy (51 Gy in 17 fractions) was delivered to the right breast and chest wall, followed by eribulin administration. Two months after the administration of eribulin, a partial response was obtained, although tumor effusion was still observed (Fig. ). However, as disease progression can result in acquired chemotherapy resistance, mastectomy and skin grafting were performed. Immunohistochemistry of the tumor confirmed the following findings: HER2 1+, estrogen receptor-negative, progesterone receptor-negative, and Ki-67 = 40%. After surgery, she experienced significant improvement in QoL based on the elimination of bleeding and odor, and she did not need to replace her bandages daily (Fig. ). Despite improvement in QoL and medical palliative care, the patient died from multiple lung metastases 12 months after surgery.


A 56-year-old woman had a history of approximately 1 year of decreased vision in her left eye. SD-OCT imaging showed a full-thickness MH with a minimum diameter between edges of 888 μm in her left eye. Macular schisis changes, as well as the presence of an epiretinal membrane, were observed, as shown in Figure . Baseline best-corrected visual acuity (BCVA) was 20/400.
Informed consent was obtained from the patient. This case report complies with the guidelines for human studies and was conducted in accordance with the tenets of the declaration of Helsinki.
Surgery was undertaken with retrobulbar anesthesia. Combined phacoemulsification and chandelier-assisted four-port 23-gauge pars plana vitrectomy was performed (OS4; Oertli platform, Berneck, Switzerland). After performing a core vitrectomy, the internal limiting membrane (ILM) was stained using Brilliant Blue G stain (Merck KGaA, Darmstadt, Germany).
Peeling around the MH of both the epiretinal membrane and the ILM was performed. ILM was also peeled from the retina superior and adjacent to the superotemporal vascular arcades at the site chosen to perform the harvest of the ART.
A laser barricade was applied around the harvest site, and balanced salt solution was injected with a 38-gauge needle into the subretinal space to create a localized retinal detachment. Afterward, under chandelier illumination, the graft was cut circumferentially using vertical 23-gauge scissors. The diameter of the graft was approximately 1.5 times the size of the MH. Using a bimanual approach, the edge of the transplant was held with an ILM forceps, moved toward the MH, and inserted inside the MH beneath its edges with the assistance of a 23-gauge soft-tipped cannula as a second instrument. Endodiathemy was applied to the bleeding edges of the retina around the harvest site. Air-fluid exchange was gently performed, and a semi-Fowler position was instructed to the patient for 2 days (online suppl. Video; for all online suppl. material, see ).
One week after surgery, OCT examinations indicated complete closure of the MH and increased reflectivity of the transplanted tissue internal layers, as shown in Figure . Ten months after surgery, the transplanted tissue was connected to the recipient's retinal tissue. No visible boundaries were seen between the donor graft and the surrounding receptor retinal layers.
BCVA gradually improved from 20/400 to 20/80 at 3 months and to 20/50 7 months after surgery and remained stable at 1 year. Continuity preservation of the ellipsoid zone (EZ) and external retinal layers of the transplant were documented at the end of follow-up, as shown in Figure .


A 22-year-old female Caucasian patient was diagnosed with UC 3 mo ago, complaining of bloody diarrhea, abdominal pain and weight loss, and discontinued mesalamine due to the gastric intolerance. The patient underwent a colonoscopy 2 wk before the admission to the hospital, which revealed lesions consistent with UC of moderate endoscopic activity (Mayo endoscopic score 2).
She was admitted to the emergency department in due to frequent liquid and bloody stool and intense abdominal pain for 2 mo, with worsening of the symptoms during the last week, in poor condition with nausea, vomiting, and weight loss (10 kg) and without the improvement from the previous use of antibiotics.
At hospital admission (day 1 of hospital admission), the patient presented in poor condition, dehydrated, tachycardic (110 beat/min), blood pressure 100/60 mmHg, temperature > 37.8 °C, with distended and diffusely painful abdomen, and rebound tenderness.
Laboratory tests showed inflammatory process (C-reactive protein 20.3 mg/dL) and anemia (hematocrit 25.8%, hemoglobin 8.1 g/dL) at admission (Table ).
Abdominal X-ray revealed colonic dilation of 7 cm, consistent with megacolon (Figure ).
Clostridium difficile (C. difficile) A and B toxin was positive, and the treatment with oral vancomycin 250 mg qid was initiated. However, the patient presented with worsening of diarrhea and rectal bleeding (> 10 episodes/d), increased abdominal distension, and fever. A flexible sigmoidoscopy was performed (day 4 of hospital admission) and inserted up to 25 cm with no insufflation, showing ulcers covered by fibrin, mucosal friability, edema, and intense enanthem with spontaneous bleeding in sigmoid and rectum, consistent with UC of severe activity (Mayo endoscopic score 3) (Figure ). Histopathological evaluation showed chronic colitis in intense activity with structural abnormalities of the mucosa, presence of crypt micro-abscesses and plasmacytosis, consistent with severe inflammatory activity without the evidence of C. difficile or cytomegalovirus infection.


A 13-year-old boy was brought to our centre because of nearly simultaneously started swellings at the right shoulder and right mid-thigh with duration of 1 month. Each swelling was gradual in nature and progressively increased over time. The patient reported progressive weight loss and dizziness. His parents were peasants and his past medical history was unremarkable. Given the profession of the parents exposure to pesticides was considered, this could however not be documented.
On general examination, he was weak, pale, wasted and tachycardic with a pulse rate of136 beats/minute. Blood pressure, respiratory rate and body temperature were within normal limits. On local examination, he had a firm round, non-tender, immobile swelling (11 × 5 cm) at the right shoulder (A). At the right mid-thigh, he had a circumferential fixed and non-tender (12 × 10cm), (). Laboratory findings revealed the haemoglobin of 8.5 g/dl (11‑15 g/dl), raised ESR of 28 mm/h (0‑19 mm/1 h), normal leukocytes 6.13 × 109/L (4.00–11.00)/l and AST: 40.60 (5–40)/l. Serum creatinine 93 (62‑106 μmol/l), AST 40.60u/l (2.00–40.00 U/l), ALT 15.90 U/l (2.00–41.00 U/l). Other parameters including a bone marrow aspirate were essentially normal.
Conventional radiography of the right femur demonstrated a huge soft tissue swelling with diffuse permeative lesions in the mid and distal femoral shaft and medial cortical destruction (). The right shoulder revealed large soft tissue swelling associated with a pathological fracture of the proximal humerus, (). Chest X-ray and abdomino-pelvis ultrasound were normal i.e. no signs of metastasis seen. A diagnosis of sarcoma was suggested. Biopsies from the lesions were taken and the patient was discharged with a plan to start treatment in 2 weeks after establishing the histopathological diagnosis.
Histopathological findings of the two lesions highlighted a similar morphology showing diffuse proliferation of monotonous medium to large-sized atypical lymphocytic cell population (A and B). Using the limited immunohistochemical panel tests that were locally available, tumour cells were strongly positive for CD20 and CD45 (), but negative with CD99 and cytokeratin 20. Diagnosis of a primary non-Hodgkin lymphoma of bone (DLBCL) with differential of Ewing sarcoma was made. Due to the rarity of the disease entity, tumour tissue blocks were shipped to Leiden University Medical Center, (Leiden, The Netherlands) for expert consultation. There, wider immunohistochemical panel tests and FISH for EWSR1 split, FUS split, BCOR split and CIC split were performed. All split-apart FISH showed the absence of split signals of tested genomic regions thus excluded the diagnosis of Ewing sarcoma and other small blue round cell tumor (SBRCT). Immunohistochemical staining were conclusive for the diagnosis of DLBCL (CD45+, CD20+ while CD99, Desmin, MYOD1, PAS negative). The Due to the COVID-19 outbreak, the patient could not manage to turn back for oncological treatment. Unfortunately, he succumbed ~30 days post-hospital discharge.


A 35-year-old male presented with low back pain of 6 months’ duration which radiated into both lower limbs. His clinical examination revealed motor deficit (MRC 3/5) in the L4 and L5 distributions, with accompanying decreased sensations (50% loss).
X-rays revealed degenerative changes in the lower lumbar spine with evidence of instability at L4-5 on dynamic imaging []. The MR revealed lumbar canal stenosis at L4-L5, a left L5-S1 HNP with inferior migration, and a left sided facet cyst []. The preoperative hematological investigations including ESR and total leukocyte count (TLC) were normal. The patient underwent a L4-L5 minimally invasive transforaminal lumbar interbody fusion (TLIF) with L5-S1 micro-discectomy [].
The initial postsurgical course was uneventful; the patient was mobilized the next day, and discharged the following day.
However, on the 10th postoperative day, he developed recurrent back pain (VAS 8), a high grade fever, difficulty in walking, and was readmitted. The following laboratory studies were abnormally elevated; CRP-115.18 mg/dl, ESR-99/1 h, and TLC-10200 with Absolute Neutrophil Count-8410. The fever profile, including tests for dengue fever, and malaria were negative. He was started on broad-spectrum antibiotics and his symptoms were partially relieved with Meropenem 1 g thrice a day. Blood cultures showed B. cepacia sensitive to meropenem, and clindamycin. The diagnosis of B. cepacia from blood culture specimens was established utilizing Bactec Model 9240 (Becton-Dickinson) or BacT/ALERT 3D. Vitek II automated antibiotic susceptibility system was utilized to detect the relevant sensitive antibiotics. VAS score for back pain reduced to two and fever subsided. Patient was discharged and advised 6 weeks of IV antibiotics.
Subsequently, 3 weeks’ post surgery, patient represented with back pain (VAS 8) and left lower limb radiculopathy. He had remained on appropriate antibiotic therapy and laboratory investigations showed improvement in the ESR (99 down to 64), and CRP (115.18 mg/dl down to 34) levels. The MR was suggestive of spondylodiscitis at the L5-S1, and he underwent a TLIF L5-S1 with insertion of Titanium Cage [ and ]. Notably, the right-sided L5 screw was removed as a medial pedicle breach was suspected (e.g., impingement on the L5 nerve root but not the site of the radiculopathy). The postoperative course was uneventful, and the patient was mobilized with an LSO brace. Pain (VAS score 3 for back pain, and 2 for left lower limb radiculopathy) improved and the patient was afebrile. Patient was discharged on 6 weeks of IV Meropenem 1 g TDS, followed by oral antibiotic Clindamycin for 6 more weeks. Repeat investigations following completion of antibiotic course revealed ESR-34, CRP-11 mg/dl. At present, patient is symptom free on 6-month follow-up.


A 71-year-old Japanese man with a BMI of 22.8 kg/m2 underwent RARP for prostate cancer. His initial PSA level, Gleason score, and dancer staging were 9.4 ng/mL, 4 + 4, and cT2bN0M0, respectively. The patient had a history of cerebral infarction and bipolar disorder. RARP was performed using the DaVinci Xi® system (Intuitive Surgical, Sunnyvale, CA, USA) with port placement as shown in Figure . Prostate resection was performed using transperitoneal antegrade and intraperitoneal posterior approaches. The trocars were removed under laparoscopic guidance. No abnormal appearance of the port site or sucking of the intestine was observed (Fig. ). The fascia of the external oblique abdominal muscle at this site was closed with a single knotted suture using 2-0 Vicryl® (Ethicon, Somerville, NJ, USA). The procedure was completed without any intraoperative complications; the total surgery and console duration were 151 and 118 min, respectively.
Immediately after the surgery, subcutaneous emphysema was observed on X-ray (Fig. ), which improved on POD 1 (Fig. ). The patient had no significant complications on POD 1. On the morning of POD 2, the pelvic drain was removed; however, he exhibited coffee ground vomiting in the afternoon, twice in quick succession. His abdomen was soft but tympanic; no metallic sound was audible. Abdominal X-ray revealed a dilated large intestine but no fluid level (Fig. ). CT revealed an intestinal prolapse into a space between the internal and external oblique abdominal muscles at the 12-mm AIRSEAL® trocar site (Fig. ). Laboratory data from the investigations are summarized in Table . Diagnosis indicated a strangulated ileus due to TSH, and an emergency surgery was performed.
The emergency surgery was initiated using a laparoscope. A 12-mm camera port and two 5-mm assistant ports were inserted. Observation of the abdominal cavity confirmed a prolapse of the small intestine at the 12-mm AIRSEAL® trocar site (Fig. ). The prolapsed intestine was carefully pulled out using Croce-Olmi forceps and it was found to be gangrenous (Fig. ). After restoring the prolapsed intestine into a normal position, the trocar site was closed using 0 PDS® suture (Ethicon) under laparoscopic guidance (Fig. ); a 4-cm incision was made, and the gangrenous intestine, which extended up to 25 cm, was explored and resected (Fig. ). Finally, functional end-to-end anastomosis was performed using a surgical stapler, and the procedure was completed. No drain was placed.
Three days after TSH repair (5 days after RARP), the patient started oral intake. The urethral catheter was removed 10 days after RARP (8 days after TSH repair), and he was discharged 15 days after TSH repair (17 days after RARP). Pathological examination of the prostate revealed adenocarcinoma, with pT2a, Gleason score 3 + 4, EPE0, RM0, v0, ly0, pn1, sv0. Six months after RARP, his PSA level was below the measurable limit, and he had no abdominal symptoms.


A 45-year-old female presented with posterior neck pain, numbness, and transient weakness on both arms. Her symptoms arose 6 months prior. One week ago after a light traffic accident, these symptoms were aggravated. She was a housewife. She did not have any medical or surgical history. She was involved in a bicycle traffic accident 5 years ago. However, she said it was not too severe.
On physical examination, she presented with weakness (grade IV) for her both grasping and radiculopathy through both the sixth vertebrae (C6) and the seventh vertebrae (C7) dermatome. Radiographic examination of the patient's cervical spine revealed a bilateral spondylolysis on C6 and spondylolisthesis at C6 on C7 (). On plain radiograph, flexion and extension lateral view showed instability between C6 and C7 (). On computed tomography (CT) scan, a bilateral defect between the pedicle and the lamina was revealed. The spina bifida occulta at C6 level was revealed on CT scan (). On magnetic resonance image (MRI), cord compression was not definitive. However, the bilateral neural foramen was compressed according to movement due to instability between C6 and C7 (). There was a neurologic symptom. Thus, we planned to perform anterior cervical discectomy and fusion on C6 and C7 with posterior decompression and fusion using C5 lateral mass–C7 pedicle screw fixation (). Postoperatively, the patient presented improved symptoms.


An 86-year-old woman presented with acute severe back pain with no neurologic deficit. Plain X-ray, computed tomography (CT) scan, and magnetic resonance imaging (MRI) () showed acute extension-distraction fracture of the T12 body with the intravertebral cleft and segmental lordotic change of the thoracolumbar spine. There were also multiple planar vertebral bodies as a result of previous osteoporotic thoracolumbar fractures. The condition of the thoracolumbar spine was highly unstable, and the aggravation of extension-distraction of the fractured vertebral body was likely to lead to neurological deficits. We decided to perform surgical treatment with instrumentation and fusion for the long segments above and below the fractured T12. However, it was predicted that stable fixation of pedicle screws would not be easy and that postoperative pseudoarthrosis and instability were likely to recur, considering the deformed vertebral bodies around the fractured T12 and the bone mineral densitometry (BMD) findings (−6.7, lumbar spine). Most importantly, the patient was judged as inoperable due to her weak physical condition caused by greatly reduced cardiopulmonary function (originating from heart failure and restrictive lung disease), in addition to a weak constitution (a height of 140 cm and weight of 38 kg). After deep consideration, the patient and her family refused surgical treatment and decided that she should be treated conservatively. As conservative treatment, bedrest in the lateral decubitus posture and pain control were performed for the initial three weeks along with the use of teriparatide (subcutaneous injection, 20 μg/day) with calcium and vitamin D supplementation. Afterwards, sitting and standing with wearable orthoses were carried out gradually depending on back pain. On the follow-up radiological examinations (), the collapse of fractured vertebral body proceeds with reducing intravertebral cleft at 3- and 6-month follow-up CT scans. The calcification and fusion of the interspinous space were identified earlier than the formation of bone bridges around and inside the fractured vertebra. Bone fusion with bone bridging and ankyloses around the fractured vertebral body, correction of the initial segmental lordotic change, and disappearance of the intravertebral gap were noted at 1-year follow-up CT scan. She completely recovered from her back pain, and is carrying out self-walking and normal daily activities.


A 62-year-old female presented with chief complaints of floaters in the right eye (RE) for 3 weeks. She was a known diabetic (on OHD) since 6 years and hypertensive since 10 years (on treatment), rheumatoid arthritis (on treatment), and with no known adverse drug reactions. Her best-corrected visual acuity (BCVA) was 4/60 in RE and 6/6 in left eye (LE). On examination, her anterior segment revealed normal findings in both the eyes except for relative afferent pupillary defect in RE. Posterior segment revealed multiple intraretinal haemorrhages all over the superior quadrant, engorged tortuous blood vessels, and CME in RE while there was no abnormality in LE. A provisional diagnosis of RE hemicentral retinal vein occlusion (CRVO) with CME was made []. Her blood pressure was 160/90 mm of Hg, and her blood investigations showed deranged lipid profile and raised blood sugar. Optical coherence tomography (OCT) showed a central macular thickness of 551 μ with intraretinal cystic spaces and fluid []. Fundus fluorescein angiography of RE revealed capillary dropouts and nonperfusion areas corresponding to the area of vein occlusion along with angiographic CME. She received a single intravitreal injection bevacizumab following which her vision improved to 6/36. Her OCT of RE revealed a full thickness MH a month later! [ and ] She was explained about requiring surgery. Over the next 18 months, she received 5 more injections of intravitreal Bevacizumab. Her RE BCVA before vitrectomy was 6/18. A 25G vitrectomy was performed and intraoperatively posterior vitreous detachment (PVD) had to be induced, conventional internal limiting membrane peeling done and a tamponade of C3F8 (perfluoropropane) was given. Four months postsurgery, her RE BCVA 6/24 with cataract formation and MH Type 1 (U-shaped) closure was seen [ and ]. In the subsequent months, she underwent cataract extraction following which she developed CME. She underwent scatter laser (sectoral superior quadrant) in her RE along with intravitreal injection Ranibizumab three times. She has remained in regular follow-ups ever since and her BCVA has remained stable at 6/9 [].


A 36 years-old man was admitted to the Emergency Department (ED) three-hours after a work accident. During the cleaning of an industrial hydraulic system, a jet of hydrochloric acid 20%, ambient temperature, injured his face and upper limbs. At the workplace, an immediate clothing removal and accurate washing with cold water was performed. At ED admission, he presented first and second-degree skin burns on the frontal region, on the scalp, on the right forearm (-A), and earlobe. He didn’t manifest signs of respiratory distress or other systemic clinical manifestations and the performed blood tests were normal. Plastic surgery management consisted in wound topical dressing with silver sulfadiazine and paraffin gauze twice a week for one month. When the skin lesions were healed, a topical silicone gel and sunscreen were applied to improve the scar outcome. Forty-eight hours after the latter topical treatment (45-days after the work accident), in the same anatomical regions of the previous burn scars, he developed a skin reaction with itchy erythema (-B). No other systemic signs or symptoms were manifested. The application of topical products was immediately suspended without improvement, excluding an allergic reaction. Within few days, the skin reaction evolved in a dissemination of multiple small inflammatory-desquamated lesions. A generalized guttate psoriasis was evident on the whole body (-C). At the successive outpatient follow-up, an improvement of these lesions was evident after one month of steroid treatment, but did not disappear completely.


A 66-year-old male with no history of recent trauma presented a sudden onset of severe headache, nausea and vomiting with no apparent cause.
At the time of admission, his blood pressure was 144/85 mmHg. The patient had not received antithrombotic or antiplatelet drugs, had scarcely smoked, and presented no alcohol abuse. He was in a somnolent state with nuchal rigidity; however, other focal neurological deficits were not observed.
He had a history of diabetes with regular medical treatment achieving good blood sugar control. The medical records of the patient revealed hypertension or heart disease.


A 59-year-old man presented, 5 days after COVID-19 symptoms of fever cough, breathlessness, muscle pain and poor appetite, with a 4-hour history of sudden onset right side incoordination, weakness, facial deviation, and altered level of consciousness. He was neither hypertensive nor diabetic. He had no history of previous transient ischemic attack or stroke and there was no history suggestive of background cardiovascular risk factors. No family history of hypertension, diabetes, heart diseases or stroke.
He did not take antiplatelet or anticoagulation prior to presentation. Examination revealed an acutely ill-looking and febrile (38° c) man with Glasgow Coma Score (GCS) of 13/15, subtle neck stiffness but absent Kernigs and Brudzisky signs. He had right upper motor facial and abducent nerves palsy. His pupils were 3 mm bilaterally and reactive appropriately to light. Motor system examination revealed right flaccid hemiplegia. His pulse rate was 96/min (normal volume and rhythm), blood pressure 140/90 mm Hq and heart sounds were normal.
The essential findings on his chest examination were tachypnea (24breath/min) and a few coarse crepitations bilaterally. His SpO2 at presentation was 90% on an oxygen mask. His CXR showed bilateral infiltrates, COVID-19 PCR test was positive, Brain CT revealed an extensive left acute fronto-parietal subcortical infarct with hemorrhagic transformation and ventricular extension ().
His COVID-19 infection severity was considered severe[]. His Lipid profile, platelet count and INR were all within normal limits. He was immediately transferred to ICU where he received treatment for COVID-19 infection and stroke as per Saudi Arabia Ministry of health COVID-19 treatment guideline (Hydroxychloroquine, Dexamethasone, Remdesivir, Antibiotics among others)[]. Later, his SpO2 declined to 70% and the mechanical ventilator was instituted. A repeat PCR test was negative on day 20th of admission. About 22 days of presentation his level of consciousness deteriorated (GCS = 3/15) and he died on the same day.


Following an acute anterior MI treated with angioplasty on proximal left anterior descending artery (LAD) in mid-February, a 70-year-old male patient with no past relevant medical history kept in contact with our cardiology department through regular phone calls. Pre-discharge echocardiography showed normal LV dimensions, severely depressed LV function (ejection fraction 35%) due to apical and anterior hypokinesis, normal right ventricular dimensions, and function. Medication consisted of metoprolol, torasemide, ramipril, spironolactone, acetylsalicylic acid, clopidogrel, and transdermic nitroglycerine.
Over the course of approximately 6 weeks post-discharge, the patients’ general conditions progressively worsened, and he complained of dyspnoea, fatigue, and ongoing hypotension. For fear of contracting COVID-19 pneumonia, the patient repeatedly refused to attend the Emergency Room, despite medical advice to do so. Conditions did not improve despite medical therapy adjustments (increase in oral diuretics and start on ranolazine), and the patient was finally admitted to hospital following a syncope. Physical examination revealed hypotension, mild apical systolic murmur, bilateral lung crackles, and ankle oedema. Blood exams showed elevated BNP (1500 pg/mL) and creatinin (2.39 ml/dL), and high-sensitivity Troponin I within normal limits. Due to a computed tomography scan which revealed bilateral pleural effusion and possible bilateral pneumonia (), he was placed in a general ‘grey’ ward while waiting for nose-swab results, as he could not be placed in the ‘red’ intensive care unit (ICU), dedicated to COVID patients for his own safety, but could not also be considered COVID-free and thus admitted to the ‘white’ (clean) ICU.
Overnight, a rapid escalation of treatment was necessary as conditions did not improve with low-dose inotropes (Dobutamine and Dopamine), and he required intubation and admittance to the white ICU once the nose-swab came back clean (after ∼12 h). Emergency coronary angiography was performed, which confirmed absence of restenosis, and Intra-Aortic Ballon Pump was placed as emergency circulatory support. High-dose inotropic support (Adrenalin and Noradrenalin) was necessary to maintain sufficient haemodynamics. Bedside echocardiography was performed, and confirmed a severely dilated [end-diastolic volume (EDV) = 198 ml, indicized end-diastolic volume (iEDV) = 94 ml/m2], hypokinetic left ventricle with apical aneurysm (distal part of the cavity, inferior to papillary muscle implant, ), ejection fraction of 30%, no LV thrombus, moderate mitral regurgitation due to multiple, central jets and annular dilatation and increased LV filling pressures. Right ventricular dimensions and function were within normal range, with severely increased pulmonary artery pressures (60 + 15 mmHg).
Chest X-ray revealed severe pulmonary congestion. Furthermore, the patient developed sustained ventricular arrhythmias.
An emergency Heart Team was arranged, where it appeared clear that surgical correction of the apical aneurysm and mitral regurgitation were mandatory to allow clinical stabilization and patient discharge. However, pulmonary congestion and consequent hypertension, associated to the high inotropic dosages required to maintain haemodynamic stability, posed a severe threat to postoperative management. It was thus decided to support the patient with a short-term mechanical circulatory support, to allow optimal bridging to cardiac surgery.
An Impella 5.0 (via surgical cut-down of the subclavian artery) was implanted, with the aim of reducing pulmonary congestion and treating the ventricular arrhythmias prior to scheduled ventriculoplasty and mitral valve repair. Intraprocedural trans-oesophageal echocardiography confirmed correct positioning of the device and no interference with the aortic valve function.
Following Impella 5.0 implantation, we immediately observed (): resolution of sustained ventricular arrhythmias; reduction of pulmonary congestion; reduction of pulmonary artery pressure by about 20 mmHg, although PCWP (Pulmonary Capillary Wedge Pressure) remained high, around 20 mmHg. Right ventricular dimensions and function remained within normal limits.
Amelioration of general haemodynamic status which allowed a down-titration of inotropes to minimal levels; anticoagulation was maintained through continuous heparin infusion with a target activated partial thromboplastin time (aPTT) of 50–70 s.
After 48 h of support, the patient’s conditions appeared optimal to undergo surgical correction of the LV apical aneurysm and mitral regurgitation. The Impella 5.0 was maintained during the procedure (), after being advanced forward to allow aortic cross-clamping despite the 9F catheter in the aortic lumen. The aneurysmatic segment was excluded with a Dacron Velour patch (with reduction of the LV cavity from 198 to 110 mL), mitral valve was repaired with annuloplasty and cryoablation of both the aneurysmatic neck and pulmonary veins was performed ().
Surgery was successful and the patient was weaned off the Impella 5.0 with the aid of intra-aortic balloon pump (IABP) on postoperative Day 5. The intermediate step of IABP positioning was felt necessary due to the development of non-negligible aortic regurgitation and the significant and constant increase in PCWP that threatened haemodynamic stability at Impella flow lower than 2.1 L/min. The patient was weaned off the ventilator on postoperative Day 10 and discharged from the ICU in the cardiac rehabilitation ward on postoperative Day 21. He was discharged home after a 1-month rehabilitation programme and is currently being regularly followed in the cardiological outpatient clinic: his condition appears stable.


A 59-year-old Asian woman (body weight: 57 kg, height: 153 cm, body mass index:
24.35 kg/m2, occupation: farmer) received TPI in the thoracolumbar
paraspinal muscles at a local medical center because of a 4-month history of
persistent middle back pain of a dull and achy nature. Her pain began spontaneously,
without any trauma history. She did not have any medical history such as
hypertension, diabetes, or neurological disorders. Prior to the TPI, she had not
exhibited any neurological symptoms. She had tenderness to palpation on both
thoracolumbar paraspinal muscles along with identifiable taut bands. A thoracolumbar
spine X-ray image revealed no specific abnormal findings. The physician, who had
25 years of training and experience, diagnosed the patient with myofascial pain syndrome. Her pain was not controlled by oral medication (meloxicam 7.5 mg). TPI was
performed using a blind technique without imaging guidance (ultrasound or
fluoroscopy) in the left thoracolumbar paraspinal muscles, with the patient in a
prone position. The patient had never received TPI prior to the injection. The
physician used a 24-gauge 60-mm spinal needle and 10 mL of 0.6% lidocaine (3 mL of
2% lidocaine and 7 mL of normal saline solution) as the injection solution. During
the procedure, the patient experienced an electric shock sensation throughout the
middle back and lower extremities. The physician stopped the procedure immediately,
and the solution was not infused.
Immediately after the TPI, the patient developed weakness and severe, sharp, and
lancinating pain in the left lower extremity. Three days after the TPI, she was
transferred to the rehabilitation department of our hospital, where she provided
written informed consent for participation in this report. The study was approved by
the institutional review board of Yeungnam University Hospital (2019-05-044).
On physical examination, the patient exhibited severe weakness in the lower left
extremity: her hip flexor and knee extensor manual muscle testing (MMT) scores were
grade 2, and her ankle dorsiflexor, long toe extensor, and ankle plantarflexor MMT
scores were grade 0. Furthermore, impaired light touch sensation was observed in the
L2 to S5 dermatomes on the left side, and she had impaired pain perception in
dermatomes L3 to S5 on the right side of the body. Based on the International
Standards for Neurological Classification of Spinal Cord Injury, her neurological level of injury was L1, and she was classified as grade D
according to the American Spinal Cord Injury Association Impairment Scale (AIS). She
was unable to walk and required a wheelchair to move around. Her tendon reflexes and
muscle tone were unaltered, and bladder and bowel symptoms were absent. The patient
complained of neuropathic pain (tingling, sharp, and lancinating; numeric rating
scale [NRS]: 7) in the left lower extremity. Thoracolumbar spine magnetic resonance
imaging (MRI) revealed a high-intensity T2 signal in the left T12 to L2 segments of
the spinal cord 3 days after TPI (). Electrophysiological recordings, which were performed 11 days
after TPI, showed no response in central motor conduction time (CMCT) in the left
tibialis anterior muscle, whereas the biceps brachii, adductor pollicis brevis, and
right tibialis anterior muscle CMCTs were within the normal range. The patient’s
compound motor action potentials and sensory nerve action potentials had normal
latencies and amplitudes during a nerve conduction test 11 days after TPI, and
electromyography revealed no active denervation potentials in the lumbar paraspinal
muscles or those of the bilateral lower extremities. Spine MRI revealed a
skin-to-epidural space depth of 4.6 cm.
The patient underwent comprehensive rehabilitative management, including
neuromuscular electrical simulation therapy for the knee extensors and ankle
dorsiflexors (20 minutes, twice per day, 7 days per week). In addition, movement
therapy was administered 6 days per week (Monday to Friday: 2.5 hours per day,
Saturday: 1 hour per day), primarily to improve motor function and postural control.
Seven months after the onset of SCI, the patient’s left hip flexor and knee extensor
motor functions had improved to MMT grade 3, and the left ankle plantarflexor muscle
function had improved to MMT grade 2. Conversely, motor functions in the left ankle
dorsiflexor and long toe extensor muscles had not improved (MMT grade: 0) (). The patient’s
pain perception remained impaired, but her ability to sense light touch in the left
lower extremity was nearly completely recovered. Additionally, her neuropathic pain
was reduced from an NRS score of 7 to an NRS score of 4 by treatment with 450 mg
pregabalin and 200 mg tapentadol, and she was able to walk independently using a
walker.


A 28-year-old wheelchair-bound man with cerebral palsy presented to the emergency department with 1 day of hemoptysis. The patient’s caretaker reported that the patient had an episode of intense coughing that was followed by expectoration of bright red blood. About a week prior, the patient had a mechanical fall onto his back while boarding a vehicle. At that time they did not seek medical care. The patient had no chest pain, dyspnea, fevers, chills, night sweats, nausea, hematemesis, or melena. Additionally, there was no recent travel outside their state of residence. The patient had a past medical history significant for cerebral palsy with a ventriculoperitoneal shunt for hydrocephalus. There was no family history of malignancy. He did not use tobacco products, drink alcohol, or use illicit drugs. He lived at home and was cared for solely by his mother. He was not prescribed any anticoagulants and did not use non-steroidal anti-inflammatory drugs (NSAIDs). He had never been incarcerated.
On presentation, the patient was afebrile, tachycardic, and saturating 95% on room air. He did not appear to be in respiratory distress. His pupils were equal, round, and reactive to light. Blood was noted in his oral cavity. His chest did not show signs of trauma and he had symmetric chest wall expansion with inspiration. Breath sounds were diminished on the right side, without wheezes or rales. The cardiovascular exam was unremarkable and the abdomen was soft, non-distended, non-tender, with no organomegaly, and bowel sounds were present. Radial pulses were present bilaterally and minimal edema was noted in both legs. The patient was awake and alert, and at baseline, he was fully oriented. Multiple neurological deficits were noted, all of which were unchanged from baseline. Chest x-ray showed diffuse mixed nodular and patchy opacities in the right middle and lower lung zones. Laboratory testing revealed hemoglobin of 12.9 g/dL, normal comprehensive chemistry panel, negative D-dimer, and normal PTT and prothrombin time. An initial CT angiogram of the chest (, row A) demonstrated no pulmonary embolism but revealed hazy opacities in the right upper and lower lobes.
During his evaluation, the patient continued to have large volume hemoptysis, which consisted of more than 200cc of blood. Due to aspiration risk, he was subsequently intubated for airway protection and was admitted to the intensive care unit. A repeat CT angiogram of the chest (, row B) performed 12 hours after the initial study again demonstrated no pulmonary embolism, but showed interval progression of the opacities in both the right upper and lower lobes, as well as a new left lower lobe opacity. Emergent bronchoscopy was performed, which demonstrated dark-colored clotted blood in both lungs (right side greater than left side), with no active bleeding. Evaluation of the upper gastrointestinal tract at this time showed normal appearing esophagus and no signs of bleeding in the stomach, but the stomach contained swallowed blood.
Due to the patient’s rapid clinical decline, a broad workup was initiated including infectious and rheumatologic testing. Additional history revealed that during the week after the fall, both the patient and his mother experienced coughing. He was subsequently started on vancomycin, piperacillin/tazobactam, and azithromycin for empiric coverage of pulmonary infections. Blood cultures, sputum smear and cultures, respiratory viral panel, legionella antigen, and mycoplasma IgM/IgG were ordered. Additionally, antinuclear antibodies (ANA), perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA), antineutrophil cytoplasmic antibodies (c-ANCA), rheumatoid factor, and anti-glomerular basement membrane antibodies (anti-GBM) were ordered.
Overnight, he remained clinically stable on mechanical ventilation and continued to be afebrile. His hemoglobin dropped to 10.7 g/dL. Sputum smear showed no organisms and no acid-fast bacilli. Sputum and blood cultures showed no growth. Mycoplasma pneumoniae IgM was positive, with a negative IgG. Respiratory viral panel was positive for rhinovirus. Antibiotics were narrowed to IV doxycycline due to concern for macrolide resistance, and possible post-viral complication from staphylococcus aureus.
Rheumatoid factors, ANA, c-ANCA, p-ANCA, and anti-GBM, were all negative. He was monitored for 36 h after the initiation of antibiotics. Serial chest x-rays showed improvement of the right lung infiltrate. The amount of blood drained by endotracheal suctioning decreased to a trace amount. On hospital day 3, the patient was extubated to a nasal cannula and then transitioned to room air. He was transitioned to oral doxycycline 100 mg twice daily. He was transferred out of ICU and continued to be afebrile without hemoptysis or breathing difficulties. He was discharged home on hospital day 5 with a course of oral doxycycline to complete a total of 10 days.


A 31-year-old woman presented to the outpatient department with dimpling on the left breast. The patient had no history of malignant tumors, no relevant family or genetic history, and no previous breast procedures. On clinical examination, a 2.0 × 1.5 cm2 firm, ill-defined, mobile, smooth mass was noted on the upper outer quadrant of the left breast. There was no tenderness on palpation and no axillary lymph node enlargement. MG revealed no distinct findings (). High-frequency US showed a hypoechoic irregular nodule, approximately 21 × 18 mm2 in size, with a partially indistinct and lobulated margin (). On color Doppler examination, only a vascular spot was seen in the lesion (). Strain elastography revealed an extremely low strain value in the lesion (). All findings suggested malignancy. This lesion was categorized as BI-RADS 4b, indicating a malignant lesion. Contrast agent began to show synchronous wash-in with iso-enhancement compared with the surrounding breast tissue 12 s after injection (). The micro-bubbles almost completely filled the lesion within 25 s, and the margin and shape could not be distinguished after enhancement (). Based on the enhancement pattern revealed by CEUS imaging, the possibility of a benign lesion was considered.
Thus, the lesion was downgraded to BI-RADS category 3. The images were analyzed by two senior sonographers with >5 years of experience in breast CEUS. The final histological confirmation (200×) revealed fibromatosis (). The immunohistochemistry results were as follows: smooth muscle actin (+), desmin (+), S-100 (−), β-catenin (+), progesterone receptor (−), estrogen receptor (−), CD34 (+), and Bcl-2 (+). Nuclear accumulation of β-catenin was present in stromal cells but not in endothelial cells or vascular smooth muscle cells, which showed only cytomembrane staining (, 400×). Combined with these results, fibromatosis was considered. Six months later, a breast mass reappeared in the area of the previous surgery and a second lumpectomy was performed. The pathology result was the same as that after the first surgery.


A 42-year-old Asian Indian female patient was referred by a private practitioner to Saveetha Dental College and Hospitals who had presented with a chief complaint of pain in the lower jaw region for the past 3 months. She did not have any contributory medical history.
Intraoral examination revealed a soft-tissue growth with erythematous and nonscrappable irregular white patches on the left alveolar mucosa in relation to 35, 36 and 37 []. Bleeding on palpation was evident, but there was no pus discharge. The patient had informed that the 36 and 37 had become mobile and fell off the socket. Orthopantamogram (OPG) did not give any significant information. The provisional diagnosis of socket granuloma was given. Upon incisional biopsy, sections showed parakeratinized stratified squamous epithelium with underlying connective tissue showing dense chronic inflammatory cell infiltrate and areas of hemorrhage. The diagnosis of reactive granuloma of the alveolus was given and excision of the lesion was suggested for final diagnosis. Under general anesthesia, 34, 35 and 38 were extracted and marginal mandibulectomy with the specimen was done in relation to 35–38 regions.
The excised specimen submitted for histopathological examination revealed lobules and sheets of clear cells which were round to polygonal in shape consisting of clear cytoplasm exhibiting pleomorphism along with few squamous cells with extending from the overlying dysplastic stratified squamous epithelium into the delicate connective tissue. A few islands had areas of comedo necrosis and retraction of the tumor islands was also noted in the connective tissue. Hemorrhagic areas were evident [Figures -]. Peroidic acid–Schiff (PAS) and mucicarmine staining showed a negative reaction.
Tissue sections were subjected to immunohistochemical analysis to define the tumor cell origin. Pan-cytokeratin, epithelial membrane antigen, smooth muscle actin, S100 and CD 117 were used. The tissue sections were immunoreactive for pan-cytokeratin which was suggestive of a malignancy of epithelial origin possibly a clear-cell variant of squamous cell carcinoma [Figure and ]. Further biochemical investigations and whole-body scan were advised, but no significant findings were evident. Considering histopathological, histochemical and IHC examination, a final diagnosis of clear-cell variant of SCC was established.
The patient revisited after 6 months with enlarging mass in the previous site in the left posterior mandibular region with difficulty in mouth opening []. Panoramic radiography revealed a pathological fracture in the left angle region []. A biopsy was done and the histopathological sections showed dysplastic stratified squamous epithelium exhibiting transition to an infiltrating tumor composed of lobules of malignant squamous cells separated by delicate fibrous connective stroma similar to the previous excisional biopsy and a hence a final diagnosis of clear-cell variant of squamous cell carcinoma []. The patient refused any further treatment and subsequently lost for follow-up.


A 24-year-old female walked in the Department of Periodontics of Saveetha Dental College and Hospital, Chennai, with the chief complaint of painless reddish swollen mass in lower right anterior region with gums which bleed profusely on mild manipulation for 4 months which increased in size with time. On further questions, the patient revealed that she was born out of a consanguineous marriage and she also revealed that she had started using herbal toothpaste approximately 4–6 months back. No history of loss of sleep or fever was given by the patient. Medical history of the patient did not give any alarming history of debilitating systemic diseases except unusual asymptomatic patchy skin lesions since birth [], additional peripheral sensory, vision and ocular examination carried out to eliminate Cockayne syndrome.[] No changes in the condition were observed postantibiotic course prescribed by the physician.
Intraoral examination revealed generalized reddish pink gingiva which easily bled on mild provocation. Enlargement of 1 × 1 ×1.5 in respect to lower right canine and first premolar the lesion showed desquamative surface changes. Periodontal examination showed generalized probing depth of 2–4 mm except in 15, 23 and 36 region where probing depth was 5–7 mm and 4–6 mm pseudopocket in relation to 43.44 region suggesting chronic generalized gingivitis with localized periodontitis in relation to 152,336 region. No mobility in any teeth was recorded. Substantial local deposits were noticed in the oral cavity. The patient was systemically healthy and did not report a positive drug history. Radiographs showed a localized horizontal bone loss of 2–3 mm in relation to 15.23 and angular bone loss in respect to 36 [Figures -].
Blood investigations did not show any abnormality. The patient presents with wrinkled skin and patches of hyperpigmentation all over the skin without any systemic symptoms. With these findings, a provisional diagnosis of chronic gingivitis with inflammatory enlargement was made. Moreover, differential diagnosis of PCG and Cockayne syndrome was made.
Phase 1 periodontal therapy was carried out which included scaling and root planing along with 0.2% chlorhexidine mouthwash twice daily, and the patient was recalled after 10 days for a review appointment; however, patient's failure to respond appropriately to initial periodontal therapy necessitated a biopsy of the involved tissue. Excisional biopsy of the lesion present in lower right anterior gingival mass was taken after acquiring patient consent and was sent for histopathological examination.
Histopathological examination revealed following findings:
Fibrocellular connective tissue stroma with sheets of plasma cells admixed with neutrophils in the superficial layers along with areas of endothelial cell proliferation and numerous capillary-sized blood vessels [] There was evidence of parakeratinized stratified squamous epithelium of variable thickness with subepithelial plane of separation consisting of red blood cells along with other areas showing ulceration replaced by fibrinopurulent membrane [].
Histopathological findings confirmed the diagnosis of PCG. Further examination of K 13 and K 5 along with laminin was suggested to rule out possible mutations of epidermolysis bullosa and Cockayne syndrome, etc.


The patient was a 32-year-old female with NMO diagnosed by magnetic resonance imaging (MRI) who had a T2-weighted hyperintense lesion in the central cord from C2 to T2 () and was positive for serum anti-aquaporin-4 antibodies. Written informed consent was obtained from the patient for her anonymized data to be published in this article. The patient visited our hospital because of left hemiplegia and limb sensory disorder. Upon admission to the hospital, her Expanded Disability Status Scale (EDSS) score, Medical Research Council (MRC) score for muscle strength score, and sensory score (according with American Spinal Injury Association sensory assessment) were 9.0, 37, and 158, respectively. She had paralysis and decrease muscle tone in the left side of her body (mainly in the lower limb, L1−S5 region), but no respiratory and pain problem. The clinical chart of the medical treatment, rehabilitation program, and clinical improvement is shown in . The patient underwent treatment by steroid pulse therapy (methylprednisolone 1000 mg/day, days 2–4, and days 6–8). In addition, plasma exchange (plasma volume = 60 mL/kg/day, days 10, 13, 16, 18, and 20) was performed five sessions and intravenous immunoglobulin (dosage = 0.4 g/kg/day, days 24, 25, 26, 27, and 28) was administered five times (). Prednisolone was taken orally 20 mg/day as post-therapy. The patient commenced physical therapy on day 4. During the first physical therapy evaluation, her general status was lucid and her left-side limb muscle strength (i.e. paralysis side) was approximately grade 1–2 by a manual muscle test (MMT). She started a standing exercise and muscle strength training immediately. Physical therapy was performed 5 days/week for 60 min. The muscle strength training started with isotonic movements (shoulder flexion, hip flexion, and knee extension). The paralyzed muscles received electrical muscle stimulation (EMS) using an EMS device (AUTO Tens PRO Rehabili Unit; Homer Ion Co. Ltd., Tokyo, Japan). We performed EMS at 20 Hz with a monophasic square-wave pulse with a duration of 250 µs, an on time of 5 s, an off time of 2 s, no rise time, and decay using the EMS device. Belt electrodes were used for skeletal muscle stimulation. The electrodes were wrapped around the waist, distal parts of the thigh, and the crus of the paralyzed side (). Each exercise was performed without exceeding 17 on the 15-point Borg scale. Furthermore, she was carried out gait practice step by step as the spasticity improved. She performed a locomotion exercise using a walker and knee-ankle-foot orthosis from day 14. She also started locomotion using an elbow crutch and foot orthosis without assistance from day 24. She was subsequently transferred to a rehabilitation hospital on day 34 because her overall condition had improved and she had completed treatment in the acute phase. Her left-side limb muscle strength improved to approximately grade 4 by the MMT, with improvements in the EDSS score (from 9.0 to 6.0), MRC muscle strength score (from 37 to 54), sensory score (from 152 to 203), and all functional independence measure dominants compared with the respective values on admission (–). She did not experience worsening of the symptoms (e.g. pain and spasticity) during hospitalization.


A 49-year-old male patient (body mass index, 23.8 kg/cm2) presented with the chief complaint of right abdominal pain persisting for >1 month. Pelvic computed tomography examination revealed part of the unevenly thickening ascending colon wall. Colonoscopy and endoscopic biopsy were performed and revealed adenocarcinoma of the ascending colon. Tumor markers and routine laboratory blood tests were within the normal reference ranges.
The surgery was performed in accordance with the procedure of totally laparoscopic right hemicolectomy. The resected specimen was deposited in the collection bag and placed in the pelvis. Before the specimen extraction, the anus was fully dilated and the rectum was repeatedly rinsed with antiseptic (1% povidone-iodine). Povidone gauze was inserted into the rectum to support the intestinal wall and the full-thickness anterior wall of the upper rectum was cut open 3–4 cm lengthwise using an electrocautery device (). Oval forceps were inserted into the rectal incision to hold one end of the collection bag and the whole specimen was gently removed through the anus (). Continuous barbed suture was used to close the rectal-wall incision from the distal to the proximal end and the seromuscular layer was sutured to reinforce the incision (). Further, 3,000 mL of hyperthermic distilled water was used to repeatedly rinse the abdominal and pelvic cavities. The trocar holes were closed and the operation was completed ().
The patient’s vital signs were stable during the surgery; total operating time was 184 minutes and intraoperative blood loss was ∼50 ml. The patient could sit up on the bed unaided post-operatively and resumed normal daily living activities without pain within 18 hours. The first flatus occurred within 48 hours. He reported a Numeric Rating Scale for pain score of 3 and 1 on the post-operative first and third days, respectively. The patient was started on a liquid diet 3 days after surgery and discharged on the post-operative ninth day. Pathology of the surgical specimen showed moderately differentiated colonic adenocarcinoma. The number of lymph nodes retrieved was 50. A follow-up colonoscopy was performed 1 month later and no stenosis or scar contracture was observed in the intestinal cavity (). The patient recovered well with accurate anal sensation and smooth defecation.


A 40-year-old man presented to the emergency department with sudden onset dyspnoea and severe chest pain radiating to his back. He also reports a year history of intermittent haemoptysis. On presentation, the patient’s observations were stable. The patient was born and raised in Tibet, and reported having previously been treated for confirmed tuberculosis.
On presentation, chest X-ray illustrated a prominent proximal descending thoracic aorta contour and a completely collapsed left lung (). On computed tomography angiogram (CTA), the patient was found to have a large saccular aneurysm measuring 5.0 × 5.0 × 5.0 cm in size, arising from a focal location of the proximal descending thoracic aorta distal to the origin of the left subclavian artery with evidence of contained rupture (). The mass was found to be causing significant external compression of the left main bronchus leading to significant effacement of the left main primary bronchi leading to extensive collapse in both left upper and lower lobes and overall reduction in volume of the left hemithorax ().
After review by both the vascular and cardiothoracic surgeons, a decision was made to proceed to an open repair. A thoracic stent graft was considered, however this procedure would not relieve the patient’s bronchial compression. An open repair would exclude the thoracic aneurysm and also relieve compression from the bronchus. Without ventilation of the left lung, an extended posterolateral thoracotomy was performed to allow pleural entry via the fifth intercostal space. The distal aortic arch was encroached and the saccular aneurysmal portion at the inferior aspect at the distal inner curvature appreciated. The patient was placed on Cardiopulmonary Bypass (CPB), via the Common Femoral Artery and Common Femoral Vein, and the patient was cooled to 20°C. Peri-aortic tissue was dissected free of the target site; the recurrent laryngeal nerve was not observed however suspected medial to the dissection area. The saccular aneurysm was opened and old clot was evacuated and the area dissected to its neck at the inferior arch. Nil communication with the bronchus was evident. Remaining aorta appeared relatively normal. The edges of the aneurysm neck were fashioned towards health aorta and the resulting defect closed primarily with a single layer of bilaterally buttressed (bovine pericardial strips). CPB was recommenced to allow de-airing via the then closed anastomosis; with full CPB flow rewarming was begun. Sinus rhythm reverted spontaneously at 32°C; at normothermia the CPB wean was commenced, well tolerated and completed at the patient decannulated and protamine administered. Pleural packing was perused to allow haemostasis which was eventually achieved. Left lung recruitment achieve eventual satisfactory re-expansion. Drains were placed as the ribs re-approximated with double figure 8.
Post-operatively, the patient experienced intermittent episodes of desaturation secondary to mucous plugging. The patient required regular chest physiotherapy, high flow nasal prongs for humidification with intermittent bi-level positive airway pressure. He also developed a hospital-acquired pneumonia which was subsequently treated with a course of intravenous tazocin.
Repeat CTA illustrated good flow through the thoracic aneurysm, re expansion of the left lung, and decompression of the left main bronchus. Histopathology of washing and fine needle aspirates was all negative for tuberculosis and bacteria. Histopathology revealed fibroid and necrotic material with mixed acute and chronic inflammatory changes, fragments of benign bronchial epithelium and ulceration and squamous metaplasia; no granulomas were present. Further, nil malignancy was detected.


A 14-year-old boy who was previously healthy developed a persistent headache 3 weeks after receiving the 9-valent human papilloma virus (HPV) vaccine (Gardasil 9 ®, Merck and Co, 0.5 mL intramuscularly). Over the following 2 weeks, the patient’s headache worsened, and he became increasingly fatigued.
On the day of presentation (40 days post-vaccination), he developed left-sided weakness, urinary incontinence, and confusion, which prompted his family to bring him to a local emergency department. There, head CT was normal and labs, including CBC, complete metabolic panel, and urine toxicology screen, were unremarkable. He was then transferred to our tertiary children’s hospital for further evaluation and management.
Neurologic exam upon admission was notable for left-sided extremity weakness, tremors of left extremities, and mild confusion. Brain MRI revealed diffuse hyperintensities on T2 and FLAIR sequences within the subcortical white matter, thalamus, and basal ganglia (
). Cerebrospinal fluid examination showed a lymphocytic pleocytosis with 56 WBC (reference range 0-5), 77% of which were lymphocytes, along with normal protein and glucose. Extensive serologic and nucleic acid amplification testing of his CSF for bacterial and viral pathogens was negative, as were blood cultures. CRP was normal.
Given the combination of his clinical picture, neuroimaging, and laboratory results, the patient was diagnosed with acute disseminated encephalomyelitis (ADEM) and started on treatment with intravenous methylprednisolone, 1 gram daily. Despite this treatment, the patient’s encephalopathy worsened, necessitating transfer to the Pediatric Intensive Care Unit (PICU) on the second day of hospitalization. Upon transfer to the PICU, the patient was non-verbal and only intermittently following commands. Exam at the time was notable for left-sided facial weakness, increased tone in the left extremities, bilateral ankle clonus, and left patellar hyperreflexia. After an episode of bilateral shoulder twitching concerning for seizure, continuous video electroencephalogram monitoring was initiated and revealed severe multifocal disturbance of cerebral function, but no epileptiform activity.
On the third day of hospitalization, the patient had a rapid deterioration in his neurologic exam and developed agonal breathing, emesis, tachycardia, and fixed and dilated pupils. Emergent non-contrast head CT showed severe cerebral edema with impending cerebral herniation, for which he was treated with hyperventilation, hypertonic saline and intravenous mannitol. An emergent right hemicraniectomy was performed. Post-operatively, 400 mg/kg of intravenous immunoglobulin (IVIG) daily was added as treatment for ADEM, but the patient had no neurologic recovery. Neurologic exam performed 3 days post-operatively was consistent with brain death. Following the patient’s death, the family consented to autopsy.
Neuropathologic examination revealed an acute vascular inflammatory process with fibrinoid vascular necrosis, marked macrophage infiltrates, parenchymal necrosis, numerous hemorrhages, and areas of myelin and axonal loss (
), consistent with acute hemorrhagic leukoencephalitis.


In 2015, a 59-year-old man was diagnosed with exudative AMD in his left eye. The diagnosis was based on fundus examination, optical coherence tomography, and fluorescein angiography. His best-corrected visual acuity (BCVA) in the left eye was 0.4. Since then, he was regularly treated with anti-VEGF injections (aflibercept, according to the label). So far, overall, he has received 26 injections into the left eye (every 2 months). The right eye did not show any signs and symptoms of wet AMD (BCVA = 1.0).
In 2017, with the advent of OCTA or angio-OCT, we were able to use this technique in all patients with AMD. The angio-OCT en face examination (Avanti with AngioVue OCTA; Optovue, Inc., Fremont, CA, USA) confirmed the presence of CNV in the left eye. Surprisingly, OCTA revealed the presence of 2 quiescent, asymptomatic, nonexudative type 1 CNVs in the right eye, too (shown in Fig. ). The bigger CNV was irregular, glomerular-shaped, composed of small, rather dense, capillaries with longer tangled filaments located under the RPE, in the subfoveal region. The smaller one was more difficult to detect. It had more regular and round shaped with loops, located in the upper area of the macular region. Structural OCT showed flat, irregular pigment epithelium elevation in the areas corresponding to both CNVs; no fluid was observed, and BCVA was 1.0. Since then, we have performed the angio-OCT examination at least every 2 months. The shape and size of these nonexudative CNVs remained unchanged, and the patient did not report any disturbances in the right eye for almost 2 years. Then on May 2019, we observed the activation of the upper, smaller CNV, which started to grow, producing sprouting, dense and thin capillaries with loops, yet BCVA was still 1.0. However, the growth of the pigment epithelial detachment was not pronounced. Four months later, subretinal and intraretinal fluid, subretinal hyperreflective mass, retinal hemorrhages, and perilesional dark halo appeared, and BCVA decreased to 0.7 (shown in Fig. ). The shape, size, and morphology of the bigger, subfoveal CNV seemed to be the same. The anti-VEGF therapy was started immediately, and the patient responded well to the treatment (so far, he has received 5 injections of aflibercept according to the label). His BCVA improved to 1.0. The edema has gone; the subretinal fluid and retinal hemorrhages have disappeared, but the shape and size of the CNVs have not changed.


Patient 1 was born at 38 weeks gestation by repeat Cesarean section to a 33-year-old G2P1001 mother. Prenatal ultrasound detected a Dandy-Walker malformation, confirmed after birth with brain MRI. There were no other prenatally detected abnormalities. The remainder of the pregnancy was unremarkable. The family history was remarkable for a sister (patient 2) with an atrial septal defect (ASD) and clubfeet. The remainder of the family history was negative for birth defects, intellectual disability, and recurrent miscarriages. The mother and father are second cousins (their mothers are first cousins).
The patient's birth weight was 3.78 kg (69th percentile), length was 54.0 cm (93rd percentile), and Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. He had neonatal hypoglycemia, which resolved spontaneously within the first day of life, and feeding difficulties, which resolved by 6 months of age. A patent foramen ovale was identified.
At birth, the patient had ambiguous genitalia with a bifid scrotum. Specifically, he had a penoscrotal transposition with buried penis and prominent suprapubic fat pad. He also had ventral chordee, left-sided hydrocele, and a left inguinal hernia. The patient had a low luteinizing hormone (LH) and lower limits of normal follicle-stimulating hormone (FSH) in the newborn period. Testosterone and dihydrotestosterone levels were normal for age, but anti-Mullerian hormone was low for newborn males, suggesting normal Leydig cell function but abnormal Sertoli cell function. A renal ultrasound showed normal-appearing kidneys bilaterally with no evidence of hydronephrosis. At 7 months of age, the patient had a penoplasty, scrotoplasty, and repair of the left inguinal hernia and hydrocele.
The patient had both developmental and speech delays, He sat alone at approximately 5 months, crawled at 11 months, and was not walking independently at 16 months of age. Growth parameters at 16 months of age were 11.4 kg (53rd percentile) for weight, 78.6 cm (29th percentile) for length, and an OFC of 49 cm (87th percentile). Mildly dysmorphic features observed included short palpebral fissures with hypertelorism, cupped ears with overfolded helices, short nose, a smooth philtrum, full cheeks, and micrognathia. (Figure ). Other features noted were displaced nipples, tapered fingers, edema of the feet, and loose skin.
At age 9 years, he underwent an adenoidectomy and turbinate cauterization due to concerns for apnea. His growth parameters for height, weight, and head circumference were at the 75th-90th percentile. He had moderate expressive and receptive language delays and received speech intervention, occupational, music, physical, and recreational therapies. He was diagnosed with ADHD and is homeschooled, working at a 3rd grade level. At age 10 years 11 months, he is prepubescent. A testicular ultrasound revealed healthy appearing bilateral testes located within the scrotum without mass or concerning features. His gender identity remains male.
G-banded chromosome analysis, performed at birth, identified additional unknown material on 9p. Parental blood studies demonstrated that the patient's father had a balanced reciprocal translocation between 3p and 9p written as 46,XY,t(3;9)(p25.1;p24.3). Based on paternal results, the patient's karyotype was revised to 46,XY,der(9)t(3;9)(p25.1;p24.3)pat, resulting in partial 3p duplication and partial 9p deletion (Figure ).
Chromosomal microarray analysis (CMA) identified a duplication at 3p26.3p25.1, approximately 13.5 Mb in size involving 55 OMIM genes (chr3:61,891-13,562,132, hg19 coordinates) and a deletion at 9p24.3, approximately 1.17 Mb in size involving 5 OMIM genes (chr9:203,861-1,373,611, hg19 coordinates). Also identified were segments of copy-neutral absence of heterozygosity (AOH) across multiple chromosomes encompassing around 2.2% of the genome (Figure ).


A 72-year-old Italian woman came for persistent non-productive cough since late 2017. Chest X-ray showed leftvbasilar atelectasia. Previous history of smoking, hypothyroidism, osteoporosis and gastroesophageal reflux disease was noted. A chest computed tomography (CT) displayed subcentimetric cavitated nodules and a 38-mm solid lung mass (). Enlarged lymph nodes were present in the left hilar region.
A positron emission tomography (PET)/CT revealed a lung mass near the left inferior lobar bronchus (). There were no other pathologic enhancement on such examination. Scintigraphy excluded bone involvement. A bronchoscopy showed a whitish polilobular mass at emergence of left inferior lobe. Histology revealed neoplastic cells with solid growth pattern. Immunophenotype: CK7+, actin+, vimentin+, CK5/6+, TTF−, chromogranin−, CD56−, synaptophysin−, p63−, GFAP−, CEA−, ki67 15%. Malignant cells were found on the bronchoalveolar lavage. A neck and salivary gland ultrasound (US) excluded lesions to thyroid and to major salivary glands, along with absence of lateral cervical and submandibular pathological lymphadenopathy.
In April 2018 she underwent a left lower lung lobectomy with atrial and bronchial plasty in posterolateral thoracotomy. The histopathological examination revealed the lesion to be an ACC. The visceral pleura was not involved, but there was neoplastic infiltration of the vascular margin. Four out of 11 peribronchial lymph nodes were positive for metastatic cells, whereas paratracheal, mediastinal, hilar and interlobar lymph nodes were negative for neoplasia. The intraoperative histological examination of the left lower lobar bronchus’ section ring resulted clean; further analysis revealed focal nests of infiltration of ACC. No tumour cells were found in the pleural fluid. A multidisciplinary evaluation, considering the clinical picture, preoperative examination and the pathological specimen concluded that it was a primary ACC of the lung pT2b pN1 (TNM VIII ed. 2017) and gave indication for adjuvant radiant treatment without chemotherapy. The patient underwent radiotherapy on the left hilar region, with a total dose of 60 Gy in 30 fractions.
In late August 2018 she reported worsening hoarseness and US showed an enlarged left thyroid lobe with pseudonodular formations. Fine needle aspiration cytology showed poorly differentiated basaloid cells, Bcl2+, CD117+, TTF1−, thyreoglobulin−, chromogranin−, consistent with ACC localization. A restaging CT showed an inhomogeneous alteration of the left thyroid lobe without lateral cervical significant lymphadenopathies (). Brain CT was negative for metastatic localization. The upper airway evaluation revealed a fixity of the left hemilarynx.
In December 2018 a total thyroidectomy was conducted, with finding of extensive infiltration of perithyroidal soft tissue, incorporation of the left inferior laryngeal nerve, infiltration of the trachea, without infiltration of the oesophagus (). The left thyroid lobe resulted subverted by neoplastic proliferation with necrosis, perineural and vascular invasion (PNVI), infiltration of perithyroidal soft tissue, lymph node and surgical margins (). Immunophenotype: smooth muscle actin (SMA)+, CD117+, CK7+, TTF1−, PAX8−, Thyroglobulin−, NapsinA−, CD45−, CK20−, S100−, GFAP−, p63−, GATA3− (). After comparison with the previous examination, the immunomorphological patterns were similar, and the possibility of a primary ACC of thyroid was also considered, but since preoperative radiological and nuclear imaging examination excluded thyroid involvement, the most likely hypothesis was for the thyroid lesion to be a metastatic localization of a primary ACC of the lung.
After 3 months a CT revealed a 2-cm area near the cervical oesophagus and the first tracheal ring, with annular appearance and peripheric contrast enhancement. Radiotherapy was performed on thyroid lodge, residual disease and lymph nodes. In summer 2019 a brain metastasis was diagnosed and treated with stereotactic radiotherapy. In April 2020 she developed a complex clinical picture comprising a seizure and an acute heart failure. Imaging studies showed absence of oncological relapse. Despite treatment, she died after progressive worsening of her general conditions.


A Caucasian 68-year-old male, without systemic diseases, was admitted in March 2020 to a tertiary care center (Hospital Vera Cruz, Campinas, São Paulo, Brazil) with history of right upper eyelid swelling and redness for 10 days, which became progressively worse. He denied fever, worsening of visual acuity, or pain due to eye movements.
At presentation, the patient's right eye was closed by erythematous and swelling of the right upper lid (Fig. ). Vital signs at the time of hospital admission were as follows: systemic blood pressure = 130 × 70 mm Hg, cardiac frequency = 71 bpm, and body temperature = 37.1°C. The full blood count presented a white blood count of leukocytes = 6,478 mm3 (neutrophils = 4,060 mm3, eosinophils 30 mm3, basophils = 20 mm3, lymphocytes = 1,790 mm3, and monocytes = 580 mm3). All of them were within the normal range.
Ophthalmologic exam at the time of admission showed visual acuity of 0.4 logMAR in both eyes (OU) with spectacles, clear conjunctiva, clear cornea, and nuclear cataract 2+ in OU. Ocular motility and pupillary reflex were normal in OU. The intraocular pressure was 12 mm Hg in OU (with Icare tonometer, which is a rebound tonometer). Fundoscopy showed pink optic disc with sharp margins and a cup to disc ratio of 0.5 in OU.
Computerized tomography revealed preseptal and soft tissue edema with an abscess in the anterior right upper eyelid but no signs of orbital involvement or orbital fractures. Figure presents the aspect of both eyelids in the tomography. A presumptive diagnosis of hordeolum with preseptal cellulitis and abscess was made, and intravenous amoxicillin and clavulanate potassium 500/125 mg were administrated twice a day.
The development of purulent discharge from the upper eyelid with an abscess and necrosis was evident. Therefore, the patient underwent abscess drainage and wound debridement. During the procedure, necrosis was observed involving almost the full thickness of the right upper eyelid, measuring 30 × 30 mm in the central area. The tissue surrounding the abscess was friable and necrotic and did not bleed. The necrotic tissue was debrided until healthy viable tissue appeared throughout the wound and no evidence of infection was present in the reminiscent tissue. The wound was left open to heal by secondary intension. Figure presents the eyelid aspect immediately after the surgery.
Given the clinical improvement in his local and systemic condition, the patient was continued on intravenous amoxicillin and clavulanate twice a day for 48 h and was discharged with the same oral antibiotics. He also started using topical medication with retinol acetate (10,000 IU/g), amino acids (25 mg/g), methionine (5 mg/g), and chloramphenicol (5 mg/g) in the affected eyelid for 7 days, 3 times a day.
Seven days after debridement, he presented satisfactory cicatrization without any symptoms (Fig. ). After 2 months, the eyelid was completely healed with no retraction (Fig. ).


The patient was a 47-year-old male who presented to us with a history of spontaneous development of an ulcer over his glans which gradually increased in size over 3 months and was associated with itching and foul-smelling discharge. He was not having any difficulty in micturition. He is a known smoker for the past 20 years. On examination, there was a 4 × 3 cm hard ulcero-proliferative growth over glans. There was no clinically palpable or sonologically detectable lymph node in the groin. After taking informed consent, he underwent partial penectomy and neourethra creation with “modified parachute technique” as described below. At 12 months of follow-up, he has a good flow of urine (Qmax-22 ml/sec) and satisfactory sexual intercourse with the International Index of Erectile Function (IIEF-5) score of 15 (mild to moderate ED).


A 58-year-old female patient, who was a known case of hypertension and hypothyroidism taking tablet L-thyroxine 50 mcg once a day and tablet metoprolol 25 mg twice a day regularly presented on 17th April 2020 with chief complaints of low-grade intermittent fever, generalized body ache, running nose and soreness of throat for last 3 days. Her reverse transcriptase by polymerase chain reaction (RT-PCR) for COVID-19 was done at Civil hospital, which returned positive. Her husband was also symptomatic for COVID-19 and was also tested positive. Both were admitted in Civil hospital on 19/4/2020. Her chest laboratory parameters including complete blood count and X-ray were normal []. She was treated with azithromycin 500 mg once a day for 3 days along with paracetamol 500 mg thrice daily apart from multivitamins. Patient became asymptomatic after 2 days. Her repeat RT-PCR for COVID-19 was done on 28th and 29th April 2020 which both returned negative after which she was discharged on 29th April 2020. Her husband had COVID-19 pneumonia for which he remained hospitalized in civil hospital for 23 days and was subsequently discharged on her regular medication for hypertension and hypothyroidism at home. She was asymptomatic for almost next 4 months.
On 17th August 2020, she again developed symptoms in form of intermittent 101°F fever, generalized body ache, dry cough, and throat pain. Her rapid antigen test (RAT) returned positive. Her husband was negative on this occasion. Patient needed rehospitalisation on 19th August 2020 where her RT PCR for COVID-19 also returned positive with cycle threshold (CT score) of 18 suggestive of high viral load, thus confirming a case of reinfection with COVID-19. Total antibody and immunoglobulin G antibody test for COVID-19 were negative suggestive of non-existent immunoglobulin memory from previous COVID-19 infection. Her inflammatory profile revealed CRP of 17.8 mg/L and IL-6 of 15.4 pg/ml with otherwise normal X-ray chest (shown below) and other reports. Patient was subsequently discharged after being afebrile for 5 days.


A 67-year-old woman presented with complete facial paralysis that had lasted for 2 years secondary to facial nerve schwannoma resection (). In the first stage, through a preauricular incision on the healthy side, cross-face nerve grafting (CFNG) was performed. Two facial nerve buccal branches were identified and the thicker one was used as the recipient nerve. Six months after the first stage, dual-innervated muscle transfer was performed, using two superficial SA subslips. Through a midaxillary lazy-S incision with extension into the axilla, the ipsilateral lower SA subslips and its overlying neurovascular pedicle were identified. The 5-mm-thick and 12-cm-long seventh and eighth superficial subslips were harvested, including the thoracodorsal vessels and long thoracic nerve, with preservation of the upper branches to prevent postoperative scapular winging ().
The seventh and eighth subslips were placed into the cheek pocket, with the neurovascular bundles oriented on the inner side. The scapular origin of the muscle subslips was divided into two portions and positioned on the oral commissure side. After the thoracodorsal vessels were anastomosed with the facial artery and vein under a surgical microscope, the seventh subslip was secured to the orbicularis oris of the upper lip and the eighth subslip to the modiolus. The long thoracic nerve was sutured to the masseteric nerve branch in an end-to-end manner and sutured to the distal stump of the CFNG in an end-to-side manner (). The opposite sides of the muscle subslip were sufficiently separated from each other to differentiate the force vector of each subslip, preserving the proper subslip vessels and nerves. The upper seventh subslip (8 cm long) was oriented to make an angle of 50° and the lower eighth subslip (10 cm long) was positioned to make an angle of 20° with the horizontal plane and secured to the deep temporal and periauricular fascia (). Furthermore, through bilateral incisions along the lower vermilion border, a horizontal fascia lata graft was added between the orbicularis oris muscle of the lower lip and the lower eighth subslip to prevent deformities, such as lower lip thinning and elongation. No muscle necrosis, vascular complications, or donor-site problems were observed, including scapular winging.
Voluntary contraction was noted at approximately 4 months, and a spontaneous smile without biting was noted 8 months postoperatively. At 18 months after surgery, the patient simultaneously demonstrated a spontaneous symmetrical smile with sufficient excursion of the lower lip, upper lip, and oral commissure (). Postoperative cheek muscle bulkiness with the two subslips was not demonstrated at rest or while smiling.


A 44-year-old woman presented with multiple asymptomatic translucent skin-colored papules present over the nasal bridge, infraorbital region, and few over upper eyelid varying in size from 2–6 mm []. She gave a history of aggravation in summer for the last 8 years. On puncturing the lesion with a sterile needle, clear fluid was noticed. Skin biopsy from most represented lesion revealed unilocular cyst lined by two layers of flattened cuboidal epithelium due to retention of sweat secondary to eccrine duct obstruction, without any evidence of decapitation in lining cells []. Dermoscopy (performed by AM7013MZTS (4S) Dino-Lite Premier; AnMo, Taipei, Taiwan) showed whitish clod without crater along with multiple telangiectasias on nonpolarized mode [] and yellowish globules with multiple telangiectasias on polarized mode [].