A 24-year-old right-handed male reported to our emergency department with the history of trauma to his left forearm and hand while working on a wood-cutting machine. There was no associated injuries or comorbidities. There was near-total amputation of the left upper limb at two levels: at the junction of middle and lower one-third of forearm and at the level of metacarpal shafts. All the forearm structures were transected except preserved skin tag of 2 cm width on the ulnar side of the forearm []. The left thumb was also amputated at the level of mid distal phalynx. After the bony fixation, revascularisation of the limb was undertaken by repair of ulnar and radial arteries. Venous flow was established by repair of cephalic and basilic veins. Perineural repair of the ulnar nerve, the median nerve, superficial branch of radial nerve. and the lateral cutaneous nerve of forearm was carried out in an end-to-end fashion. Similarly, the first, second and third common digital arteries and nerves were repaired after the fixation of metacarpals. Thumb stump was closed primarily. Injury to reperfusion time was 7 h and total operating time was 13 h.
In the post-operative period, the patient developed vascular insufficiency of the distal part of the hand which could not be salvaged. We performed trans-metacarpal amputation of the left hand and covered the stump with a pedicled groin flap. Small raw area on the dorsum of the forearm was skin grafted. Complete healing of the wounds occurred after 1 month, at which time the patient was discharged from the hospital []. The patient was referred to the physiotherapy unit for rehabilitation and was followed up in our outpatient department monthly for sensory and motor evaluation.
Four months after the discharge, the patient reported with acute-onset skin lesions over the revascularised part of the forearm and hand. The physical examination revealed weeping and crusting exudative lesions suggestive of of eczematous dermatitis. The revascularised part of an extremity developed irregular erythematous plaques covered with yellowish thick crust. There were multiple erosions at places along with serous discharge. These lesions were strictly limited to the revascularised part of the limb; rest of the limb was normal []. The patient did not have any allergy and other reactive skin lesions in the past. Negative Patch test with standard series ruled out contact dermatitis. Skin biopsy revealed the findings of acute eczematous dermatitis.
Several studies in the past have reported the association between autonomic dysfunction and skin lesions like atopic dermatitis, psoriasis and CRPS.[] As the patient had suffered traumatic neuropathy, investigations were done to rule out autonomic dysfunction in the revascularised part. We performed Ninhydrin sweat test and Sympathetic Skin Response (SSR) test. Negative Ninhydrin sweat test indicated disturbance of sweating function.
SSR test was performed using a four-channel electromyography machine as described by Cicek et al.[] The affected hand did not show any waveform indicating sudomotor dysfunction.
Sympathetic dysfunction in the revascularised part of the limb was confirmed by above investigations. Sympathetic dysfunction led to abnormal sudomotor and vasomotor functions and eczematous dermatitis in the revascularised part of the limb. Therefore, we coined the term sympathetic dysfunction dermatitis to describe the skin lesions developing in the revascularised or replanted part of an extremity.
The patient responded well to a topical cream of 2% fusidic acid and 0.1% betamethasone along with oral prednisolone for 1 week. All the skin lesions subsided with appearance of a normal skin texture []. However, there was one episode of recurrence 3 weeks after the resolution of the skin lesions which was treated as before. There was no further episode of dermatitis. The patient is presently on emollients to prevent recurrence.
To evaluate the sensory recovery, Semmes–Weinstein monofilament test and 2-point discrimination test (2PD) were performed at the 4th, 5th, 6th and 8th months postoperatively. On evaluation at the 6th month, the patient was free of skin lesions and his sensory recovery improved.


A 71-year-old man was referred by his General practitioner to a district general hospital head and neck clinic with breathlessness and haemoptysis. On initial presentation the patient did not describe any changes in voice, dysphagia, odynophagia, weight loss with a prior smoking history. His past medical history revealed that 6 years previously, he had been fully investigated for a left vocal cord palsy of presumed idiopathic aetiology and had undergone medialisation of injection thyroplasty. Physical examination did not reveal any enlarged cervical lymphadenopathy of the neck. At fibre-optic nasal endoscopy he was noted to have a subglottic mass and therefore he was referred to a tertiary centre to be cared for under the head and neck multidisciplinary team.
Computed tomography (CT) imaging depicted a paratracheal mass within the left trachea-oesophageal groove. Several enlarged lymph nodes were found in the antero-superior mediastinum and left paratracheal space as well as individual lymph nodes in the retrocaval, pretracheal and subcarinal regions. Ultrasound demonstrated several colloid nodules in the thyroid with abnormal heterogenous areas and focal areas of calcification. A positron emission tomography computed tomography (PET/CT) scan further identified lung and bony metastatic deposits. At microlaryngoscopy under general anaesthesia a subglottic mass was biopsied. The initial biopsy results showed stratified squamous epithelium that was hyperplastic and spongiotic with scattered and highly atypical cells with nuclear polymorphism and abundant eosinophilic cytoplasm. Immunohistochemistry of these tissue samples showed positivity for Cytokeratin7 (CK7) and Periodic Acid Schiff Alcian (PAS-alc) blue and negativity for Cytokeratin20 (CK20) and Thyroid transcription factor 1 (TTF1). Due to lack of evidence of thyroid markers on these tissues, an initial diagnosis of ‘mucoid’ tumour of the trachea was made. Based on this evidence, the tumour was staged at T4N2M1.
Clinical management of the patient involved microdebridement of the tumour under general anaesthesia and a palliative dose of radiotherapy (20 Gray in five doses) which failed to improve the patient’s airway obstruction. The patient underwent a surgical tracheostomy at which multiple further pathological samples were taken. These showed evidence of papillary thyroid carcinoma with a follicular growth pattern which was shown to blend imperceptibly with another component of tumour wherein the cells are present in irregular discohesive infiltrating growth pattern. The nuclei of these cells were found to be hyperchromatic with moderate cytoplasm, whilst several of the cells showed intracytoplasmic lumen and eosinophilic inclusions. Immunohistochemistry showed positivity for TTF1 and thyroglobulin in the papillary component of the carcinoma whilst the poorly differentiated area showed negativity for TTF1 and weak positivity for thyroglobulin. This led to the diagnosis of a follicular variant of papillary thyroid carcinoma with composite MEC of the thyroid. Due to the extensive nature of the disease, the patient was managed with palliative intent and died 2 months later (Figs –).


During a routine educational dissection of the foot, variation of MPN was found on the left side of a 78-year-old Korean male cadaver. The skin and soft tissues of the plantar area were elevated over the plantar area of the feet. The subcutaneous fat and the plantar aponeurosis were carefully removed. The tibial nerve divided into lateral plantar nerve and MPN under flexor retinaculum of foot (laciniate ligament). The MPN were located superficial to the first layer of the sole (). It passed under plantar aponeurosis and the abductor hallucis muscle, and run superficial to the flexor digitorum brevis (). At the master knot of Henry, MPN gave off the a common plantar digital nerve and then divided into three proper plantar digital nerves near the metatarsal bases. These proper planter digital nerves accompanied with the plantar metatarsal arteries from the deep plantar arch. There was no variation in the other neurovascular structures.


A 59-year-old female patient presented to her local family doctor with chronic generalized intermittent colicky abdominal pain and altered bowel habit for a few months. She has no other associated symptoms. She previously had laparoscopic adjustable gastric band (LAGB) insertion 8 years prior with good result (BMI pre-procedure was 56 kg/m2, and now 36 kg/m2). Her other comorbidities include hypertension and colonic diverticular disease with previous acute diverticulitis. She was organized to have an elective colonoscopy. Colonoscopy revealed tubular foreign body embedded in the wall of colon, with an entry and exit point, ~55 cm from anal verge (Fig. ). There was also significant sigmoid and descending colon diverticular disease.
CT abdomen with oral and intravenous contrast was organized to further investigate the tubular foreign body. It revealed concurrent gastric band erosion into gastric lumen and connection tubing eroding into the posterior wall of transverse colon and exiting inferiorly (Figs –). There was no evidence of any oral contrast leak from the stomach.
This patient has previously been admitted for acute diverticulitis 4 years prior. Reviewing prior imaging did not reveal any gastric or colonic erosion. The gastric band tubing is noted to be running along the inflamed colon. Since the initial admission for acute diverticulitis, she has had multiple further acute diverticulitis episodes, which were treated with oral antibiotics. We suspect recurrent diverticulitis lead to the erosion of the gastric band into the colon and stomach.
As part of the surgical management, both colorectal and upper GI surgeon were involved in the operation. Patient underwent laparoscopic removal of gastric band and laparoscopic assisted wedge resection of transverse colon. The gastric band was removed following adhesiolysis and the gastric defect was repaired with intracorporeal suturing. The gastric band port was subsequently removed. Gastroscopy was done to ensure the repair was airtight. For the colectomy, transverse colon and splenic flexure was mobilized laparoscopically and the transverse colon was extracted through the gastric band port site for external inspection. A tract was identified passing from the antimesenteric border to colonic lumen and then along the colonic mesentery. A wedge resection performed with stapler end to side anastomosis. Flexible sigmoidoscopy was performed to confirm the anastomosis was airtight. Her post-operative recovery was uneventful, and she continued to be well on post-operative follow up in clinic. She remains well on subsequent phone follow up 12 months post operatively.


A 16-year-old Caucasian boy was transferred from an outside facility with fever,
rash, and sore throat. Prior to this admission, he had a right femoral osteotomy
that was complicated by infection requiring irrigation and debridement and a
prescribed course of intravenous vancomycin. He had completed over 4 weeks of
vancomycin treatment via peripherally inserted central catheter. Two days prior to
admission, the patient developed a rash that began on his shoulders and progressed
to involve the entire body. The patient complained of facial edema, nausea,
diarrhea, and a sore throat. A rapid strep test and antistreptolysin O (ASO) titers
were negative. A respiratory viral panel was positive for rhinovirus/enterovirus
polymerase chain reaction (PCR). Laboratory values demonstrated absolute
eosinophilia (1000/mL) and an elevated alanine aminotransferase level (103).
Physical examination revealed a diffuse morbiliform rash involving the upper
extremities more than lower extremities, sparing the palms, soles, and mucous
membranes. Vancomycin was changed to doxycycline. Over the course of 3 days, the
patient continued to have fever, chills, and rising eosinophilia (peak 2000/mL). The
rash became more confluent with overlying areas of purpura in areas of pressure such
as the back and around the knee brace on his right leg (). There were areas on the upper
extremities progressing to vesicular lesions (). Petechial lesions developed on the
soft palate. Based on the RegiSCAR criteria, our patient met diagnostic criteria for
DRESS syndrome. Intravenous methylprednisolone (30 mg intravenous every 8 h) was
started on the fifth day of admission. Within 12 h of introduction of steroids, the
patient became afebrile with improvement in the rash. The patient’s rash continued
to fade over the course of his hospital stay and he had no further fever. The
patient was transitioned to an oral prednisone taper and discharged with oral
doxycycline for osteomyelitis.


A healthy, active, 49-year-old woman initially presented to our team in January 2017 with a history of pain, tenderness and swelling in the left middle finger following a minor trauma to her right hand 1 year previously. She denied any history of constitutional symptoms. Physical examination showed a swollen and tender mass with firm consistency at the middle phalanx of the middle finger of the left hand. Range of motion of the adjacent joints (distal interphalangeal and proximal interphalangeal joints) was preserved and capillary refill time was normal.


On December 2016, an esophageal tumor was incidentally found during positron emission tomography scanning (PET scan) (), which was performed annually in an asymptomatic 67-year-old man with a history of lymphoma since 2015. There was no local glucose metabolism, and the hypothesis of a benign origin was raised. Retrospectively, this tumor had been yet visible at previous PET scans. Endoscopically, the tumor appeared like a pedunculated submucosal polyp developing from the cervical esophageal—mouth, with a 50-mm head and a 50-mm long thin peduncle (, ). The scope could pass easily without any evidence of obstruction. The diagnosis of fibrovascular polyp was yet suspected at this time of investigation. Because this kind of tumors have been described as richly vascularized, ultrasound endoscopy was performed in the same operative time with pretherapeutic appraisal intent. The tumor developed under the mucosal layer that encompassed a homogenous hypoechogenic circular infiltration of the submucosa. The peduncle seemed to be tumor-free. The mobile characteristic of the tumor made the examination with fine Doppler sensitive. Hence, no vessel in either the head or peduncle of the polyp was shown by this method. An ultrasound contrast agent, Sonovue® (Bracco, Milan, Italy) was used to assess tissue microcirculation. With a low mechanical index, an intense homogeneous contrast enhancement was observed within the head of the tumor, starting at 25 s of infusion and maintained durably for >2 min. The intensity of this enhancement was relatively comparable as aorta that was seen in the same echographic plan. Microcirculation was particularly well visible through the microbubble movement (). Polyp resection was indicated to prevent aspiration. The endoscopic resection was performed twice (, ) after obtaining the patient’s consent. We chose to start by applying a large clip INSTINCT (Cook Medical Inc., Winston-Salem, NC, USA) at the base of the polyp to prevent bleeding and to maintain the remaining pedunculated mucosae closed. Adrenalin was injected in the downstream part of the peduncle before its coagulation (30 W) and resection (Endocut Q effect 5) by using a 30-mm snare. Neither early nor late complication occurred. Histopathological examination showed a well-differentiated adipose tumor with a superficial network of small vessels, that raises a hypothesis of a lipoma or an atypical lipoma (). Neither mitotic figure nor necrosis or infiltration of surrounding tissue was present. Degenerative cyto-nuclear atypias were present. There was no MDM2 amplification (ZytoLight SPEC MDM2/CEN 12 Dual Color Probe; CliniSciences, Nanterre, France) by fluorescence in situ hybridization, which excludes an atypical lipoma. Numerous dilated vessels were present under the surface epithelium, explaining the intense enhancement with the contrast agent. After three months, control endoscopy showed the remaining peduncle without the clip.


A 62-year-old man underwent bilateral common femoral endarterectomy and aortobifemoral bypass for severe claudication secondary to extensive atherosclerosis. On postoperative day 1, he developed melena and hematochezia. Emergency colonoscopy demonstrated severe ischemia of the proximal colon and severe circumferential ischemic proctitis. Due to severe hypoxia, hypotension, and lactic acidosis, exploratory laparotomy was performed on postoperative day 2. Necrosis of the distal ileum and cecum was identified, and these segments were subsequently resected. Dusky areas in the remainder of the small bowel and colon were left intact, pending future operative evaluation. On the following day, the patient developed multi-organ failure, and a second-look exploratory laparotomy was performed. Diffuse small bowel and ascending colon necrosis was identified, and these segments were resected. Intraoperatively, the patient became acidotic and hyperkalemic, and upon transport to the intensive care unit, the patient expired.


The patient is a 27-year-old male with no significant past medical history. He presented to the emergency room with a 24-hour history of lower abdominal pain, nausea, and vomiting. On clinical examination, a febrile, tachycardic and dehydrated patient was encountered. He reported pain on his right lower quadrant with a positive Mcburney sign and localized abdominal tenderness. Laboratory blood analyses revealed leukocytosis with neutrophilia. With these findings, acute abdomen due to appendicitis was suspected, and surgery was decided.
Intravenous antibiotics were commenced preoperatively and a Mcburney incision was made, multiple adhesions were found near the cecum, and the cecum wall appeared hyperemic with intense inflammation near the base of the appendix. After blunt dissection, two 3 cm toothpicks were discovered, one that perforated the appendix wall near its base and another one that jeopardized the cecum wall (Figs –).
Surgery was straightforward from this point. The toothpicks were carefully removed, an appendectomy was performed, and the perforation at the base of cecum was repaired with an absorbable suture and covered with an omental patch. An extensive washout with saline solution was carried out and the remainder of the procedure was completed without complications (Fig. ).
After surgery, the unusual discovery was reported to the patient. However, he didn’t recall swallowing the toothpicks. His postoperative course was uneventful, and he was discharged after a full diet was tolerated. In follow-up controls, the patient shows signs of recovery, and still has no memory of having ever swallowed the toothpicks.


A 45-year-old healthy woman initially presented with acute onset of right upper quadrant abdominal pain and subjective fever. Physical findings and abdominal ultrasound were consistent with acute cholecystitis and percutaneous drainage of the gall bladder was planned. A routine preprocedure electrocardiogram (EKG) was obtained (Figure A) and revealed sinus rhythm with a PR interval of 118 ms with preexcitation. The delta wave was positive in the inferior leads except for lead III, positive in I and aVL, and had an R wave transition at V3 consistent with a midseptal accessory pathway (AP).
On further history, the patient noted 5 episodes of palpitations over the preceding 4 months. Episodes had an abrupt onset, lasted for ten to twenty minutes, and abruptly terminated. The episodes were associated with lightheadedness, but the patient denied syncope. The patient underwent gall bladder drain and ultimately cholecystectomy. Two months later, she was brought to the electrophysiology laboratory. An EKG was repeated prior to testing. This revealed sinus rhythm with preexcitation different than previously noted. The delta wave was positive in all inferior leads, positive in I and aVL, and had an R wave transition at V4. This suggested an AP at a more anterior location (Figure B).
After informed consent was obtained, she was referred for electrophysiologic study. Baseline HV interval was 0 ms with manifest preexcitation. During incremental atrial pacing , there was a change in the preexcitation pattern following an atrial premature contraction (Figure A). During atrial extrastimuli testing, there was a change in the preexcitation pattern following a premature beat at 400 ms indicating effective refractory period (ERP) of the first AP; with an even more premature beat at 330 ms, the ERP of the second AP was reached (Figure A,B). During ventricular extrastimuli testing, change in retrograde atrial conduction also indicated more than one pathway (Figure B,C). A short RP tachycardia at a cycle length of 262 ms and VA time of 84 ms was induced with incremental atrial and ventricular pacing (Figure D); ventricular overdrive pacing generated a VAHV response and the tachycardia was advanced and reset with His synchronous premature ventricular contractions (PVCs). These findings were consistent with orthodromic reciprocating tachycardia (ORT).
The AP was mapped during sinus rhythm. The earliest ventricular activation was recorded in the anteroseptum; with ablation, there was a change in preexcitation (Figures C and A). Additional mapping identified early signal along the anterior tricuspid valve annulus (approximately 10 mm from prior ablation site); ablation at this site resulted in complete loss of preexcitation (Figure D and B). There were more obvious changes in the preexcitation pattern upon reaching ERP of the first AP (Figure A,B) compared to when the first AP was ablated (Figure C) probably on account of more delay and less fusion with atrioventricular (AV) nodal conduction during atrial extrastimuli testing. No return of AP conduction was found during a 25 minute waiting period and following isoproterenol infusion. On follow-up, her resting EKG showed no preexcitation.


A 12-year-old boy with a large retroperitoneal sarcoma with bilateral obstructive uropathy was planned for bilateral ureteric stenting. His preoperative serum creatinine was raised and coagulation parameters were normal. Cystoscopy showed a deformed bladder with severe bullous edema of the trigone. Both the ureteric orifices could not be identified on cystoscopy; hence, a decision of antegrade ureteral stenting was taken. Based on the preoperative plain computed tomography (CT) scan determined landmark of the renal pelvis, a Chiba-needle puncture was made 5 cm lateral to the midline at the level of the third lumbar vertebra. Once the right pelvicalyceal system was opacified, mid calyceal puncture was made using an 18G three-part percutaneous access needle (Surgimedik Healthcare India Pvt. Ltd, Mumbai, India). Guidewire could be negotiated into the bladder, and antegrade double-J stent was placed. A similar procedure was performed on the left side. The procedure was uneventful.
Postprocedure, the patient had a progressively increasing abdominal distension, right flank pain, and hypotension. Bedside ultrasonography indicated a large right perirenal hematoma. Contrast-enhanced CT scan confirmed the hematoma [] and demonstrated active contrast leak from the right lumbar artery during the arteriography phase of the CT scan. Renal vessels appeared normal. In view of the dropping blood pressure and hemoglobin levels, a decision of angioembolization was taken.
Transfemoral aortography and renal angiography were performed. Renal vasculature was normal. Selective catheterization of the second right lumbar artery confirmed the extravasation of contrast solution from the middle part of the anterior branch of lumbar artery. The bleeding vessel was embolized using polyvinyl alcohol particles (Boston Scientific Target Therapeutics, California, USA). Posttranscatheter embolization, the pain reduced and blood pressure stabilized. There was no increase in the size of hematoma over a 1-week hospitalization period.
The second patient was a 45-year-old recently diagnosed patient of chronic kidney disease. An ultrasonography controlled renal biopsy was performed. Immediately after the biopsy, the patient complained of significant flank pain with hypotension. An urgent CT scan was performed that showed a large left perirenal and retroperitoneal hematoma with bleeding from the left lumbar artery []. Transfemoral aortography and renal angiography confirmed the renal vessels to be normal. Active bleeding was documented from the second left lumbar artery. He was also managed by an emergency transcatheter angioembolization of the lumbar artery using gelatin foam (Gelfoam, Upjohn, Kalamazoo, MI, USA). Postembolization, the hematoma stabilized, pain reduced, and blood pressure stabilized. At 3-month follow-up, ultrasonography showed a small residual hematoma.


A 14-year-old female patient reported to the Department of Oral Pathology with a chief complaint of swelling on the left side of the face since 4 months. She had a previous history of a similar lesion at the same site 9 months back, which was excised by a private practitioner and was histopathologically reported as neurofibroma. The swelling appeared again after 5 months, which was initially small and gradually increased in size over a period of 4 months. There was evidence of rapid growth in the past 1 month. The patient took non-conventional medicine for the same, but the swelling kept on increasing in size. It was associated with mild and intermittent pain, the intensity of which increased with time. The patient’s medical, family, and habit history were unremarkable. On extraoral examination, diffuse swelling was present on the left side of the face extending from midline to 4 cm posteriorly toward the outer canthus of eye and from corner of mouth to 4.5 cm superiorly toward the inferior orbital margin and was causing deviation of the nasal septum to the right side (). The swelling was firm and tender with normal color and texture of the overlying skin. The mouth opening was found to be normal and lymph nodes were not palpable.
Intra-oral examination revealed a well-defined soft tissue swelling of size 3 cm × 3.5 cm in the maxillary anterior region extending from distal aspect of 11 to distal aspect of 24 with erythematous overlying labial mucosa that was fixed to the swelling. It was firm in consistency and tender on palpation causing palatal displacement of 11, 21, 22, and 23. Grade I mobility was observed in these teeth ().
Orthopantomogram showed no bony changes, except displacement of teeth 21 and 22. Contrast-enhanced computed tomography (CECT) revealed heterogeneously enhancing mass measuring 4 cm × 4.5 cm × 5 cm in size anterior to the left maxillary sinus with destruction of its anterior and medial wall. The lesion was extending into the left maxillary sinus. It was indenting over the left inferior turbinate and extending into the left anterior nasal cavity ().
The histopathologic examination of the incisional biopsy taken from the lesion revealed highly cellular tumor tissue composed of intersecting fascicles of spindle-shaped cells. Cells in cross section showed vesicular nuclei with vacuolar degeneration of the cytoplasm (). Few hyperchromatic nuclei and mild nuclear pleomorphism were also observed. Increased and abnormal mitotic activity was observed throughout the lesion. The nuclei varied from ovoid to blunt-ended with spherical nuclei also observed at places. The minimal supporting stroma was fibro collagenous with variable vascularity. The tumor tissue was separated from overlying parakeratinized stratified squamous epithelium by fibrous tissue. Tumor cells were diffusely positive for pan-cytokeratin (AE1/3) and vimentin and negative for S100, smooth muscle actin (SMA), Desmin, bcl-2, and CD99 ( to ). Absence of osteoid with these findings pointed toward the diagnosis of monophasic variant of synovial sarcoma.
The patient underwent segmental resection of the left maxilla. On histopathologic examination of the resected tissue, hypercellular, and hypocellular areas were noted. The hypercellular areas were composed of spindled to plump fibroblasts. At areas, these cells showed Herring bone pattern intersecting at right angles with scarce cytoplasm, vesiculated nuclei, and exhibiting cellular and nuclear pleomorphism and nuclear hyperchromasia. Two to four abnormal mitotic figures were observed per 10 high power fields (). Malignant osteoid formation was seen only at foci ( and ). A few tumor giant cells were seen in close approximation with the tumor osteoid.
The remaining connective tissue stroma was hypocellular, showing loosely arranged collagen fibers in whorled pattern. Mild diffuse infiltration of chronic inflammatory cells was seen throughout the connective tissue. Peripheral area showed degenerated muscle fibers exhibiting fragmentation and loss of striation. The lesional tissue was moderately vascular with deeper area comprising intact muscle tissue and many neurovascular bundles. All surgical margins were negative for tumor tissue. The tumor cells were positive for vimentin and pan-cytokeratin and negative for EMA (, , and ). A differential histopathologic diagnosis of monophasic synovial sarcoma and fibroblastic OS was considered. Furthermore, the tissue was subjected to fluorescent in situ hybridization (FISH), which was negative for SYT gene translocation. Hence, the final diagnosis was signed out as fibroblastic variant of OS. The patient was referred to an oncology center for further treatment involving chemotherapy.


A 14-year-old boy presented with pain in the right hypochondrium for 5 months, associated with hepatomegaly. Ultrasonography of the abdomen revealed multiple, predominantly hypoechoic liver lesions. Contrast-enhanced magnetic resonance imaging (CEMRI) of the abdomen showed moderate ascites and hepatomegaly with multiple mass lesions in both lobes of the liver with restricted diffusion and peripheral enhancement on arterial and venous phases. In view of the US and CEMRI findings, suggesting hepatic EHE, the patient was planned for liver transplantation. Subsequently, 18F-FDG PET/CT was performed for lesion characterization and evaluation of disease extent []. An ultrasound-guided fine-needle aspiration cytology, performed on the liver lesion, revealed hemangioendothelioma on histopathological examination. With the diagnosis of metastatic hepatic EHE, the transplant was deferred, and the patient was advised for chemotherapy.


A 38-year-old male patient, businessman by profession, presented to the outpatient department with a chief complaint of diffuse and continuous pain in the left ankle and difficulty in walking since the past 6 months. The pain was more on lateral aspect of ankle and more in the night time. There was no history of trauma, fever, loss of weight, and loss of appetite. He was taking tablet aspirin orally as when required, which helped him to get relief from pain. On examination, there was local tenderness and mild swelling at the anterolateral aspect of ankle. Ankle movement was full with dorsiflexion terminally painful. On radiological examination, X-ray showed osteosclerotic lesion around a central lucent area suspicious of OO with nidus in the medial aspect of distal fibula at the level of ankle joint []. CT scan showed the nidus with surrounding reactive sclerosis in the left distal fibula []. Three phase bone scan and SPECT-CT using Technetium-99m (Tc-99m) methylene diphosphonate were also done. Three phase bone scan showed increased tracer accumulation in the left ankle joint []. However, the increased tracer uptake was diffuse heterogeneous in pattern and was not specific to OO. Therefore, SPECT-CT was performed, which localizes most focal uptake to a sclerotic lesion with central nidus in the left distal fibula anteromedially [Figures and ]. The lower grade diffuse uptake localized to the ankle joint, likely due to articular changes because of pain. This confirmed the diagnosis of OO in the left distal fibula.
We decided to perform an open procedure using anterolateral approach to excise the lesion along with the reactive bone, sparing the syndesmosis, and articular cartilage. The patient was placed in supine position with a sandbag under the affected side buttock under regional anesthesia with pneumatic tourniquet at the thigh. A longitudinal incision of 5 cm was given at the anterior border of fibula the ankle joint, and distal fibula was exposed. The nidus location was identified by reactive cortical bone area of about 0.5 cm × 0.5 cm and further confirmed by fluoroscopy. The lesion was excised and sent for histopathology study. Adequate care was taken to prevent injury to syndesmosis joint and articular cartilage of fibula.
Postoperatively, the patient was comfortable, and the earlier specific type of continuous pain was disappeared except for surgical site pain which was reducing gradually. The patient was advised for full weight bearing mobilization. At 2 weeks, stitches were removed, and at that time the patient was absolutely pain free. Postoperative X-ray showed complete excision the lesion. Histopathological examination confirmed the diagnosis of OO of distal fibula. The patient was followed up at 1, 3, and 6 months’ postsurgery and there was no evidence of any recurrence.


A 62-year-old female visited our department for the treatment of moderate psoriasis vulgaris of 2 years. Six months after starting secukinumab, an IL-17 A inhibitor, alopecia diffusa began to cover her whole scalp (Fig. ), although her skin symptoms due to psoriasis had completely disappeared by then. Her medication was switched to brodalumab, an IL-17R antagonist, but her loss of hair continued. Then, 10 mg oral prednisolone was supplemented, and this stopped her loss of hair and she recovered from her alopecia (Fig. ). Psoriasis is also well-controlled until today. Her antinuclear antibody test was negative.
Our other patient was a 40-year-old female with the history of breast cancer. Moderate type psoriasis vulgaris had occurred 12 years ago, and we treated her with brodalumab. Her skin eruption disappeared quickly, but alopecia diffusa started after 2 months (Fig. ). We changed her medication to ustekinumab, an IL-12/23 p40 inhibitor, and her hair recovered without the administration of oral immune suppressants (Fig. ). No relapse of alopecia has been observed. Her antinuclear antibody test was negative.


A 75-year-old male was referred to the Emergency Department from his GP, with possible diverticulitis. He had been unwell for the past 2 weeks, with intermittent lower abdominal pain. There was no associated nausea or change in bowel habit. He denied any recent ingestion of meat or fish bone. His medical history was significant for hypertension, cardiomyopathy and rheumatoid arthritis. His regular medications included clopidogrel. His last colonoscopy was performed 10 years ago for surveillance which was unremarkable.
On examination, the patient was haemodynamically normal and afebrile. He had a soft non-peritonitic abdomen, which was mildly tender in the lower abdomen. Rectal examination was normal. His bloods on admission demonstrated an elevated white cell count 13.2 × 109/l (reference range 3.9–11.1), with rest of the blood work unremarkable.
The patient had an outpatient intravenous contrast-enhanced CT abdomen and pelvis (Fig. ) which demonstrated extensive sigmoid diverticulosis, with diffuse mural thickening and surrounding inflammatory stranding. The surrounding inflammatory changes extended towards a loop of adjacent small bowel. Within the sigmoid lumen at the site of these changes, was noted to be a linear dense foreign body.
The patient was admitted to hospital and commenced on intravenous antibiotics. The following day he underwent a flexible sigmoidoscopy, which demonstrated multiple small and large diverticulum in the sigmoid colon. A foreign body was found in the sigmoid colon at 28 cm from the anal verge, suggestive of ingested bone (Fig. ). The foreign body appeared to be lodged within a diverticulum. Adjacent to this, was a localized area of moderately inflamed mucosa, possibly reactive to the foreign body. No obvious entero-colonic fistula was identified. Biopsies were taken of this inflamed area, which later demonstrated on histopathology to be consistent with non-specific reactive changes. The foreign body was retrieved successfully endoscopically using tripod forceps (Fig. ).
The patient recovered well post-operatively and was commenced on a regular diet. He continued on intravenous antibiotic therapy until his discharge from hospital on Day 2 post-procedure.


This is a 45-year-old male patient with the diagnosis of squamous carcinoma of the tongue originally manifested as oral leukoplakia in the right lingual area, treated with laser vaporization for several years. A head and neck MRI revealed tumor-related lymphadenopathies. Due to the extension of his disease, the patient underwent a partial right glossectomy and functional neck dissection.
During the postoperative period, the patient experienced severe (VAS 80–90) and persistent pain in the anterior neck region. The pain was treated for several years in other pain centers with neuromodulators to include gabapentinoids, tricyclic antidepressants and opioid analgesics with minimal results. The patient continued to report severe pain during his initial visits (VAS 90), localized in the retroauricular and occipital areas, as well as the upper region of the chest and shoulder. The pain was described as severe, neuropathic in nature associated with dysesthesia, allodynia, hyperalgesia, but no hypoesthesia. He also mentioned increased pain with ipsilateral rotation of the head to the affected side.
Physical examination showed dysesthesia in the territory of the following nerves: great auricular, transverse cervical and supraclavicular nerves. The patient experienced severe allodynia over the territory of the superficial cervical and supraclavicular nerves. The examination did not disclose any areas of hypoesthesia. The patient did not present any signs of motor deficits in the upper extremities, and the reflexes were normal.
With these symptoms and physical examination findings, the patient was diagnosed with chronic postoperative pain associated with the alteration of his cervical plexus. Pharmacological therapy with amitriptyline 50 mg each 24 hrs, pregabalin 150 mg each 12 hrs and tapentadol 100 mg each 12 hrs was kept during the interventional procedure.
In view of the patient’s refractoriness to the pharmacological treatment, he was offered an ultrasound-guided cervical plexus block using local anesthesia with the purpose of confirming the diagnosis. We have informed the patient about the risks and benefits secondary to the treatment with cervical plexus block and even with a possible treatment with PRF. Institutional approval (CEA EOXI from Clinic Hospital of Santiago de Compostela) was required to publish the case details and we got the patient written informed consent for publication of the case details and any accompanying images.
For the cervical plexus block, we have applied a total amount of 5 mL 0.25% levobupivacaine applied between the superficial and the deep (prevertebral) cervical fascia over C4 and C6 levels using ultrasound guidance (the protocol to identify those levels with ultrasound guidance was identifying the C7’s transverse process and since that level we have counted the different levels until arriving at C4). The goal of using such a limited volume of medication was to evaluate the ability of nerve blocking to obtain pain control and after that apply some type of radio frequency with consistent options.
At the 4-week follow-up visit, the patient reported complete resolution of his symptoms during the first 2 weeks (VAS 0). After the first 2 weeks, the pain level started to increase, reaching VAS of 20 (during the last 2 weeks). The presumed diagnosis was confirmed in view of this improvement, and a third visit was scheduled 2 weeks after. During Visit 3 (6 weeks postdiagnostic block), the patient reported recurrence of his pain to the preprocedure baseline status. Having confirmed the diagnosis using the blockade, and in view of the short duration of the patient’s improvement, he was offered the application of PRF jointly with a 5-mL injection of 0.25% levobupivacaine.
The procedure was performed in a surgical room under ultrasound guidance and local anesthesia. PRF of the cervical plexus was carried out in the interfascial compartment at C4 level (). PRF protocol was the following: 8 mins of PRF on each branch, applying 45 V, with temperature control at 42°C, and with a pulse width of 20 ms. After the PRF application, a total volume of 5 ml of local anesthetic (levobupivacaine 0.2%) was deposited at treated levels.
The patient was given a follow-up appointment on weeks 4, 12 and 24 post radiofrequency application (Visits 4, 5 and 6). The test results can be seen in . With this result, we have reduced pharmacological therapy. We have discontinued tapentadol treatment, amitriptyline was reduced until 10 mg each 24 hrs and pregabalin was reduced until 75 each 12 hrs.


A 50-year-old healthy female came with a complaint of gradual painless diminution of vision associated with a floater in her left eye from the last one month. On examination, her visual acuity was found to be CF 3/4M Vision in the Left Eye and CF — M in the left eye. Anterior segment examination was unremarkable with intraocular pressure 19 mmHg in the right eye and 9 mmHg in the left eye. Fundus examination revealed myopic tessellated fundus with macular degeneration with the presence of an oval greyish lesion inferior to the macula within the deep posterior staphyloma symmetrically in both eyes [Fig. and ]. The right eye also showed macular hole with retinal detachment. The left eye showed macular hole with Bullous Retinal Detachment extending from 11 to 7’o clock hr with choroidal detachment as evident on Bscan [Fig. , , and ].
A spectral domain OCT was performed and confirmed the presence of macular hole with retinal detachment in both eyes along with the presence of deep macular staphyloma []. Interestingly, deep within the base of the staphyloma on SD–OCT, there was further deep excavation within the staphyloma with thin RPE and choroid which was bilaterally symmetrical suggestive of choroidal coloboma [Figs. , , and ]. This coloboma was corresponding to the oval dark grey excavation seen clinically inferior to the macula and was found to be symmetrical in both eyes. She underwent Encirclage with Pars Plana Vitrectomy with Silicon oil injection. The ILM peel was not done in this case as the posterior staphyloma was too deep and could not be reached.
She improved to 6/36 in the left eye three months post-surgery with maintenance till the last follow up six months later. After surgery, the thin retina was seen to be completely reattached along its contour without any gap even over the colobomatous area [Fig. and ]. There was no surgery done for the right eye as the patient complained of the visual loss from the last 30 yrs or so and was thus considered to be amblyopic and, hence, had nil visual prognosis.


Our patient is a 16-years-old boy born at term after uneventful pregnancy and delivery, from non-consanguineous, healthy parents. Following a normal early psychomotor development, since 5 years of age he has started to toe walk, with constant, progressive difficulties in walking.
His last neurological examination shows distal lower limbs hypertonus, bilaterally brisk tendon reflexes in his lower limbs and extensor plantar reflexes, no clonus, cavovarus supinated feet, postural/intention tremor in his upper limbs, hypotrophy of the intrinsic hand muscles and of the peroneal and extensor digitorum brevis (EDB) muscles. MRC muscle strength is mildly reduced (4/5) in the peroneal/extensor, thumb abductor/adductor, intrinsic and orbicularis oculi muscles. EMG/ENG shows a sensori-motor polyneuropathy in all four limbs.
The patient has undergone serial, non-contributory diagnostic investigations, including brain and spine MRI, full ocular examination, audiometric evaluation, array-CGH, vitamin E dosage, urinary organic acids profile, molecular testing for SPG3A. Somatosensory evoked potentials (SSEP) in the lower limbs are in keeping with bilateral central conduction delay.


A 46-year-old female patient reported to the outpatient department of our hospital complaining of pain and swelling over the right middle-third region of the face for 1 month. Past dental history revealed extraction of 48 1 month back, after which she noticed a painful swelling which was initially peanut in size and gradually increased to attain the present size. Past medical history was noncontributory and general physical examination revealed no abnormality.
Extraoral examination revealed facial asymmetry on the right side of the face. On inspection, a solitary, diffuse swelling over the middle-third region of the face was noticed []. The overlying skin appeared to be normal. Swelling was roughly oval measuring approximately 5 cm × 6 cm, extending superioinferiorly from 1 cm below the infraorbital margin to lower border of the mandible and anteroposteriorly from 0.5 cm away from ala of the nose to tragus of the ear. On palpation, all the inspectory findings were confirmed and the swelling was soft to firm in consistency. Single right submandibular lymph node was palpable, which is nontender and firm in consistency measuring approximately 1.5 cm × 1 cm.
Intraoral examination [] revealed a well-defined solitary erythematous growth in the right retromolar region at the previous extraction site. The lesion was extending posteriorly from distal aspect of 47 to retromolar pad, measuring approximately 3 cm × 3 cm. On palpation, all the inspectory findings were confirmed and growth was soft to firm in consistency with smooth surface and well-defined margins.
Orthopantamograph [] revealed ill-defined radiolucency encompassing entire right side of the mandible extending posteriorly from 47 to ramus, angle, coronoid and condylar process. Reconstructed computed tomography scan revealed large expansile lytic lesion with irregular borders on the right posterior mandible region []. Appreciable erosive changes of alveolar surface posterior to 47 were noted. Medial aspect of the ramus was completely resorbed []. Based on the above clinical and radiological findings, a provisional diagnosis of intraosseous carcinoma of the right retromolar area was given. However, central giant cell lesion and osteosarcoma were considered in the differential diagnosis.
An incisional biopsy was performed and sent for histopathological examination. Histopathology revealed solid sheets of densely packed, uniformly appearing round-to-ovoid cells with eccentrically placed nucleus resembling plasma cells []. These plasma cells are scattered over background of numerous lymphocytes with relatively sparse stroma. Anaplastic cells with hyperchromatic nucleus and occasional binucleated forms [] suggesting malignancy were also observed. Based on the above findings, a histopathological diagnosis of plasmacytoid non-Hodgkin's lymphoma was given. Differential diagnosis of plasmacytoma and large-cell lymphoma of immunoblastic type was considered.
To confirm the diagnosis, laboratory investigations such as routine blood investigations were performed which revealed elevated serum-free lambda light chains to 325.9 mg/L where the normal levels range from 5.71 to 26.30 mg/L. Based on laboratory findings, the final diagnosis of solitary plasmacytoma of the mandible was given which was then confirmed by immunohistochemistry which revealed strong positivity for CD138 [], MUM1 [], variable cell membrane positivity for CD45 [] and negativity for CD20 [].


A 24-year-old, primigravida was referred to us at 24 weeks of gestation, as a case of AIHA, first diagnosed during pregnancy. Initially she was presented with fatigue and dizziness and low hemoglobin (Hgb) with no history of any medical illness or surgery. She had not been started on any new medications and had no family history of hematological diseases. Initial laboratory tests showed white blood cell (WBC) count 22.9 x 109/L, red blood cell (RBC) count 2.68 mcL, hemoglobin (Hgb) 7.7 g/dL (normal: 120-160 gm /L, platelet count 545000 (normal: 150-400X10A9 /L), reticulocyte percentage 18.63 (normal: 0.5-2.5%), lactate dehydrogenase (LDH) 567 U/L (normal: 125- 243U/L), and total bilirubin 44.1 (normal: 3.4-20.5 umol/L. Kidney function tests were within normal limits, and the direct Coomb’s test was positive. Viral serology, anti-nuclear antibodies, anti-double stranded DNA antibodies, anti-lupus, anti SS-A, anti SS-B were all negative. Ultrasound showed a normal fetus with size corresponding to gestational age. However, the maternal right ovary was enlarged, measuring 7.7 x 7 cm. A complex cyst measuring 6.7 x 6 cm was seen within the ovary, and was thought to be a dermoid cyst ().
She received high dose steroids (started by prednisolone 100 mg) with no significant improvement. Rituximab once a week four doses and intravenous immunoglobulin 3 doses were added, without any success. Hemolysis was refractory a trail of Azathioprine post delivery. Transfusion of multiple packed red blood cells (PRBCs) reached 44 units.
During follow up, the patient received a total of 44 units of PRBC for refractory low Hgb level. At 36-37 weeks of gestation, ultrasound revealed fetal pericardial effusion, and a slightly enlarged dermoid cyst.
Induction of labor was carried out and she uneventfully delivered a healthy baby vaginally. Postnatal echocardiography revealed no pericardial effusion and no other significant abnormalities.
Postpartum, Hgb level dropped from 11.0 g/dl to 7.0 g/dl. Azathioprine and prednisone, along with 6 units of PRBC were transfused. Two weeks later, the patient was seen on outpatient basis, with condition having worsened, with Hgb level having dropped further, to 6.1 g/dl.
Laparoscopic right ovarian cystectomy was performed and intraoperative findings of right ovarian dermoid cyst were confirmed on histopathological examination. Postoperatively, she improved significantly; signs and symptoms of anemia reduced and Hgb level increased up to 13.8 g/dl, while LDH levels dropped to 169 ().


Our patient was a 19-year-old male who presented for a general medical exam and blood
pressure check prior to leaving for college. He was overall healthy and active. He
noted high blood pressure readings at home but did not remember specific details. He
also reported occasional frothy urine. He noted no other symptoms. He denied
alcohol, tobacco, and drug use. He was taking a multivitamin and fish oil as well as
occasional acetaminophen. He had a family history of hereditary nephritis in his
mother that resulted in 2 kidney transplants, the first at age 30 years. His
paternal grandfather had the same disease. He did have urine testing at age 4 that
was normal without signs of hereditary nephritis. During a routine visit at age 13,
he had a blood pressure reading of 140/88 mm Hg, which was greater than the 95th
percentile for height and age. At that visit, he had screening labs with a fasting
blood sugar of 93 mg/dL, creatinine of 0.7 mg/dL, and a normal urine dipstick.
On his physical exam, his blood pressure was 130/88 mm Hg and pulse was 59. His body
mass index was 26.9 kg/m2. He was a well appearing young adult. His
cardiovascular exam was normal without murmurs and his respiratory exam was benign.
His neurologic exam was normal. He had no edema, skin rashes, or musculoskeletal
abnormalities noted.
Because of the patient’s history of elevated blood pressures and family history of
kidney disease, we obtained basic labs, including a thyroid-stimulating hormone
(TSH), creatinine, sodium, potassium, and urinalysis. TSH and electrolytes were
normal. His creatinine was 1.3 mg/dL (range 0.6-1.3 mg/dL). His urinalysis showed
protein of 237 mg/dL, trace hemoglobin, and fatty casts. He returned for further
discussion and repeat urinalysis, which again showed proteinuria. An in-depth
history was obtained that was unrevealing for a cause of his proteinuria with the
exception of his family history. He underwent a 24-hour urine collection that showed
7 g of protein. His liver enzymes were within normal limits. He subsequently was
evaluated by Nephrology who performed additional testing, including coagulation
studies that were normal and a kidney biopsy. His kidney biopsy showed focal
segmental glomerulosclerosis (FSGS) with moderate chronic changes including focal
global glomerulosclerosis and moderate tubulointerstitial scarring. He was diagnosed
with FSGS thought to be hereditary. Given his strong family history of kidney
disease, he visited with Medical Genetics and is in the process of undergoing
genetic testing.


A 3-year-old female was admitted to a pediatric hospital with nausea, vomiting and hepatomegaly. A percutaneous tumor biopsy established the diagnosis of hepatoblastoma. Shortly after the biopsy, the patient underwent emergency laparotomy and liver packing due to hemoperitoneum, once she was hemodynamically stable, she was referred to our center and admitted to the ICU in respiratory distress that required mechanic ventilation.
Tumor staging revealed a PRETEXT IV hepatoblastoma (Fig. a) with Alpha-fetoprotein (AFP) levels of 1 059,240 ng/ml. After 15 days in the ICU, when the patient’s condition had improved, we initiated NACT (3 courses of Doxorubicin and Carboplatin). At its completion, the AFP levels had decreased to 1 573 ng/ml and a follow-up CT scan showed tumor involvement of segments 1-7 except for s6 (POST-TEXT IV). The latter segment was vascularized through the IRHV but it was deemed insufficient (FLR 21.34%) (Fig. b). The absence of a liver donor within reasonable time prompted a multidisciplinary committee meeting that approved an ALPPS procedure after securing informed consent from the parents.


A 69-year-old male, with a history of 30 years of smoking, presented on 9 April 2015 suffering from an intense chest pain for half a day. After several tests, his positron emission tomography/computed tomography on 16 April 2015 showed right lung lesion without pancreas lesion () and left lung lesion (). During that period his carcino-embryonic antigen level was 26.80 ng/mL (normal range <4.70 ng/mL) and his carbohydrate antigen 199 was 17.46 U/mL (normal range <39.00 U/mL). He underwent right upper lobectomy and left upper lobectomy, on 23 April 2015 via thoracoscopy. Histologically, the right and left lesions were 4.0 × 3.0 × 3.0 cm and 1.3 × 1.0 × 0.6 cm, respectively; both were adenocarcinomas. The right adenocarcinoma had directly invaded the right bronchus. Lymph node metastasis was found near the bronchus (1/7). Stage IIIa (pT3N1M0) is for the right lung adenocarcinoma of alveolar type and stage I (pT1N0M0) is for the left lung adenocarcinoma of alveolar type. Post-operative course was uncomplicated. The patient underwent four cycles of chemotherapy based on ‘Pemetrexed 950 mg d1 + Cisplatin 40 mg d1–3’. No evidence of any recurrence was apparent during subsequent follow-up until March 2017. Positron emission tomography/computed tomography scan showed abnormal fluorodeoxyglucose metabolism only from the pancreatic body to the tail and a lesion at the body of the pancreas (). Computed tomography scan showed a normal sized pancreas with normal form and a hypodense area on the body of the pancreas, which was slightly enhanced compared with normal pancreatic tissue, of diameter 1.1 cm, and slight dilatation of distal pancreatic duct (). On second admission, carcino-embryonic antigen and carbohydrate antigen 199 levels were 36.13 ng/mL (normal range < 4.70 ng/mL) and 46.93 U/mL (normal range < 39.00 U/mL), respectively. On laparotomy, the mass was found to be at the body and tail of the pancreas. Distal pancreatectomy with en-bloc splenectomy was carried out on 16 March 2017. Immunohistochemical demonstrated metastatic lung adenocarcinoma of intermediate differentiation measuring 1.5 × 1.2 × 1 cm, thyroid transcription factor-1(+) (), Napsin A (+) (), cytokeratin 7 (+), cytokeratin 20 (−), Villin (−), Ki-67 (>30%+). The margins were negative. The final diagnosis was metastatic pancreatic carcinoma from lung adenocarcinoma (). The patient was discharged on the 18th post-operative day. On 29 April 2017 (25th postoperative day), he began chemotherapy, based on ‘Anzatax 270 mg d1 + Paraplatin 560 mg d1’ for four cycles. After the four cycles, the agent Anzatax was changed to gefitinib as maintenance therapy. On 11 May 2017 (56th post-operative day), the patient was readmitted because of abdominal effusion at the surgical region. Computed tomography-guided abdominal drainage for abdominal effusion was applied on 12 May 2017. So far, no other abnormalities have been found in the patient during follow-up for a period of nearly two years.


A 52-year-old female presented with a sudden onset of right-sided numbness and weakness that was accompanied by a left temporal cluster-like headache. No fever or prodromal infection was found at disease onset.
The family and personal history was unremarkable.
On physical examination, the height and weight of the patient were 154 cm and 56 kg, respectively. Vital signs were normal, as were heart, lung and abdominal exami-nations. Neurological examination showed intact mental status, with normal speech and comprehension. Mild 4/5 right-sided hemiparesis was present with normal tone in both the arm and leg, though no other focal neurological deficits were found. After admission, she complained of discomfort and tingling in the right leg, after which a generalized tonic-clonic seizure for 3 min occurred before it was stopped by a bolus of intravenous diazepam.
Laboratory tests, including D-dimer, lactic acid, and serum autoantibody levels, as well as thyroid function and tumor markers indicated no apparent abnormalities. Glucose tolerance and lactic acid movement tolerance tests were normal. A lumbar puncture was performed, and her open intracranial pressure was 180 mm H2O. Cerebrospinal fluid (CSF) testing showed that cell counts and protein, glucose, chloride, monoclonal antibody, adenosine deaminase, and lactate dehydrogenas levels were within normal ranges.
MRI demonstrated a lamellar left parietal lobe lesion predominantly involving the cortex, with hyperintensity on both diffusion-weighted imaging and fluid-attenuated inversion recovery (Figure ). The apparent diffusion coefficient map revealed a preserved, isointense signal. No abnormalities were found by susceptibility weighted imaging or magnetic resonance angiography and venography (Figure ). Due to the stroke-like onset pattern and MRI features, further thrombophilia screening was performed and showed decreased protein S activity. A diagnosis of cortical venous thrombosis was first proposed. Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) was also considered but temporarily excluded because of the incomplete manifestation and lack of genetic evidence. Anticoagulation therapy was initiated, and follow-up was performed to maintain the international normalized ratio (INR) within the target range.
Two months later, the patient was readmitted for subacute cognitive impairment. She was unable to identify and communicate with family members; she also had difficulty understanding questions or instructions and instead responded by repeating the word "nothing". During hospitalization, a secondary generalized seizure occurred, initially with eyes gazing to the right and then convulsion developing, which lasted for approximately 10 s before self-alleviation. Neurological examination suggested transcortical sensory aphasia, with fully covered limb strength. Blood tests and CSF examination were normal; INR was 2.21. On repeated MRI, new lesions were identified in the left temporal lobe and were also detected 10 days later in the right temporal lobe on radiological follow-up (Figures and ). Although the MRI signal characteristics are consistent with the initial findings, the original lesion in the left parietal lobe had been alleviated, with cortical atrophy. We further conducted magnetic resonance spectroscopy (MRS), which revealed markedly elevated lactate (Lac) concentrations in the regions of interest in the left temporal lesion (Figure ). Mitochondrial encephalopathy was diagnosed, and genetic testing using peripheral blood was performed. However, DNA testing for frequent MELAS and myoclonic epilepsy with ragged red fibers syndrome mutations were negative. Because of the lack of symptoms of muscle weakness or pain, the patient declined our suggestion of performing a muscle biopsy. Anticoagulation therapy was terminated, and levetiracetam (1000 mg/d) was administered.
At 3 mo after her second admission, the patient was experiencing involuntary movement in her left limbs, with repetitive flexion/extension. An MRI scan showed a hyperintense signal abnormality in the right parietal lobe (Figure ). Brachial biceps biopsy was performed. Histopathology revealed no abnormalities, and no necrotic or regenerating fibers were observed; ragged-red fibers and intense succinate dehydrogenase activity were not detected. Nonetheless, complete sequencing of mitochondrial DNA samples extracted from the biopsied muscle revealed a heteroplasmic m.10158T>C mutation, with a heteroplasmy level of 69.6%, in the mitochondrial complex I subunit gene MT-ND3. In contrast, this mutation was not found in her peripheral blood cells.


An 81-year-old male, with a history of ischemic heart disease, impaired left ventricular systolic function, and coronary artery bypass graft surgery, presented for elective ablation of slow ventricular tachycardia. After femoral venous access was obtained, an 8-French transseptal sheath and Brockenborough's needle were positioned in the fossa ovalis, and a single puncture was made under fluoroscopy followed by passage of the dilator and sheath. A test injection of contrast showed the dilator/sheath to be in the aortic root []. A subsequent transesophageal echocardiogram demonstrated hematoma adjacent to the aortic root posteriorly and along the atrial walls with the dilator/sheath visualized within the aortic root.
To avoid uncertainty with withdrawal of the dilator/sheath and conservative management, and possible need for open-heart surgery with its attendant morbidity, a decision was made to proceed with transcatheter device closure of the perforation. The transseptal sheath was passed fully into and maintained in the ascending aorta, over a 0.035” guidewire. An Amplatzer Duct Occluder II 6 mm × 4 mm (St. Jude Medical, Cardiovascular Division, St. Paul, MN, USA) was successfully deployed through the transseptal sheath with the distal disc opposed against the aortic wall, guided by transesophageal echocardiography. After an aortogram showed the device to be in a good position with no residual leak, and the echocardiogram confirmed normal aortic valve function, the device was released []. Following this, a repeat transseptal puncture, guided by transesophageal echocardiography and full systemic heparinization, allowed the patient to have a successful ablation with an uneventful postprocedural recovery.


A 21-year-old female attended the Department of Conservative Dentistry, Chonnam National University Dental Hospital, Gwangju, Republic of Korea. She was referred from the Department of Oral and Maxillofacial Surgery for evaluation and the treatment of the tooth #45. All diagnosis and treatment procedures were conducted following informed consent. She was a type I MPS patient with mitral and aortic regurgitation. Her sisters were also MPS patients. First, she visited the Department of Oral and Maxillofacial Surgery and complained ectopic eruption of tooth #15 and tooth #25. She wanted to extract both teeth. In panographic radiograph findings, supernumerary tooth between the root of tooth #21 and tooth #22, abnormal mandibular condyles, and shortened ramus were identified ().
After 1 year, she came back because of swelling and pain on the lower right jaw. In clinical examination, swelling and fluctuation on buccal gingiva of tooth #46 area were observed. Destruction of alveolar ridge was identified on area of both unerupted upper and lower posterior teeth (). The patient was diagnosed with dentigerous cyst on tooth #46 and tooth #47. Thus, marsupialization was done () and periodic examination was performed for 6 years ().
After another year, she complained pain of the tooth #35 and tooth #45. Spacing, severe labioversion, and gingival inflammation on both tooth #35 and tooth #45 were observed (). Responses to Electric pulp test and cold test were positive. The tooth #45 was decayed. It was sensitive to percussion with slight mobility (). The tooth #45 was diagnosed with caries of dentin. Thus, caries removal and resin filling were planned. Before the next appointment, the patient suffered from severe spontaneous pain on tooth #45. It was diagnosed with irreversible pulpitis, and conventional root canal treatment was performed. Under rubber dam isolation, the access opening was prepared. The pulp tissue was extirpated and the working length was determined using an electronic apex locator (DentaPort ZX, J Morita Corp., Osaka, Japan) with periapical radiograph (). Nickel-titanium rotary instrument (ProTaper universial, Dentsply Tulsa Dental, Tulsa, OK, USA) with crown-down technique was used for instrumentation. The canal was enlarged to size F2. During instrumentation, the canal was irrigated copiously with 5.25% sodium hypochlorite solution and sterile saline. Sterile paper points were used to dry the canal and intracanal medication with calcium hydroxide was applied. The access cavity was temporarily sealed with Caviton (GC, Tokyo, Japan). After 2 weeks, the pain disappeared, and the canal was obturated with gutta-percha and AH26 plus sealer (Dentsply DeTrey, Konstanz, Germany) using a continuous wave technique (). Crown restoration was performed (). Tooth #35 treated with amalgam previously showed positive percussion sensibility, uncomplicated crown fracture, and secondary caries. For tooth #35, fractured amalgam and caries were removed and composite resin restoration was done ().
On 1-year follow-up, the patient felt spontaneous pain on tooth #35 again. Conventional root canal treatment was performed as describe previously (). In following check-ups, no symptoms were identified.


A 66-year-old Taiwanese man was admitted to our medical oncology ward with the chief complaint of progressive exertional dyspnea for twenty days in December 2017. He had been diagnosed with bony metastasis from prostate cancer for 8 years and failed various kinds of treatment including luteinizing hormone-releasing hormone agonist (leuprorelin), androgen receptor antagonist (bicalutamide), denosumab and docetaxel. He was brought to our hospital after starting on dexamethasone and abiraterone acetate without improvement of serum prostate specific antigen level for two months in a medical center nearby.
There was no obvious bone pain, chills or fever. He denied other major systemic disease except essential hypertension under regular medical control. His chest X-ray film disclosed right side costophrenic angle blunting and a little fluid accumulation in the minor fissure without extensive pulmonary edema. Blood chemistry showed that levels of alanine aminotransferase, gamma glutamyltransferase, blood urea nitrogen and creatinine were within normal ranges. Abnormal results included alkaline phosphatase of 123 iu/L (normal 32 to 91), albumin of 3.2 g/dL (normal 3.5 to 4.8) and calcium of 7.7 mg/dL (normal 8.6 to 10). Serum prostate specific antigen level was 905 ng/mL (normal 0 to 4). Prolonged activated partial thromboplastin time (41.2 sec, control 31.5) and prothrombin time (international normalized ratio 1.23) were noted. Although plasma fibrinogen level was still normal (335 mg/dL, normal 200 to 400), the concentration of D-dimer was extremely high (over 20,000 ng/mL, normal less than 500). Blood routine test revealed hemoglobin of 6.4 g/dL, mean corpuscular volume of 89.4 fl, platelet count of 1,1000/μL, and white cell count of 7,200/μL with extraordinary abnormal differential counts: segments 19%, lymphocytes 35%, monocytes 1%, eosinophils 3%, bands 19%, metamyelocytes 11%, myelocytes 6%, promyelocytes 4%, blasts 1%, and atypical lymphocytes 1%. There were 48 nucleated red cells per 100 white cells. A diagnosis of leukoerythroblastosis was thus established based on morphological evidence ().
Bone marrow aspiration from right side posterior superior iliac crest gave a smear of full-blown metastatic carcinoma with many clustered, dispersed or microacinar groups of epithelioid malignant cells. Bone marrow biopsy from the same area showed a picture of metastatic adenocarcinoma composed of highly pleomorphic tumor cells with hyperchromatic nuclei, prominent nucleoli, and vacuolated cytoplasm, infiltrating diffusely in the marrow with a sheeted pattern. The carcinoma cells were positive for prostate specific membrane antigen, negative for cytokeratin 7 and cytokeratin 20 on immunohistochemical stains using Bond Polymer Refine Detection Kit (Leica Biosystem, Milton Keynes, UK) performed on automated Leica Bond MAX stainer (Leica Biosystem, Melbourne, Australia) with three primary antibodies (Leica Biosystem) ().
There were only a few small metastatic lesions over skull, manubrium, and ribs in bone scan performed two months earlier but diffuse bone marrow involvement and destruction could be seen in magnetic resonance imaging of spine done one month prior to the present hospitalization (). The patient decided to receive palliative treatment upon knowing his incurable disease status and died of multiple organ failure resulting from fulminant disseminated intravascular coagulation two weeks later.


A 78-year-old Hispanic female with a significant past medical history of type 2
diabetes mellitus, hypertension and hypothyroidism presented with altered mental
status. She was brought to the emergency department by her family members who
assisted with history gathering. According to her family, the patient had a cough
and worsening shortness of breath over 3 days prior to admission unrelieved by
over-the-counter antihistamine and antitussive medications. The family did not know
how long she had been diabetic or hypertensive. Nor could they list her medications.
Upon presentation she was lethargic, had labored breathing and was lying in bed
shaking. Her blood pressure was 142/67 mmHg in the supine position, heart rate
114 bpm, axillary temperature 36.7°C and she weighed 51.7 kg. On physical
examination, she was ill-appearing, obtunded, not following verbal commands and with
Glasgow coma scale of 9. She had decreased breath sounds over the left lung lower
field. The examination of the heart, abdomen and extremities was normal. On
neurological examination, she had hyperreflexia at the patellar and ankle joints, as
well as stimulated bilateral clonus and positive Babinski sign. The screening blood
tests performed upon her admission to the hospital were consistent with severe HHS.
Her initial laboratory findings revealed glucose 635 mg/dL (normal: 70–105), sodium
175 mEq/L (corrected Na: 188 mEq/L) (normal: 135–145 mEq/L), blood urea nitrogen
(BUN) 76 mg/dL (normal: 6–20 mg/dL), creatinine 1.61 mg/dL (normal: 0.5–1.2 mg/dL)
with a serum osmolality 410 mOsm/kg (normal: 280–300 mOsm/kg). Her urine ketones
were negative. On arterial blood gas her pH was 7.43, and HCO3 29 mEq/L
(normal: 22–29). Her initial hemoglobin (Hgb) was 16.8 g/dL, white blood cell count
(WBC) 18.3 × 103/µL and platelet count 194 × 103/µL. The
initial chest X-ray and noncontrast head computed tomogram (CT) were negative with
the head CT showing only mild diffuse cortical atrophy, proportional to the size of
the ventricular system. The calculated water deficit on admission was about 5.5 L.
In the emergency department, aggressive fluid resuscitation for volume replacement
was started using normal saline (NS), which initially caused worsening in sodium
values to 180 mEq/L (corrected Na: 193 mEq/L). After 2 L of NS, WBC was
23.2 × 103/µL, Hgb was 15.1 g/dL, platelet was
160 × 103/µL and her HCO3 was within normal limits in our
laboratory at 28 HCO3 mEq/L. She was admitted to the intensive care unit
(ICU), and nephrology was consulted. She was started on 0.45% NS and subsequently
switched to 5% dextrose in water. The sodium began to trend down, while maintaining
a mean steady decrease of 6 mEq/L of sodium daily, resulting in desired sodium range
within 5 days ().
An insulin drip was placed to control the severe hyperglycemia, which resolved
steadily over the first 48 h. The insulin drip was discontinued, and insulin
glargine with correctional insulin lispro was started. An abdominal pelvic CT was
negative. Due to her neurological findings, a continuous EEG (cEEG) was ordered,
which showed left frontocentral and temporal PLEDs on day 1. By day 2, the cEEG
showed only abnormal slowing without epileptiform discharges. During the
hospitalization, a nasogastric tube was placed and tube feeds were started due to
her poor mentation. Her kidney function improved and returned to baseline. She was
also found to have a left lower lobe infiltrate and was treated for community
acquired pneumonia. She was initially treated with ceftriaxone and azithromycin;
however, over the hospital course she clinically improved and was switched over to
oral cephalexin to finish the course. Her mental status improved and returned back
to baseline. In order to prevent potential aspiration, she underwent a successful
swallow study with modified barium and was started on regular diabetic diet. She
stayed in the hospital for 7 days and was diagnosed with severe hypernatremia
secondary to osmotic diuresis and dehydration from HHS. Her hemoglobin A1c was found
to be 9.9%, and upon discharge, she was placed on metformin, insulin glargine and
insulin lispro sliding scale. Due to her decline in functional status and
deconditioning, she was discharged to a skilled nursing facility. She received
diabetes teaching, which included lifestyle modifications, proper nutrition, insulin
administration and glucose checks. Unfortunately, there was no good follow-up with
the patient, because she returned to her home abroad.


Our patient was an 83-year-old man. In October 2016, he started to experience right mandibular pain radiating to the zygomatic and mastoid regions. The pain worsened progressively and required a combination of oxycodone, paracetamol and ketorolac to manage it. Since a trigeminal neuralgia was suspected, an empirical course of prednisone (50 mg per day) was started, but with no benefit.
Contrast-enhanced maxillofacial MRI and CT scans were performed ( and (). ENT evaluation of the patient by endoscopy of the upper airways showed a purulent discharge in the sphenoethmoidal recess. With the suspicion of sphenoid sinus disease with radiological complications and worsening right facial pain, the patient underwent right-sided endoscopic sinus surgery (ESS). After middle turbinectomy, a transnasal paraseptal sphenoidectomy was performed. The natural ostium of the sphenoid sinus was obstructed by a pyocele which was marsupialized and the content drained. This was sampled and, along with samples of the sphenoid mucosa, was sent for bacteriological and histopathological examination. The surgeon opened the natural ostium of the maxillary sinus and then the postero-anterior ethmoid sinuses was performed. The breach in the posterior-lateral sphenoid wall was repaired with medium turbinate mucoperiosteum. After careful haemostasis, a Merocel sponge was positioned in the right nasal fossa ().
There were no postoperative complications and the patient was discharged after 2 days. Histopathological examination was negative for both hyphae and neoplastic cells. Cultures were also negative, both for bacteria and fungi. After an initial improvement, the right trigeminal neuralgia gradually returned. A follow-up MRI, performed 1 month after surgery, confirmed persisting inflammation of the sphenoid sinus, skull base and pterygoid fossa.
A consultation with an infectious diseases specialist was sought. He ordered a serological work-up, which was negative for galactomannan and positive for beta-D-glucan. Then empirical antifungal therapy with voriconazole was commenced. The initial dose was 800 mg on the first day, followed by a dosage of 200 mg twice a day. Voriconazole serum levels were then regularly monitored along with liver enzymes and kidney function. After approximately 1 month of antifungal therapy, a spike in liver cytolysis markers was detected. The possibility of voriconazole-induced acute hepatitis was investigated with a liver ultrasound and liver MRI, which were both negative. Hepatic enzymes also gradually decreased. Thus, a decision was made to continue the antifungal therapy.
Follow-up maxillofacial MRI, performed 1 month into the antimycotic chemotherapy, showed improvements, with shrinkage of both the sinus and the intracranial component of the phlogistic tissue. This was matched by an improvement in clinical condition: facial pains gradually decreased and finally disappeared.
A follow-up MRI performed after 12 weeks of therapy showed that the infection had almost completely resolved. Thus, antifungal therapy was discontinued and at the present time, 11 months after surgery, the patient is still symptom-free ().


A 46-year-old male was presented with a history of low backache and radiation to
the right lower limbs for 2 months duration at S1 root distribution.
The pain started 2 months ago, with sudden onset of lower backache, then
progressed 1 week later to the right lower limb with paresthesia nerve lateral
aspect of the calf muscle and button of the foot. It was severe in nature,
progressive, aggravated by cough, straining and sitting for long durations,
partially relieved by lying down and taking pain killer.
On examination, the straight leg-raising test of the right leg was positive at
40° with no obvious weakness in the leg. Magnetic resonance imaging (MRI)
findings revealed L5-S1 a right-sided posterolateral disk herniation with
foraminal stenosis ().
A course of conservative treatment was given, which included rest, NSAID, and
Paracetamol for 6 weeks. This failed to relieve the symptoms.
Surgery was planned to relieve the symptoms in the form of tubular
microdiscectomy. Surgery was performed with pre-incision antibiotic under
general anesthesia; prone position; under C-arm guides, a K-wire was inserted to
L5-S1 level at right paramedian site; followed by 2 cm skin and fascia incision,
then tubular dilators were inserted to 22 mm, with the aid of Loop
magnification; identification of Lamina and partial laminotomy with flavectomy
was performed using high-speed burr and bionate kerrison; the right S1 nerve
root was explored and retracted; a large sequestrated disk was identified and
removed using bionate pituitary rongeur, and further discectomy was performed to
remove the remaining nucleus pulposus. At the end of discectomy, the site was
irrigated with Amikacin, and the wound was closed by subcuticular suturing, with
uneventful recovery. Two hours postoperatively, the patient began to complain of
severe, continuous, burning pain in the entire left lower limb, partially
relieved by flexion of hip and knee, not relieved by analgesia. Examination of
distal pulsation was negative in comparison with another site (negative dorsalis
pedis, posterior tibia and popliteal artery, weak femoral pulsation).
Consultation with the vascular surgeon included a computed tomography (CT) angio
request which revealed pseudoaneurysm of the common iliac vessels (–). An emergency operative procedure was
performed for retroperitoneal exploration, and repair of the defect using a
synthetic graft, with distal embolectomy at the end of the repair.
Postoperatively, the pain subsided, distal pulsation was regained, and the
patient was discharged from the hospital 5 days later. Follow-ups at 2 weeks,
6 weeks, 3 months, 6 months and 1 year revealed a complete recovery from
vascular injury with no signs or symptoms of ischemic pain.


A 62-year-old male, who is a known diabetic presented with sudden, acute severe abdominal pain with vomiting for fifteen days. He was in pain, not pale or jaundiced. Abdominal examination revealed positive Murphy’s sign, but no palpable gallbladder. Abdominal ultrasound showed thick-walled gallbladder with multiple stones and thick bile content with fluid level suggesting chronic cholycystitis. CT abdomen showed distended gallbladder, thick enhanced wall with peri-cholycystic inflammatory changes and a large stone at the gallbladder neck. Adjacent liver parenchyma showed ill-defined hypo-density, focal inflammatory changes in the right lobe indicating calcular cholecystitis with element of hepatitis (star sky appearance). MRI showed features of acute calcular cholecystitis with markedly dilated gall bladder. Blood analysis showed hemoglobin concentration of 11.0 grams/dl, total white cells count of 8 000 cells/Cumm, total bilirubin of 1.1 mg/dl, albumin concentration of 3.2 grams/dl, AST and ALT levels of 50 IU/dl and 33 IU/dl, respectively. HBs Ag/HCV serology was non-reactive. CA19-9 level was 914.8 U/ml. Following informed consent, open cholecystectomy was done using inverted L-shaped incision. Intra-operatively, the liver was cirrhotic, Calot’s node was enlarged and adhesions were found in the hepatic flexure, duodenum, gallbladder and colon. Neither, ascites nor peritoneal lesions were seen. The right hepatic artery was encased by the tumor. Intra-operative cholangiogram and Doppler ultrasound was used to assess the patency of the right hepatic artery. The cystic artery was identified and ligated. The patient recovered uneventfully. Macroscopically, the specimen was yellow-white with thick-walled and ulcerated gallbladder. Microscopically, the gallbladder wall was infiltrated by sheets of polygonal cells showing eccentric nuclei, abundant eosinophilic cytoplasm with some multinucleated (PAS+) cells (Fig. ). There was no evidence of malignancy. The tumor cells were positive for S-100 protein (Fig. ). The tumor was diagnosed as a benign granular cell tumor of the gallbladder (Fig. ). The patient was well with no surgical complications or tumor recurrences after one year follow up. The patient consented to the publication of his case.


A 12-year-old Moroccan female who presented a nephrotic syndrome was treated with corticosteroids, without any effect. A renal biopsy performed 8 years later showed typical focal glomerulosclerosis. Renal insufficiency developed rapidly, with the concomitant development of cardiac failure. Dialysis was required at the age of 22 years. Two years later the patient moved to France and was dialysed in our unit. Dialysis was carried out via an arteriovenous fistula and comprised 4-h sessions three times a week, with a dialysate Ca level consistently maintained at 1.5 mmol/L. When the patient first presented in our unit, our main concern was severe cardiac failure due to uraemic cardiomyopathy, with a left ventricular ejection fraction (LVEF) of 28%. After a few months, following treatment adjustment using diuretics, β-blockers and angiotensin-converting enzyme (ACE) inhibitors, as well as a decrease in body weight, the LVEF improved to 54%. The next important problem was SHPT. The main biological parameters and medications prescribed to the patient are shown in . Despite an increase in the dosage of C-HCl, the level of PTH did not decrease but paradoxically increased. To ensure that the prescribed doses were effectively taken by the patient, the medication was given at the dialysis unit on the days of dialysis at the end of the dialysis session. However, the level of PTH consistently increased.
In May 2007, an ultrasound scan of the parathyroid glands revealed normal upper right and upper left parathyroids of ~3 mm in diameter and two enlarged parathyroids, with the right lower gland measuring 8 × 6 × 5.2 mm and the left lower gland measuring 7 × 6 × 4.5 mm. Consequently, a parathyroidectomy was performed in July 2007, at a preoperative PTH level of 2162 pg/mL. The two upper parathyroid glands were slightly hyperplastic but were left intact and controlled with a clip to ensure that they could be easily identified, if necessary. The two lower glands, each ~10 mm in diameter, were resected, with each gland weighing 5.3 and 5.2 g, respectively. The histopathological examination revealed the presence of a benign parathyroid adenoma consisting of chief cells in each resected gland; however, 30–40% of each gland contained oxyphil cells, which was classified as an oxyphil adenoma (), and a parathyroid carcinoma was excluded.
Two hours post-surgery, the serum Ca level dropped to 1.30 mmol/L and the PTH level to 8 pg/mL. The patient was prescribed 12 g/day of intravenous Ca and 6 µg/day of alfacalcidol. Four months later, with a treatment regimen of 4 g/day of Ca and 4 µg/day of alfacalcidol, the Ca level was 2.00 mmol/L, P level 1.20 mmol/L and PTH level 22 pg/mL. In the following year, the patient received a kidney transplant, was pregnant 3 years later and remained well 9 years later, with a creatinine level of 118 µmol/L, Ca level of 2.36 mmol/L and PTH level of 36 pg/ml on a treatment regimen of 2 g/day of Ca and 2 µg/day of alfacalcidol.


A 79-year-old man underwent esophagogastroduodenoscopy with a small-caliber endoscope (EG-L580NW; Fujifilm) using a laser endoscopic system as part of a medical examination at a Neurology clinic. He complained of slight epigastric bloating. He reported a history of hypertension and was prescribed an antihypertensive drug. He reported no other symptoms at the time of the esophagogastroduodenoscopy. Laboratory tests showed anti-Helicobacter pylori antibody 6.4 IU (positive) and a positive stool antigen test for H. pylori. Other blood and chemistry tests showed normal results. Abdominal ultrasonography and a computed tomography scan showed no abnormal findings. White light imaging with a small-caliber endoscope showed a red area measuring 3 mm in diameter on the posterior gastric wall near the gastric angle (), which was not suspicious for gastric cancer based on its appearance. LCI enhanced the red lesion and the surrounding red area (). BLI revealed a discolored lesion measuring 10 mm around a central red area with an apparent demarcation between the cancer and the surrounding mucosa with high color contrast (, ). Several irregular vessels were observed on the discolored lesion even with the use of small-caliber endoscopy, suggesting an early gastric cancer. The biopsy showed well-moderately differentiated tubular adenocarcinoma. The patient was referred to Jichi Medical University Hospital for further evaluation and treatment.
Laser endoscopy was performed using a transoral endoscope (EG-L590ZW; Fujifilm); however, the lesion could not be clearly visualized without magnification because of tangential views obtained (, ). Magnified BLI imaging showed an apparent demarcation between the slightly depressed cancer and the surrounding mucosa, as well as irregular microvessels and microstructure distinct from the surrounding mucosa (, ). Endoscopic ultrasound revealed cancer limited to the mucosa. Two months later, marks were placed 5 mm outside the demarcation line, and endoscopic submucosal dissection was performed (). The resected specimen showed a slightly depressed early gastric cancer with well-moderately differentiated tubular adenocarcinoma limited to the mucosa (, ). Additionally, microvessels were identified in the intervening part of the superficial layer of the mucosa (), supporting the identification of vessels with BLI using small-caliber endoscopy.


A 24-year-old man with complaints of fever, abdominal pain and 3 episodes of passing loose stools consulted an alternative medicine practitioner and was given ayurvedic medications. Following intake of the medicines, he had worsening diffuse abdominal pain and vomiting along with decreased urine output. He went to a local hospital on the 2nd day and was found to have deficient renal function (his serum creatinine level was 10.3 mg/dl). He was referred to our emergency department (ED) on the 3rd day for further management. He had no history of co-morbidities or any known underlying disease.
On examination, he was conscious, oriented, with a pulse rate of 64/min, blood pressure of 132/80 mmHg, respiratory rate 24/min, and an O2 saturation (SpO2) of 99% on room air. He also had some minor facial and pedal edema. Respiratory and cardiovascular system examinations were normal. Abdomen examination showed moderate tenderness in the left lower quadrant with no mass palpable and no flapping tremors.
His electrocardiogram (ECG) showed sinus bradycardia (). Non-enhanced computed tomography (CT) scan of the abdomen showed no obvious renal or ureteric calculi, nor any pelvicalyceal/ureteric dilatation on either side. He had minimal ascites and bilateral basal pleural effusion. Upon admission, his hemoglobin was 13.5, blood urea 121, serum creatinine 11.33 mg/dl, serum sodium 139 mmol/l, serum potassium 3.9 mmol/l, total bilirubin 0.5 md/dl, and direct bilirubin 0.1 mg/dl. His ABG showed compensated metabolic acidosis with a pH of 7.36, PCO2 of 28 mmHg and HCO3 of 18meq/l.
The patient was admitted to the nephrology department since he had metabolic disturbances and AKI. He was taken for emergency hemodialysis via a left double lumen femoral catheter. He started improving clinically after one session of dialysis and other supportive care. His renal function rapidly improved and his serum creatinine was 2.17 mg/dl on the fifth day of admission. The femoral catheter was then removed and he was discharged on day six. On follow up his serum creatinine was within normal limits (1.2 mg/dl). The ayurvedic supplement he had been taking was sent for toxicological analysis and showed the presence of a high concentration of lead which might have caused the interstitial nephritis leading to AKI in our patient. The serum level of lead was not measured in this patient


A 7-year-old female patient presented with pain and delayed mandibular molar eruption. Clinically, right and left mandibular buccal swelling of about 2–3 cm in diameter was observed. The local mucosa was more whitish than the surrounding one. The left first molar was not clinically erupted, while partial eruption of the right first molar was evident. Both regions were resistant to palpation.
Cone beam computed tomography (CBCT) was requested to establish the vestibular-lingual extension of the lesion, the relationship with the teeth, and the lamina dura maintenance. The images showed hypodense lesions involving the crowns and roots of the first mandibular molars. Basilar cortical resorption of the mandible was present on the right side. The evident expansion of the buccal cortical bone and the tilting of the molar roots toward the lingual cortex were observed ( and ).
These findings, as well as the relationship of the lesion with adjacent structures, were also analyzed in a three-dimensional volume rendering reconstruction (). With the hypothesis of an odontogenic cyst, an excisional biopsy of the right side and ulectomy of the left side were performed. The histological analysis revealed cystic lesions partially lined by non-keratinized stratified epithelium, predominantly presenting a few layers of cells. Epithelial hyperplasia, exocytosis, and spongiosis were observed in some areas. The cyst wall, especially of the right side, had intense chronic subepithelial inflammation, which was mainly composed of lymphocytes and plasma cells (). Based on the clinical, microscopic, radiographic, and CBCT images, the diagnosis was bilateral MBBC.


A 48-year-old man with a space-occupying lesion on a chest radiograph presented to our hospital. The patient complained of chest discomfort with intermittent back pain. Physical examination revealed normal limb strength and muscular tension and negative pathological reflexes. Computed tomography (CT) revealed a hemispheric soft tissue mass of 5.6 × 3.8 × 3.5 cm in the third thoracic vertebra and paravertebral region near the thoracic cavity (). The intervertebral foramen and T3 vertebral body were obviously compromised (). The tumor protruded into the spinal canal through the left intervertebral foramen, while the right side of the vertebra was intact. Further examination by thoracic magnetic resonance imaging (MRI) showed a hemispheric large space-occupying lesion that was isointense on T1-weighted imaging and hyperintense on T2-weighted imaging, located at the T3 to T4 level of the spinal cord and paravertebral tissues ().
Based on the CT and MRI results, the tumor was most likely a benign lesion. The primary diagnosis was suspected to be a neurilemmoma in the thoracic spine. The patient refused a CT-guided biopsy because of concerns regarding the biopsy risk and hospitalization costs and instead preferred to undergo surgical resection. After the patient had provided informed consent and undergone preoperative preparation, surgery was performed to remove the lesion. After induction of anesthesia, the left-side paraspinal muscles were dissected along the left side of the spinous processes until the left lamina and lateral costotransverse joints from T2 to T4 were adequately exposed. The left lamina was then removed to open the spinal canal, and the left costotransverse joint of T3 was resected to expose the tumor both inside and outside of the spinal canal. The tumor body was completely excised by a posterior and anterior lateral approach, and unilateral pedicle screws and rods were then instrumented at the T2 and T4 levels.
Hematoxylin and eosin staining of the postoperative specimen showed that the tumor was composed of diverse-appearing rounded cells with regular, round to ovoid individual nuclei and no significant nuclear pleomorphism (). The immunohistology results showed that the tumor was positive for smooth muscle actin, CD34, and CD31; negative for S100, CD68, and CD57; and had a Ki67-positive rate of <5%. The final pathologic diagnosis of a GT was confirmed. The patient underwent 1 week of hospitalization after surgery, and postoperative radiographic examination showed stable internal fixation (). During the 18-month follow-up, the patient showed no sign of recrudescence and was satisfied with the treatment.
The study was endorsed by the Ethics Committee of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology. The patient provided informed consent to publish this case report.


This was a 31-year-old woman who had previously had a CS because of prolonged first stage of labour with cervical dilatation up to 7 cm. She was admitted to hospital with menometrorrhagia and transvaginal ultrasound examination showed the presence of a CSD. The scar thickness was 0.19cm and the CSD measured 0.86cm with a rectangular shape (). Surgical CSD correction was recommended but the patient deferred treatment, ignored contraceptive advice and shortly afterwards became pregnant.
Sonography confirmed a single pregnancy with correct location of gestational sac within the uterus. The pregnancy was monitored every two weeks, and additional clinic visits were made if the patient experienced pain in the location of the CSD. At each clinic visit, TVUS assessments of the lower uterine segment were made and a thickness <0.25cm was assessed as a high risk of uterine rupture.
During her pregnancy, the patient was hospitalized three times. At 26 weeks, she reported moderate pain in the CS scar. A scar dehiscence of 3.08cm was visualised by TVUS (). At 30 weeks, scar dehiscence was estimated to be 4.94 cm (). At 36 weeks, the patient was admitted to the hospital because of lower abdominal pain; scar dehiscence was confirmed by TVUS and because of the high risk of uterine rupture an emergency CS was performed. The caesarean scar dehiscence (transverse extent) was estimated to be 8 cm ().
The patient delivered a healthy girl with a birth weight of 2810g. During her CS, the CSD was repaired. At the two-year follow-up, the patient reported no symptoms related to the CSD and TVUS confirmed there was no defect. The patient has no future pregnancy plans.


This was a 32-year-old woman who had been actively trying to conceive for 18 months and had been diagnosed with asymptomatic CSD. She was admitted to hospital for surgical correction of the defect. A possible predisposing factor for the CSD was a previous CS because of a prolonged second stage of labour. Laparotomy with hysteroscopy support was performed. Only serosa of the anterior wall covered the CS scar. The CSD was classified as droplet-shaped with inclusion cysts ().
Twelve months after the repair of the CSD, residual myometrial thickness measured 0.97cm () and the patient successfully conceived. During the 11–14 week ultrasound scan, placentation was observed in the area of the surgically repaired CSD. During the second trimester ultrasound examination, placenta previa was diagnosed (). Colour Doppler ultrasound images confirmed that invasive placental vessels were not present in the CSD and there was no evidence of any abnormally invasive placenta. An elective CS was performed at 39 weeks without complications. No scar dehiscence nor any abnormally invasive placenta were observed during the caesarean (). A healthy girl was delivered weighing 3520g.


The third case was a 30-year-old woman who had previously had a CS at full cervical dilatation because of prolonged second stage labour. She was admitted to hospital at 6 weeks gestation because of suspicion of pregnancy of unknown location. A large CSD was visualized on TVUS examination. The gestational sac was implanted on the anterior uterine wall at the cervicoisthmic level over the CSD (). The residual myometrial thickness at the CSD was 0.1cm and it had a rectangular shape (). Diagnosis was confirmed using TVUS in 3D mode with Oblique View software ().
During hospitalization, spontaneous miscarriage occurred and dilatation and curettage was performed. After the procedure, the CSD was visualized during TVUS examination (). Surgical correction of the CSD was performed three months later (i.e., laparotomy with hysteroscopic support). At the six month follow-up, the patient reported no symptoms related to the CSD and TVUS confirmed there was no defect. The patient wanted to try and conceive again.