A 61-year-old man had been experiencing severe low back pain, and intermittent abdominal fullness developed 3 months before the admission. The pain sensation with dullness in quality was located over the sacroiliac area. The pain exacerbated particularly at night and radiated to the bilateral scapula. The patient visited the clinic several times, and chronic muscle strain was suspected because no trauma or specific medical history was mentioned. The pain sensation became more severe even under medicine and was accompanied with dysuria, voiding frequency, and poor defecation, thereby prompting the patient to visit our outpatient clinic 1 month before the admission.
At that time, muscle power in all 4 limbs was normal, but the patient could not stand up or change posture because of severe back pain. The pain occurred spontaneously or by movement. The initial physical examination showed a positive finding in right straight leg raising test (20 degrees) and a negative finding in bilateral Patrick test. The pain became severe while coughing and doing lumbar flexion with radiating numbness and pain to the right thigh and leg. The lateral view of x-ray showed a vertebral compression fracture with an osteoblastic lesion at the L2 vertebral body (Figure ). Two weeks before admission, the patient underwent MRI of the lumbar spine, which revealed osteoblastic metastasis with heterogeneous enhancement in the L2 vertebra, direct tumor invasion of left paraspinal soft tissue, and psoas muscle myositis (Figure ).
One day before the admission, severe back pain was exacerbated with abdominal fullness and cold sweating. Thus, the patient came to our emergency room. Abdominal sonography showed multiple masses over the liver. Severe back pain lasted throughout the day with a visual analog pain score (VAS) described as 9 to 10 even under treatment with Ultracet (tramadol 37.5 mg/acetaminophen 325 mg) thrice per day, but quit because he could not tolerate the side effect such as nausea, vomiting, and general weakness after medication. Under the impression of osteoblastic metastasis in the L2 vertebra with direct tumor invasion of left paraspinal soft tissue, and psoas muscle myositis, the patient was admitted. During admission, the laboratory data, such as complete blood count, electrolyte, liver function, and renal function, were within the normal range. The tumor markers of alpha-fetaprotein, prostatic-specific antigen, and carbohydrate antigen-199 were also within the normal range. However, carcinoembryonic antigen (454.63 ng/mL, normal range <5.0 ng/mL) and carbohydrate antigen-125 (2412.9 U/mL, normal range <35 U/mL) were elevated. Abdomen CT (Figure A) was arranged and showed a 60.8 mm × 16.5 mm ill-defined mass at the pancreatic body, with encasement of the celiac trunk, superior mesenteric artery and aorta, and multiple liver and L2 vertebral metastasis (Figure B). Enlarged or confluent lymph nodes were noted at the paraaortic region, paracaval region, and right subphrenic region. Metastatic lymphadenopathy was highly suspected. The technetium-99m-methylene diphosphonate whole-body bone scan showed abnormal increased uptake at the L2 level (Figure C). Percutaneous vertebroplasty with injection of 5 mL bone cement and L2 vertebral body biopsy were performed under guidance of radiology 3 days after the admission (Figure ), and metastatic adenocarcinoma (cT4N1M1) was diagnosed (Figure ).
After receiving percutaneous vertebroplasty, the severe back pain subsided with VAS about 3 to 4, and the patient could walk without any device under the same medicine prescribed before for pain control. The performance status under Karnofsky and Eastern Cooperative Oncology Group (ECOG) scales were improved from 20 to 80 and 4 to 1. Chemotherapy and radiotherapy treatment for the pancreatic cancer was added into the treatment, but the course of treatment was halted because the patient could not tolerate the side effect. Currently, the patient is on best supportive care and palliative treatment, and the quality of life and activity of daily living were the same as the time after this procedure, which was performed for >1 year.


A 51-year-old female was diagnosed to have essential hypertension since 12 years and CKD since last 4 years. She progressed to end-stage renal disease 2 years back and was initiated on maintenance hemodialysis. For initial 1-year, she was on twice-weekly hemodialysis, which was subsequently increased to thrice weekly. She presented to us with complaints of progressive painless abdominal distension of 8-month duration along with anorexia and weight loss. There was no history of abdominal pain, altered bowel habits, pedal edema, fever, jaundice and no history to suggest hypothyroidism or connective tissue disease. There was no history of diabetes mellitus, jaundice, abdominal surgery and anti-tubercular treatment in past. Her medication included prazosin 10 mg/day, amlodipine 10 mg/day, calcium carbonate 1500 mg/day, twice weekly subcutaneous erythropoietin, oral iron and multivitamin. On examination, she had normal sensorium with blood pressure of 180/120 mm of Hg, pulse rate - 110/min, respiratory rate - 20/min, was afebrile and pale. Her abdomen was symmetrically distended with fluid thrill. There were no visible veins; hernial sites were normal with no cutaneous stigmata of chronic liver disease. Patient had hemoglobin of 7.7 g/dl, total leukocyte count (TLC) of 10400/mm3, with normal differential, platelet count 2.50 lakh/mm3, mean corpuscular volume 90.8 fl, mean corpuscular hemoglobin 30.1 pg/cell, mean corpuscular hemoglobin concentration 33.2 g/dl, normal coagulogram, urea 197 mg/dl, creatinine 9.4 mg/dl, sodium 144 mEq/L, potassium 6.1 mEq/L, chloride 110 mEq/L, aspartate aminotransferase, alanine aminotransferase and alkaline phosphatase were 27, 15 and 254 IU/L respectively, bilirubin 0.8 mg/dl, total protein and albumin 6.5 and 2.7 g/dl, calcium 9.7 mg/dl, phosphorous 9.3 mg/dl, and intact parathyroid hormone 346.8 pg/mL. The serology was negative for hepatitis B, hepatitis C and human immunodeficiency virus. On tapping, the ascitic fluid was hemorrhagic and showed TLC of 70/mm3 with 70% polymorphonuclear cells, protein was 3.8 g/dl, sugar 83 mg/dl, with adenosine deaminase of 32 IU/L, and serum ascites albumin gradient of 0.8. The Ziehl–Neelsen stain and Gram-stain were negative, as was the culture for Mycobacterium tuberculosis, and pyogenic organisms. The TB polymerase chain reaction and ascitic fluid for malignant cytology were also negative. Other cancer markers such as cancer antigen (CA) 125, CA 19–9, and carcinoembryonic antigen were also normal. Her electrocardiogram revealed left ventricular hypertrophy with strain pattern, while echocardiography revealed mild mitral regurgitation, left ventricular ejection fraction of 45–50% with no evidence of systolic or diastolic dysfunction. An ultrasound abdomen performed showed gross ascites, bilateral contracted kidneys and cholelithiasis while other abdominal organs were normal. Subsequently, a contrast-enhanced computed tomography (CECT) abdomen was performed which revealed gross ascites with peritoneal enhancement and hyper-densities within fluid, in addition to the finding of contracted kidneys and cholelithiasis []. Suspecting inadequate dialysis, the patient was subjected to daily dialysis. However, there was no improvement in her ascites, and it required repeated therapeutic aspiration. To ascertain the cause of refractory ascites, the patient was subjected to exploratory laparotomy, which showed hemorrhagic ascitic fluid, thickened peritoneum and dense adhesions in-between the bowel loops and bowel loops with the abdominal wall. Keeping the possibility of cocoon abdomen, an intra-operative peritoneal biopsy was taken, which showed hyalinized fibrocollagenous tissue devoid of any lining epithelium with fibrin deposition and inflammatory cell infiltrate. There was no evidence of granulomatous inflammation or malignancy in biopsy specimen []. A diagnosis of cocoon abdomen secondary to uremia was made, and the patient was managed with daily intensive hemodialysis. Over next 1-month, there was gradual improvement in her symptoms along with decrease in ascites.


A 41-year-old woman was diagnosed with complex regional pain syndrome (CRPS) using the "Budapest" criteria [] due to lower extremity pain after thigh contusion caused by dropping a heavy box on her thigh at work 28 months ago. She was admitted for a trial spinal cord stimulation (SCS) for treating her lower extremity pain that was resistant to multimodal pain treatments for 28 months after pain onset. Results of her blood tests including coagulation study were within normal ranges at the preoperative evaluation.
During her first visit to our clinic, she complained of lower extremity pain with pain sites gradually extending to her upper extremities. She underwent surgery for a trial SCS at the lower thoracic vertebral segment to alleviate her lower extremity pain, and her lower extremity pain score decreased moderately from 9 to 5 on the visual analog scale (VAS). However, on the 3rd day of the trial SCS she was still suffering from upper extremity pain and her upper extremity pain score was increased from 7 to 9 on the VAS despite oral analgesics and intermittent intravenous opioid rescue medication. Cervical epidural catheterization was planned for continuous administration of analgesics to manage her upper extremity pain.
The patient underwent cervical epidural catheterization with a 20-gauge catheter through an 18-gauge Tuohy needle at C7-T1 with LOR using air under fluoroscopic guidance. Total amount of air instilled into the epidural space was uncertain; however, the practitioner (4th grade of anesthesiology residency) recalled administering about 7 ml of air.
She was comfortable and able to ambulate in the in-patient ward after cervical epidural catheterization. Six hours after insertion of the cervical epidural catheter, she suddenly complained of hypoesthesia and motor weakness of both lower extremities. Neurologic assessment revealed markedly decreased sensation to pinprick, cold, and touch below the T10 dermatome and slight contraction of the leg and foot muscles without movement (grade 1/5). The authors suspected an epidural hematoma around the thoracic spine possibly related to the previous epidural procedures and considered whole spine magnetic resonance imaging (MRI) although she did not have typical pain accompanying an epidural hematoma. However, she had received a trial SCS lead and underwent whole spine CT. Definitive findings of whole spine CT scan were multifocal air densities in the epidural space, intervertebral foramen, and paraspinal muscles between C1 and T9 and no obvious spinal cord compression (). While evaluating the patient and performing CT scan within 1 hour, the sensation below the T10 dermatome was totally absent and muscle power of both lower extremities was zero with no contraction (0/5).
We consulted a neurosurgeon for emergent decompressive surgery although there was no obvious spinal cord compression due to a mass-like lesion such as epidural hematoma or abscess. Within 3 hours after the paraplegia developed, decompressive operation was started by targeting the insertion site of the trial SCS electrode at the lower thoracic spine first because the neurologic deficit developed below the T10 level. However, there was no hematoma or abnormal findings in the epidural space where the trial SCS electrode was placed at T9–12. The radiologist and the authors thought that multifocal air collection in the epidural space and intervertebral foramen could be the cause of paraplegia, and a decompressive operation in the cervical spine was performed immediately after the closure of the thoracic spine. As soon as the cervical epidural space was opened, the neurosurgeon noticed escape of air bubbles with the naked eye and there was no hematoma or any other lesion.
Immediately after the decompressive surgery, the patient underwent whole spine MRI for evaluation of the spinal cord and epidural space. There were no findings of spinal cord ischemia on the whole spine MRI. Her sensation and motor function recovered to normal immediately after she awoke in the post-anesthesia care unit. The following day, whole spine CT was performed and it revealed nearly complete disappearance of epidural and paravertebral air (). One month after this incident, she underwent SCS for the management of pain in the lower extremities.


A 29-year-old male patient was presented with the chief complaint of pain in and around the neck since 3 months with a metallic tracheostomy tube in situ. Furthermore, the patient is apprehensive of the rope tied around the neck for the retention of the metallic tracheostomal tube. No history of difficulty in swallowing was noted. On clinical examination, no scar or ulceration is seen around the stoma. The skin around the stoma is healthy. The patient had undergone for suicidal attempt 3 months before. Following a suicidal attempt with the patient complaining of breathing difficulty he underwent immediate video laryngoscopy examination, which reported as bilateral vocal cord movements were restricted, and the cords were in adducted position with minimal glottic chink. The recurrent laryngeal nerve was severely damaged, and the patient have undergone for gasping with the difficulty in breathing. Emergency tracheostomy was done, and the patient was with the metallic tracheostomy tube for the last 3 months. The patient was apprehended with the metallic tube and had a frequent history of pain and irritation around the tracheostomy site for the past 3 months. The patient was referred to the oral and maxillofacial Prosthodontics Department from Department of ENT to customize tracheal prosthesis for the stoma site instead of the metallic tracheostomy tube.
On physical examination, the patient was with a metal tracheostomy tube tied by a rope around his neck. Mild hoarseness of voice noted, and there was no difficulty in swallowing. There were no secretions, ulcerations and granulation around the stoma. The skin around the stomal tissue was healthy with a stomal diameter of 6–7 mm. Routine blood and relevant investigation reports were within the normal limits. The patient consent was obtained. A custom made tracheal button made of polyethylene urethane sheet was fabricated for the patient to maintain the airway patency of the mature stoma.
Poly ethylene urethane sheet – 2 mm commonly used for bleaching the tray Patient's old tracheostomal tube Ruler scale for measurement Bunsen burner Sharp scissors or bard parker blade no 15 Cotton tip applicator Silicone burs Glutaraldehyde (1%) solution (Sporicidin Sterilizing Solution).
A poly ethylene urethane sheet of 2 mm was selected [] The snug fit of the old metal tube was tested in all head movements. As custom impression was not done the width and length measurement of the old tube was taken as the guide and noted [Figures and ]. It was approximately of 6 mm × 10 mm dimensions With the informed consent of the patient, the tracheostomal diameter of 6.5mm was measured with a vernier caliper. The distance of 15mm from the anterior edge of the stoma to the posterior tracheal wall was determined with a cotton tip applicator. This measurement was done to cross verify whether the determined measurement of the old tube approximates the original measurements of the stoma. A difference of 5 mm from the original length of the stoma to the metal tube was noted. This 5 mm of difference in length compensates the posterior tracheal wall from the contact of the prosthesis to avoid irritation of the posterior tracheal wall The polyethylene sheet was cut for the above measurements (6 mm width × 10 mm length) with sharp scissors or BP blade. As the sheet is thermoplastic, it is easily flamed over the burner, rolled and fused, which forms the body or shaft [Figures and ]. This urethane tube was lukewarm and soft at this stage and inserted into the stoma with fingers to customize for stomal patency and check for fit Anterior retention was achieved by a 2 mm flange []. A 2 mm width × 10 mm length polyethylene sheet was cut, flamed and fused to the anterior region of the shaft to produce the flange. Now the body and flange were cooled to room temperature to make it semi-rigid Again, only the flange area was softened to the temperature that could be withstood by the patient and inserted into the patient's stoma. Now the flange would contact the anterior tissue surfaces, and the flange was kneaded over the peristomal skin surface to achieve better adaptation of the prosthesis Lipping was done by heating the posterior region of the shaft and rolled backward by finger manipulation. This lipping would aid in posterior retention of the prosthesis [] The finished product was thin, flexible with enhanced tear strength. The edges of the prosthesis were trimmed with silicone burs to allow for better accommodation to the tissue surface without distortion An ideal tracheostomal button with the body or shaft, anterior flange and posterior lip [] was ready for insertion After an acceptable prosthesis was obtained, it was cleaned, and cold sterilized in glutaraldehyde (2%) solution [Sporicidin Sterilizing Solution] for overnight. The prosthesis was checked and verified for the fit and inserted into the patient [Figures –] The insertion was done by flattening and folding the prosthesis with the fingers and then inserting the prosthesis at a 45° angle to the patient's stoma. After insertion, the fingers were released. Now the prosthesis would open and conform itself into the stoma. To remove the prosthesis simply grasp it on one side and gently pull toward the opposite side. When the prosthesis was in place inside the stoma, the prosthesis would fit snugly and require no tapes or adhesives The patient recalled the next day for initial follow-up and was instructed about the placement, removal and homecare of the button. The tubal patency was checked for every 2 weeks, and the initial gradual improvement of speech with reduction in hoarseness of voice was also noted. The intake of food and regular activity were noted and found to be normal The patient has been on regular follow-up in ENT OPD since 7 months after the placement of this prosthesis, and an excellent cure of his symptoms was noted [].


A 76-year-old male with a past medical history of coronary artery disease, status post coronary artery bypass graft and chronic anemia presented to the emergency department after he developed episodes of chest pain and pre-syncope. He denied any non-steroidal drug or alcohol use.
On presentation, he was normotensive with a sinus tachycardia. His hemoglobin was 6.1 mg/dL, and the platelet count was 202.0 mg/dL. Initial fecal occult blood test was negative. He received multiple blood transfusions for his symptomatic anemia with a goal hemoglobin of greater than 7.0 mg/dL. There was a transient increase in his hemoglobin. A computerized tomography (CT) scan of the abdomen and pelvis without contrast did not reveal any bleeding source.
The following day the nurse witnessed him having a significant amount of hematochezia. Subsequent upper and lower endoscopy was done that revealed two 5 mm blue venous blebs in the esophagus and multiple patches of blue venous blebs throughout the colon ( and ). Given the absence of active bleeding, no endoscopic intervention was undertaken. Through the course of his hospitalization, the patient received a total of five units of blood. He was managed medically with oral iron and periodic monitoring of his hemoglobin.
One year after initial diagnosis, the patient is doing well on oral iron supplementation, and his hemoglobin is being closely monitored by his primary care physician.


A 39-year-old, Nigerian woman was referred to our dermatological clinic due to painful genital swelling. Her medical history included a female genital mutilation (FGM) at the age of 5 years and an appendectomy 10 years before. She was otherwise in excellent health.
She had begun to notice a genital swelling 1 year prior and gradually increasing in size. She denied any trauma in the area. The patient had no history of difficulty with urination or with her sexual relations, but she recognized psychological discomfort since the cyst had begun to increase in size.
The clinical examination showed a nodular lesion covered with preserved mucosa, 30 mm × 20 mm in diameter, smooth surface, and not attached to deeper layers. The lesion was located in the scar of the mutilation.
Under local anesthesia and in lithotomy position the cyst was excised. It was easily removed by making a vertical incision in the skin and making a dissection along the lines of cleavage. The redundant skin was trimmed, and the edges were approximated. The nodule was a well-encapsulated unilocular cyst containing serous gray material [].
The histological examination showed a cystic lesion containing abundant laminated keratin. Walls were formed by keratinizing epithelium with the presence of granular layer. Diagnosis of infundibular inclusion cyst secondary to genital mutilation was established [].
The clinical follow-up of the patient after 6 months of the excision revealed no recurrence, with good appearance of the vulva and without pain.


A 38-year-old male presented to the hospital with a chief complaint of abdominal pain and hematuria 1 day after eating a barbecue pulled pork sandwich. He described the pain as ‘deep’ in his abdomen, sharp and non-radiating with no episodes of nausea, emesis or diarrhea. He denied any dysuria or frequency. The patient's past medical and surgical history was unremarkable. He had no abnormalities on his laboratory values besides a urinalysis demonstrating 2+ blood and 11–24 RBCs/hpf. Physical examination revealed point tenderness to deep palpation to the right of his umbilicus, but his abdomen was soft with no signs of peritonitis. An upright abdominal X-ray was unremarkable; however, a CT of his abdomen demonstrated a 2-cm linear density representing the FB in the posterior third portion of the duodenum perforating into the retroperitoneum abutting the right ureter causing hydronephrosis (Figs and , arrow). Two separate attempts were made at endoscopic retrieval in the first 24 h without successful visualization or removal of the FB. Due to the ureteral involvement and hydronephrosis, an operative intervention was recommended.
Urology performed a right retrograde pyelogram demonstrating a point of obstruction in the proximal ureter with no contrast extravasation. A guide wire and stent were passed through the obstruction into the hydronephrotic right kidney without difficulty. Following successful stent insertion, fluoroscopy was used to confirm the location of the FB at the junction of the second and third portion of the duodenum. A full Kocher maneuver was performed and the duodenum and ureter were separated. A small, linear, FB was identified projecting from the posterior third portion of the duodenum into the ureter (Fig. ) and extracted without injury (Fig. ). The patient's original abdominal pain resolved after the surgery. He was able to tolerate a diet and be discharged on postoperative day 4.
Pathology confirmed a wire metal bristle, likely from a grill brush.


An 8-day-old male neonate with frequent episodes of non ketotic hypoglycemia and seizures, despite 15 mg/kg/min glucose infusion rate, was admitted to neonatal intensive care. The biochemical and urinary analysis was carried out to rule out other metabolic and endocrinal conditions. Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) was diagnosed from inappropriate plasma insulin: Cortisol ratio (74.4 IU/ml: 16 g/dl) and elevated serum insulin levels.
Positron emission tomography computed tomography (CT) scan (18 F-DOPA) revealed diffuse increased radiotracer uptake in body and tail of the pancreas [].
The neonate was managed with intravenous (IV) 10% dextrose (15 mg/kg/min) to maintain blood glucose of more than 60 mg/dl. Two hourly feed through a nasogastric tube, oral diazoxide 24 mg t.i.d., and hydroclorthiazide (25 mg on an alternate day) were given.
The patient was scheduled for near total pancreatectomy due to the persistence of symptoms in spite of aggressive medical management. Prior to surgery, the baby was kept fasting for 3 h, IV, infusion of 10% dextrose with all other drugs was continued till the morning of surgery. In the operation room, 24-gauge IV cannula was secured in the right upper limb. Anesthesia was induced with fentanyl 2 µg/kg, propofol 1 mg/kg, atracurium 0.5 mg/kg and airway was secured with 3 mm uncuffed tube, and oral packing was carried out. Monitoring included an electrocardiogram, noninvasive blood pressure, pulse oximetry, capnography, temperature, and urine output. Anesthesia was maintained with oxygen and nitrous oxide (60:40), sevoflurane 1 to 1.5%, and intermittent atracurium.
Ringer lactate 10 ml/kg/h was used as replacement fluid and 10% dextrose infusion was kept going from 40 to 50 ml/h to keep blood sugar between 100 and 200 mg/dl. Intra-operative blood loss was 70 ml for which 75 ml of blood was given. The case lasted for 4 h. Urine output was 20 ml. Intra-operative hemodynamic parameters were stable, and the procedure was uneventful. Residual neuromuscular blockade was reversed with glycopyrrolate 0.02 mg/kg and neostigmine 0.07 mg/kg. The child was extubated and shifted to the neonatal intensive care unit. Immediately after removing the pancreas [], 10% dextrose infusion was stopped due to anticipated hyperglycemia but by the conclusion of surgery, blood sugar came down to 80 mg/dl. Therefore 10% dextrose (20 ml/h) was started at the time of shifting and blood sugar was stabilized between 80 and 100 mg/dl. Histopathological examination of specimen confirmed the diagnosis of PHHI. Postsurgery oral diazoxide and hydrochlorthiazide had to be added to attain sustained euglycemia (at a lower dose and glucose infusion was avoided). On follow-up examination, he was euglycemia with persistent seizures (electroencephalography: Focal epileptic discharges from occipital lobe), and poor head growth. Magnetic resonance imaging showed encephalomalacia of the left cerebellum. At 1 year, the baby had a developmental age of about 7–8 months pointing toward neurological sequelae of hypoglycemia.


A 10-month-old male child, weighing 8.0 kg, presented with the complaints of regurgitation of milk, vomiting, and cough with a recurrent chest infection. Ultrasound scan showed bowel loops in the thoracic cavity and congenital absence of left kidney. Abdominal and thoracic magnetic resonance imaging confirmed the diagnosis of a left posterolateral CDH. The hernial sac was found to contain the left kidney, left colic angle, and the spleen. The surgical repair was performed using thoracoscopy.


A fifty-four year old female presented to the Pain Clinic with a general history of arthropathy pain for approximately ten years. The medical history consisted of the following: Lupus Erythematosus, Scleroderma, Raynaud’s disease, Sarcodosis, Fibromyalgia, Rheumatoid Arthritis, and Osteoporosis that ranged from a two to ten year history. There was a surgical history of hip replacement, left pelvic bone reconstruction, thoracic disk degeneration release procedure. The patient presented with symptoms of low back and lower extremity pain, with muscle spasm, and myofascial pain. The spasms in the patient’s legs had become involuntary secondary to little muscle control (i.e., involuntary spasms). The review of systems and neurological exams were negative per patient self-report. Patient was wheel chair bound for the last number of years as the back, hip and thigh pain was extreme and muscle tone was weak. Additionally, the spasms in her back were reported to extend to her hips, thighs and knees and prevented her walking and being in one position for longer than a thirty minute period of time. At intake, her Oswestry Disability Index score was 80%. Following medication management that included hydrocodone and fentanyl patches and four sessions of cartilage replacement therapy, an Oswestry Disability Index of 58% was reported. An Oswestry Disability Index was 32% following the implantation of temporary spinal cord stimulation trial lead bilaterally. The patient was taking minor tranquilizers at the maximum dosage/dosing previous to intake. She was counseled about the medication management protocol and endorsed the medication agreement and opioid consent form. The referral for Psychological treatment was made to setup ongoing supportive counseling, goal setting exercises, cognitive behavioral therapy and biofeedback approaches to address her pain condition. At intake, the Psychosocial Pain Inventory was used to identify the onset, duration, frequency, severity and location of the pain. Pain, prior to the intake was managed with a prescribed minor tranquilizer and active coping using her religious beliefs and practices. The patient was trained and worked as a professional nurse for some twenty years and possessed an understanding of her conditions. The patient’s home had been modified for wheelchair passage, rails in the bathroom and in the common area on the first level that had been transferred into a bedroom. The patient was attended by family members on two week interval rotations. The patient’s husband attended to the patient in the evening and weekends. The Strategies to Improve Motivation to Change, Pain Beliefs and Perceptions Inventory, and Oswestry Disability Index Scale were administered at intake. The findings from these scales indicated difficulty sleeping and a need to manage her time during the day. The patient was cooperative with the Psychological intervention addressing these two areas.


A 10-year-old male patient and his caregiver were looking for orthodontic treatment. Clinically, dental elements 53, 12, 51, 21, 22, and 63, including two supernumerary teeth erupted into the palate [], were observed in the region. A slight tilting in the palatal raphe associated with changes in the number of teeth and dental eruption chronology determined the complementary exams to be performed. The panoramic radiograph allowed identification of mesiodens in close contact with the tooth 21, tooth 51 in the oral cavity, and supernumerary teeth adjacent to the impacted permanent incisor (tooth 11). The occlusal radiograph, however, showed no well-defined position of the incisor and therefore it was not possible to define how many supernumerary teeth were present, nor the position of them in relation to the nasal fossae floor. There was no images compatible with expansive lesion [Figure and ].
CBCT images identified of the impacted tooth (11), which was horizontally positioned, in addition to other four supernumerary teeth presenting developmental anomaly [Figure and ]. One of the supernumerary teeth was centrally positioned on the alveolar ridge, between teeth 11 and 12, whereas the other was buccally positioned. The third supernumerary tooth was positioned in the palatal face of tooth 21, and the fourth one had the developmental anomaly and was transversally retained on the maxilla middle line, with its crown being posteriorly oriented. No evidence of cystic lesions and root resorption as dental follicle proliferation result.


A 10-year-old male patient and his caregiver were looking for an evaluation of the delayed dental eruption in the anterior region of the maxilla. Clinically, only teeth 53 and 63 were present in the region, in addition to a residual root of tooth 52 []. Impacted teeth (12, 11, 21, and 22) with suggestive images of supernumerary teeth in the maxilla anterior region were identified in both panoramic and occlusal radiographs, but these complementary exams provided no detail necessary for planning a surgical removal [Figure and ].
CBCT images showed that teeth 12, 11, 21, 22, and 23 were impacted and had an unfavorable eruption axis [Figure and ]. A hyperdense image, compatible with an amorphous structure of the teeth suggestive of complex odontoma, was identified in the region of the alveolar ridge of the right anterior maxilla, between teeth 11 and 21. Three abnormal supernumerary teeth were removed during the surgical procedure, 2 for lingual, and 1 for buccal. Absence of root resorption and cystic lesions in permanent teeth in the region [].


A 4 year old, ill looking male child presented one and half years back with one month history of left sided abdominal mass and intermittent fever. Developmental milestones were normal. Physical examination revealed large, irregular, firm, and nontender lump in the left iliac region. Complete blood counts (CBCs) showed hemoglobin 11.2 g/dl, total leukocyte count 7700/mm3, and platelet count 303,000/mm3. Liver and renal function tests were within normal limits including alkaline phosphatase. Lactate dehydrogenase was elevated. Chest X-ray was normal. Initial abnormal abdominal/pelvic ultrasonography supplanted by contrast enhanced computed tomography (CT) of abdomen and pelvis showed 12 cm × 10 cm × 12 cm heterogeneously enhancing soft tissue density lesion with internal necrotic areas and few specks of calcification in the region of the left suprarenal gland displacing left kidney, spleen and reaching up to the midline suggesting the possibility of left suprarenal mass. Biopsy and histopathology of the left suprarenal mass showed small uniform cells with dense hyperchromatic nuclei and scanty cytoplasm suggesting malignant round cell tumor possibly NB []. Immunohistochemistry was positive for chromogranin and synaptophysin []. Bone scan was normal. Bone marrow aspiration and biopsy showed involvement by metastatic tumor cells. Based on these findings, a definitive diagnosis of International Neuroblastoma Staging System stage IV NB was made. Patient was treated with Pediatric Oncology Group 8742 protocol consisting of five cycles of course A (cisplatin 40 mg/m2/day from day 1 to 5, etoposide 100 mg/m2/day from day 2 to 4) alternating every 21 days with course B (cyclophosphamide 150 mg/m2/day PO from day 1 to 7, doxorubicin 35 mg/m2 on day 8). The patient tolerated chemotherapy well without any toxicity. Evaluation by CT abdomen/pelvis showed partial remission in primary suprarenal mass and bone marrow was uninvolved. He underwent left adrenalectomy (R0 resection). Postoperative imaging did not reveal any abnormality at primary or at any other site (complete remission) []. He had very good clinical recovery but, unfortunately, was lost to follow-up.
After about 6 months, the patient again presented to local emergency department with acute onset altered sensorium and seizures. Routine blood tests such as CBC, renal function tests, liver function tests, serum electrolytes, viral studies for HIV/hepatitis C virus, and chest X-ray were normal. Magnetic resonance imaging (MRI) brain showed multiple patchy areas of cortical hyperintensities on T2/fluid-attenuated inversion recovery (FLAIR) images involving bilateral cerebral hemispheres and subcortical U-fibers without any postcontrast enhancement []. Cerebrospinal fluid (CSF) examination had mild pleocytosis, elevated protein level but was negative for malignant cells. Considering the possibility of acute encephalitis, he was treated successfully with intravenous methylprednisolone 30 mg/kg/day for 3 days followed by oral prednisolone (1 mg/kg/day) and gradual taper with dramatic complete recovery over a period of 2 weeks after which he was referred to our institute. There was a period of around 4 weeks between the onset of this acute episode and admission to our centre. On repeated enquiry history of occasional, intermittent, mild abdominal pain were elicited. The patient was conscious, oriented, and cooperative without any focal deficit. Physical examination revealed left supraclavicular lymphadenopathy, palpable mass in the left iliac region. CT abdomen/pelvis/thorax showed extensive recurrent lesion involving the left suprarenal region causing displacement of adjacent structures with extension to the thoracic cavity [Figures and ]. Serum paraneoplastic titer had high levels of anti-Hu antibody. Biopsy of left supraclavicular lymphadenopathy favored recurrent NB. Hence, a final diagnosis of paraneoplastic encephalitis preceding recurrent NB was done. Due to disseminated nature of the disease, he was planned for palliative chemotherapy. An extensive review of literature revealed only single case report of paraneoplastic encephalitis that too in the setting of recurrent NB prior to this one.


An 81-year-old woman with a background of asthma, ischaemic heart disease and achalasia presented to hospital with a 2-h history of worsening shortness of breath. On examination, she was in visible respiratory distress and was tachypnoeic at 24 breaths per minute, with oxygen saturations of 93% on room air. Examination of the chest revealed diffuse bilateral wheeze. She was tachycardic at 130 beats per minute and hypotensive. There was no specific trigger apart from the patient eating her lunchtime meal. She was also noted to have noisy inspiratory stridor. Furthermore, she had bilateral neck swelling which moved with expiration, and her neck veins were visibly distended. High-flow oxygen was administered, and an arterial blood gas revealed a respiratory acidosis with pH 7.19, p02 15.7 (on 15 l of oxygen), PC02 8.6 and a lactate of 2.9. A provisional differential diagnosis of infective exacerbation of asthma was made with stridor of unknown cause. She was given intravenous fluids and nebulized steroids, intravenous steroid and nebulized adrenaline.
A plain chest radiograph was taken demonstrating a massively dilated air and fluid-filled oesophagus, with no visible intraparenchymal lung abnormality. A 16-French gauge nasogastric tube was immediately placed into the oesophagus with aspiration of air, fluid and food debris. This resulted in almost immediate relief of the patient's respiratory distress, and she clinically improved.
After decompression of the oesophagus, a computed tomography (CT) scan of the chest confirmed the diagnosis of megaoesophagus causing tracheal compression. The patient, now stabilized, was referred for oesophago-gastro-duodenoscopy (OGD) with a view to Botulinum toxin treatment for underlying achalasia (Figures –).


A 26-year-old male patient resident of Nagpur reported at a private E.N.T clinic with a chief complaint of a mass in the right nasal cavity since 3 years. The patient also gave history of right nasal blockage and nasal discharge since 3 years. It was a slow growing growth since onset. The patient gave similar history of right sided nasal mass 5 years back, for which he was operated upon in a private clinic and the mass was removed. The histopathological examination was not performed at that time. He remained alright for 2 years postoperatively. After few months, patient started experiencing intermittent nasal obstruction and nasal discharge in the absence of upper respiratory tract infection. However, as the time passed by these symptoms aggravated and he started experiencing some nasal mass inside right nasal cavity. On anterior rhinoscopy, a solitary, pinkish, pedunculated, irregular, firm mass was located in right nasal cavity. On probing, mass was attached to lateral wall of right nasal cavity and mass did not bleed on touch. Computed tomography (CT) scan was advised and it revealed that the tumor was arising from middle meatus of right nasal cavity and there was widening of osteomeatal complex of right side. On contrast, there was mild to moderate enhancement seen. This mass was quite large and measured approximately 7 cm × 6 cm. Based on the clinical features and radiographic findings, a provisional diagnosis of papilloma was given. The mass was surgically excised by lateral rhinotomy with medial maxillectomy [] and the excised tissue was sent to the Department of Oral Pathology and Microbiology for histopathological examination. Gross examination revealed a single bit of soft tissue specimen of size approximately 3 cm × 2 cm, pinkish-white in color, irregular in shape, firm in consistency with rough surface texture. On histological examination, the hematoxylin and eosin stained section showed polypoid tissue covered with pseudostratified columnar ciliated epithelium with admixed mucocytes (goblet cells) and intraepithelial mucous cysts at places, which showed inversion into the underlying connective tissue stroma to form large clefts, ribbon and islands. The connective tissue cores were fibrocellular in nature with chronic inflammatory cells chiefly lymphocytes. Clinicopathologic correlation was suggestive of final diagnosis of inverted papilloma [Figures –].


A 42-year-old male patient was referred to our hospital with a painless swelling in the right mandible of 6 months duration. Clinically lingual expansion was evident. Skin over the lesion was normal and no regional lymph node enlargement was noted. Intraorally, there was marked bone expansion. Both lingual and buccal cortical plate expansion extending from right lower first premolar to retro-molar region was noticed. On palpation, swelling was smooth, nontender and bony hard in consistency. Mucosa over the lesion was normal. Orthopantomogram [] showed expansile lytic lesion in the body of mandible involving the roots of premolars, first and second molars. The lateral aspect of the lesion shows faint sclerosis. Computed tomography (CT) [Figures and ] showed expansile lytic lesion with patchy sclerosis measuring about 4.2 cm × 3.5 cm (Tr × AP). No unerupted teeth were noted within the lesion. There were no loculations or fluid-levels within the lesion. The central densities within the lesion were of soft tissue density, suggesting solid or fibrous lesion rather than a cystic lesion. The CT diagnosis was that of OF due to patchy sclerosis. No cortical breach was noted in three-dimensional surface shaded display images. The margins of the lesion blended smoothly with rest of the body of mandible.
The incisional biopsy and surgical enucleation with curettage of lesion [] that were done under local anesthesia and sent for histopathological examination, revealed similar findings. Grossly, specimen consisted of multiple irregular mass of pinkish-white tissue largest measuring 3 cm × 2.5 cm. Mass was gritty on cut section with grey-white solid area. Histopathologically, [] a mass of highly cellular stroma with calcified areas was evident. The stroma composed of proliferating fibroblasts arranged in various patterns such as storiform and whorls was noted. Calcified areas appeared to be composed of cementum-like substance. No cellular atypia or atypical mitotic activity was noted. The lesion was diagnosed as COF. The patient was reviewed after 2 months of surgery; complete healing had taken place and was asymptomatic on follow-up after 6 months.


A 3-day-old female full-term infant weighing 2.45 kg at birth was admitted with complaints of a mass in the oral cavity measuring about 4.3 cm × 3.2 cm. Clinical examination of the newborn revealed the presence of a pink, bilobed, pedunculated, nontender smooth surfaced mass with a firm consistency arising from the right side of the maxillary alveolar ridge []. Respiratory distress was not evident, but the child had sucking problems. In discussion with the pediatrician and anesthetist, surgical excision was planned under general anesthesia. After preoperative evaluation, surgical excision of the mass was done by the use of cautery after orotracheal intubation under general anesthesia [] on the 5th day of life without any complications. The examination of the resected specimen showed a bilobular, encapsulated, smooth mass which was pedunculated. On histological examination, the tissue was seen to be composed of sheets of large polygonal granular cells with distinct borders, having abundant granular eosinophilic cytoplasm and predominantly eccentrically located vesicular nuclei with conspicuous nucleoli [Figures and ]. Infant was able to commence feeding on the second postoperative day and was discharged on his 8th day of life with normal closure of the mouth and was able to suck normally. The postoperative period was uneventful with infant not showing any signs of recurrence after 4 months of follow-up.


A 61-year-old woman presented to the gynecology department with complaints of atypical genital bleeding. Vaginal examination revealed an elastic-hard mass beneath the anterior vaginal wall. Magnetic resonance imaging (MRI) revealed a localized urethral tumor extended to vagina (Fig. ). Histological test of the biopsy tissue of the mass suggested the adenocarcinoma. Computed tomography did not reveal any evidence of metastasis. Under the diagnosis of urethral tumor, the patient was referred to our department. Because the fenestration of the anterior vaginal wall was performed under the diagnosis of the abscess in the pelvic floor for the patient ∼15 years ago and the histological test demonstrates the adenocarcinoma, we suspected a urethral diverticular adenocarcinoma.
On admission, we performed standard open total cystectomy with lymph node excision and ileal conduit. The resected specimen showed the mass on the anterior vaginal wall (Fig. ). Histopathological examination of the specimen showed adenocarcinoma tumor that continues to anterior vaginal wall, but urethral diverticular wall could not be identified (Fig. ). We could not establish a diagnosis of urethral diverticulum; however, we clinically diagnosed as urethral diverticular adenocarcinoma. The proximal margin was negative, and all lymph nodes were negative. Because the post-surgical course was uneventful, the patient was discharged from our hospital on Day 27 post-surgery. The patient is doing well without recurrence or metastasis for 12 months.


A 16-year-old male presented with asymptomatic facial skin lesions which he had since early childhood. There was no history of predisposing factors. He had been using topical treatment but without any help. Family history revealed a similar case in his younger brother. His parents are not consanguineous. Skin examination revealed diffuse nonscaly reddish-brownish patches and multiple skin-colored, hypopigmented follicular papules on both cheeks (fig. ). On the basis of the above classical clinical findings, the diagnosis of EFF was made. The patient was reassured and put under periodic follow-up.


A 63-year-old right-handed man with type 2 diabetes, hepatitis C virus treated with interferon several years ago, and alcohol and opiate use disorders presented with altered mental status. Twenty-one days prior to arrival at our institution, the patient had been admitted to the intensive care unit at an outside hospital for treatment of a morphine overdose, having been found unconscious and hypopneic by his wife. He was treated for opiate overdose, acute kidney injury and aspiration pneumonia, and discharged home after 1 week with a normal mental status. Head CT during that admission was normal. He was readmitted 10 days later for evolving neurobehavioral symptoms including walking around nude in his apartment, trying to use a remote control as a telephone, and having difficulty dressing himself. Workup included normal CBC, CMP, ESR, TSH, B12 and folate; Lyme and HIV were negative; urine toxicological assay was positive only for THC. Brain MRI 17 days after the overdose revealed bilateral cerebral white matter FLAIR hyperintensities, sparing the cerebellum and brainstem (fig. , top row).
On transfer to our institution, the patient displayed signs of a florid disinhibition syndrome with facetiousness and inappropriate jocularity, as well as disorientation, confabulation, and perseveration. Attention and short-term memory were profoundly impaired. Cranial nerves and motor strength were normal. There was hyperreflexia, more notable in the lower extremities; gait was wide-based, with short steps. DPHL was suspected based on the radiographic findings and history of recent hypoxic injury.
Further evaluation at our institution included anti-thyroid peroxidase antibodies, RPR, and HIV RNA PCR, which were all negative; serum methylmalonic acid was normal. HCV PCR was undetectable, consistent with reported prior treatment. EEG showed diffuse theta and frontally predominant delta slowing. Lumbar puncture was bland, including bacterial cultures and HSV PCR. MRI with contrast, performed 6 days after admission to our hospital (27 days after overdose), showed worsening T2 hyperintensity in the cerebral white matter and corpus callosum, as well as new frontoparietal white matter diffusion restriction (fig. , bottom row); frontoparietal magnetic resonance spectroscopy displayed a mild decrease in the NAA to creatinine ratio, and a mild increase in choline to creatinine peaks, without a lactate peak.
His neuropsychiatric function continued to deteriorate, with loss of bowel and bladder control and emergence of parkinsonism with rigidity, cogwheeling, and bradyphrenia, progressing to marked apathy and mutism. This continuing decline prompted an initiation of antioxidant therapy for the reasons outlined below, comprising vitamin E 400 mg daily, vitamin C 1,000 mg daily, B-complex vitamins, and coenzyme Q10 400 mg three times a day. His neurocognitive status markedly improved after the initiation of antioxidant therapy, with increased spontaneous movement and speech, and gradual improvement in memory, orientation and motor function. He continued to make significant gains during inpatient and outpatient rehabilitation. Ten weeks after the initial date of admission, his gait and strength had returned to baseline, but he was left with residual emotional lability and impaired impulse control.


A 76-year-old male presented with a six-month history of pain in his right knee joint. The pain occurred insidiously without any antecedent trauma. He exhibited no signs of meniscal tear, ligamentous injury, or limitation of motion, but had pain on terminal extension. He also complained of intermittent pain while walking, but he denied any pain at rest or constitutional symptoms.
An initial physical examination showed no specific swelling of the right knee joint. He experienced anterior knee pain on terminal extension with a limited knee extension of 10°. The patient showed neither ligamentous instability nor positive findings on mechanical tests.
Simple radiographs of the knee showed no definite osteoarthritic change on the tibiofemoal joint or a soft tissue density lesion, although small calcification was observed on the suprapatellar pouch (). T1-weighted MRI scans of the right knee joint showed a lobulated, well-defined mass in the IFP with intermediate signal intensity, whereas T2-weighted images showed homogeneous and relatively high signal intensity but no hypointense areas such as calcified nodules or hemosiderin deposits. Both T1 and T2 weighted images showed that the mass was bisected by band-like septa of low signal intensity ().
The patient underwent arthroscopic excision. Conventional anteromedial and anterolateral portals were introduced to confirm the preoperative MRI findings. Far medial and far lateral portals were made to clearly visualize the mass and thoroughly remove it arthroscopically. The arthroscopic findings showed a whitish, ovoid-shaped mass buried in the IFP ().
After debridement of some of the fat pad adjacent to the mass, a freely movable large-sized mass was exposed (). The mass was completely excised with a punch and shaver and completely removed. No damage to the cruciate ligament was found but mild osteoarthritic changes, considering the old age, were shown, such as minimal meniscus tear and articular cartilage wear. Histopathological examination of the mass showed unevenly distributed plump chondrocytes with cellular atypia, some binucleated, within irregularly-shaped nests of cells. Neither zonal ring-like calcification nor enchondral ossification was observed (). These findings were consistent with a diagnosis of primary synovial chondromatosis. At 20-month follow-up, the patient was taking part in normal daily activities.


A 17-year-old female patient presented with a subcutaneous swelling on the flexor surface of the lower part of the left arm for last 3 weeks. The swelling was accompanied by mild pain. It was 2 cm × 2 cm, spherical in shape with well-defined margins. The swelling was freely mobile without any signs of acute inflammation. The patient did not reveal any other swelling in the body. Routine hematologic tests showed complete blood count and erythrocyte sedimentation rate within normal limits. Peripheral smear prepared from the patient's blood did not demonstrate any parasite. Absolute eosinophil count and eosinophil count were within normal limits (absolute eosinophil count 200/mm3, eosinophils 2%).
Clinical diagnosis of neurofibroma/lipoma was made by a treating physician and the patient was referred to the Department of Pathology for FNAC, which was done using a 10 mL syringe and a 22 gauge needle under aseptic precautions yielded pus. Aspirated material was spread on slides, air-dried, and stained with Giemsa stain and Ziehl-Neelsen stain for acid-fast bacilli.
Cytological examination of Giemsa-stained smear showed a large number of microfilaria in the background of degenerated inflammatory cells that comprised of neutrophils, eosinophils, histiocytes, and lymphocytes. The microfilaria had typical features of the presence of hyaline sheath, cephalic space, and tail end devoid of nuclei. Thus, these Wuchereria belonged to the species bancrofti [].
Ziehl-Neelsen staining did not show any acid-fast bacilli.
The patient was treated with diethylcarbamazine [100 mg ter die sumendum (TDS)] for 21 days and kept on follow-up. The swelling subsided by the end of the 3rd week.


Female patient, 70 years old, phototype III, retired, sought medical attention due to
10-year-old lesions that progressively increased in number and size. She was a
smoker, with a history of bilateral saphenectomy at 24 years of age and ischemic
stroke at 62. A dermatological examination revealed erythematous papules of
translucent surface, some of them confluent forming well-delimited plaques affecting
mainly the pretibial region ().
Laboratory investigation did not show alterations, including TSH, free T4,
anti-peroxidase, anti-thyroglobulin and anti-TSH receptor antibodies. Echo-doppler
of lower limbs showed venous and lymphatic insufficiency.
Histopathological examination demonstrated, with hematoxylin-eosin staining, loss of
collagen-fiber deposition, discrete perivascular infiltrate, prominent fibroblasts
and presence of hemosiderin; with Alcian Blue staining, mucin deposition across the
entire dermal thickness ( and ).


Herein we present the case of a 57-year-old non-smoking male patient who suffered left subtotal ear amputation because of an iron-plate cutting accident. On examination, the subtotal ear amputation of the helix, antihelix and a part of the choncha from the apex of the helix to the middle part of the lobule was seen. The subtotal amputated ear was measured as 80 × 25 mm. Only a 5-mm wide skin pedicle, which connected the amputated ear to the inferior part of the lobule, was left intact (). The edges of the wounds were irregular and the superior part of the amputated ear had congestion due to its bleeding too little. The patient had no associated injury or medical disorders.
The operation was performed under general anesthesia, about two hours after the injury. First, the wound margin was debrided for about 1 mm until bleeding was observed, except for the skin pedicle. The ear was reattached without microsurgical techniques and layers including skin and cartilage were sutured by using 5/0 PDS sutures with 2 mm suture intervals. A light compression bandage was used at the end of the operation. Post-operatively, low-molecular weight heparin (clexane 0.4 ml, every 12 hours) and a prophylactic antibiotic (1 g cefazolin, every 12 hours) were administered for one week. Venous congestion was seen just after the operation and intermittent bleeding was performed especially in the upper part of the segment to improve circulation for three days (). After two months, the replanted auricle healed completely and, compared to the right ear, the reconstructed ear had the same two-point discrimination sensitivity ().


Ms X, a previously healthy 41-year-old woman, was diagnosed with metastatic oesophageal adenocarcinoma 2 months preceding this acute episode. She completed a course of palliative radiotherapy (30 Gy in 10 fractions) to the primary tumour for local symptom control, before commencing systemic therapy with FOLFOX chemotherapy. On day 3 of her first chemotherapy cycle, 8 h following disconnection of the 5-fluorouracil infusion pump, she presented acutely, complaining of progressive central chest pain, shortness of breath, palpitations and diaphoresis. Her blood pressure was 92/60, and her heart rate was 110, with a regular pulse. Systemic examination was otherwise normal.
Blood tests revealed a troponin-T of 29 ng/l (twice the upper limit of normal) and D-dimers of 2.0 μg/ml (four times the upper limit of normal). A biochemistry profile and full blood count were otherwise unremarkable. An electrocardiogram (ECG) demonstrated T-wave inversion in the lateral leads, which was new compared with her baseline pre-chemotherapy ECG (Fig. ). A transthoracic echocardiogram showed impaired left ventricular systolic function, with mid- and apical left ventricular hypokinesis, and an estimated ejection fraction of 25% (Fig. ). Later that day, she proceeded to coronary artery catheterization, which demonstrated normal coronary arteries, severe left ventricular dysfunction and a measured ejection fraction of 15%. A CT pulmonary angiogram examination showed no evidence of pulmonary embolus.
Ms X was treated with bisoprolol and ramipril, and analgesia as required for the chest pain, along with supportive measures. No further cardiac medications were indicated. Serial cardiac data demonstrated normalization of ECG changes and troponin within 2 days of presentation. Ms X's symptoms resolved over the same time period. A repeat echocardiogram carried out 2 weeks later demonstrated normal left ventricular function.
For her second chemotherapy cycle—commenced 3 weeks after cycle 1—5-fluorouracil was discontinued and replaced with capecitabine, which was well tolerated. Two weeks after commencing capecitabine, an echocardiogram demonstrated normal left ventricular function. She remained symptom free for the duration of her treatment.


A 23-year-old male was referred to the emergency unit because of rapidly progressive gait difficulties with subacute onset.
The patient had a history of depression and substance use disorders (alcohol and amphetamine). He was treated as an outpatient at the department of psychiatry. Current medications included citalopram 40 mg, hydroxyzine 25 mg and quetiapine 50–100 mg per day, and oxazepam 15 mg as needed. A year before presentation, the patient had a transient episode of mild gait difficulties with unclear aetiology that had resolved spontaneously. At that time, he had gait ataxia with signs of upper motor neuron damage in all extremities. Brain and cervical spinal cord MRI were unremarkable, except for mild atrophy of the cerebellar vermis and frontal cortex, which were interpreted to be related to the long-term alcohol abuse.
The patient presented at the university hospital emergency care unit (ECU) with a 2–3-week history of progressive, painless gait difficulty associated with numbness in the hands. The patient had been abstinent from alcohol and amphetamine at least for the past 6 months, which was confirmed by regular laboratory investigations. However, the patient reported having replaced these substances with excessive daily ‘whippet’ abuse. He had discontinued ‘whippet’ use and started oral vitamin B12 substitution based on the information he found on the Internet a couple of weeks before presenting to the ECU. At the time of presentation, the gait difficulty had progressed to a state that he was unable to walk unaided.
In the ECU, the patient showed bilateral lower extremity weakness that was the most prominent in distal lower limb muscles. In addition, there were minor distal paraesthesias in all extremities. Vibration sense was absent up to the knee level, but all other sensory modalities were intact on clinical examination. Deep tendon reflexes were 2+ in the upper limbs but absent in the lower limbs. Plantar reflexes were evaluated as extensions in the ECU, but as flexions later in the neurological ward. Gait was ataxic, and there was ataxia in the lower limbs, but not in the upper limbs. There were no signs of cerebellar involvement. Mental status and cranial nerves were intact. Vital signs, general medical examination and laboratory examinations were unremarkable.
In the neurological ward, laboratory examinations revealed markedly elevated plasma homocysteine levels (110 umol/l, normal range 5–15 umol/l), indicating vitamin B12 deficiency despite normal B12 levels (plasma B12 176 pmol/l and serum active B12 116 pmol/l). Electrophysiological examination was consistent with subacute axonal motor polyneuropathy affecting mainly the lower extremities. In addition, there was also mild demyelinating polyneuropathy in all extremities (Tables and ). The patient was treated with intramuscular vitamin B12 injections 1 mg per day for 2 weeks, followed by oral supplementation. At the ward, the clinical condition remained unchanged, and the patient was transferred to a rehabilitation unit 8 days later.
Three months later, the patient was re-evaluated as a neurology outpatient. The patient had remained abstinent from nitrous oxide and showed marked improvement. He experienced only weakness (muscle strength 4/5) in the distal lower limb muscles. Vibration sense had normalized, and tendon reflexes were normal throughout with plantar flexions. There was no muscular atrophy present, and he was able to walk unaided.
Approximately 1 ½ years following the symptom onset, the patient was found from his home lifeless in a ‘lotus’ position, face towards the floor. The patient was surrounded by empty nitrous oxide cylinders, and altogether there were thousands of nitrous oxide cylinders in the apartment. At the medicolegal examination, the main cause of death was determined as acute amphetamine intoxication. Furthermore, in the toxicological analysis of post mortal femoral blood, hydroxyzine (0.35 mg/l) and alprazolam (0.060 mg/l) concentrations exceeded the therapeutic levels. In the qualitative drug analysis of urine, also methamphetamine, phenylpropanolamine and fentanyl were found. There were no alcohols, volatile substances nor nitrous oxide detected in the samples, but the investigation was limited by the long interval between death and medicolegal examination.


A 4-year-old female child came to the emergency of a medical college with the history of accidental impaction of the head of a toothbrush while brushing her teeth. The handle of the toothbrush was broken, and the head along with the adjacent part of the handle remained in her throat. She was unable to expel it out from her mouth. Instead, she tried to swallow it repeatedly and eventually got it stuck in her throat.
Her parents took her to the emergency of a nearby health center but, unfortunately, no dentist was posted there. The patient would have been relieved immediately if the service of a dental surgeon was available. The general physician took no risk and after initial supportive treatment with parenteral analgesics and antibiotics, he referred the patient to a higher level medical institution, where proper medical facilities are available.
On the next day, she was brought to the emergency of a medical college with odynophagia, swelling on the left side of the neck and fever. As it was not a dental college, the patient was admitted under the Department of Otolaryngology. Joint effort of a dental surgeon and an otolaryngologist would have been the best, but due to infrastructural constraints, the otolaryngologist had no other option.
She was complaining of pain in the throat and was unable to open her mouth completely or take food and drinks. She was restless and was having mild respiratory distress. Her temperature was 102°F, and she was mildly dehydrated.
On examination, there was edema of the uvula and the left lateral wall of the oropharynx including both pillars of the left tonsil. Bloodstained saliva was found in the oropharynx, but there was no mucosal injury. There was a swelling on the left side of neck posteroinferior to the angle of the mandible which was extremely tender. As the patient was a child and was in distress, the indirect laryngoscopic examination was not possible. The patient was unable to cooperate for flexible pharyngolaryngoscopy.
Plain radiograph of the neck and chest revealed no significant abnormality. Computed tomography (CT) scan of the neck [] revealed the head of the toothbrush with its bristles occupying the left parapharyngeal space.
The patient was administered intravenous fluid, broad spectrum antibiotics, corticosteroid, and others to improve her condition before the operation. Taking a decision about the approach for its removal was a little difficult. It was decided that the toothbrush should be tried to be removed by endoscopic approach first, and if it failed, the external approach would be adopted.
The patient was operated under general anesthesia. A Boyle Davis mouth gag was introduced. The oral cavity and the oropharynx were cleaned by suction. Initially, the toothbrush could not be located. There was a moderate degree of edema involving the left lateral wall of the oropharynx and hypopharynx extending toward the laryngeal inlet. After a thorough examination, the broken end of the handle, which was light yellow in color, was found to be protruding inside the left pyriform fossa from its lateral wall. However, the exposure of the foreign body was not satisfactory. The Boyle Davis mouth gag was removed, and a rigid hypopharyngoscope was introduced. The entry point of the toothbrush was located. The head along with the bristles was found to be embedded inside the left parapharyngeal space. The handle of the toothbrush was grasped with a foreign body removing forceps and pulled gently, but the head was found to be strongly impacted within the soft tissue of the neck due to the presence of the bristles in it. The entry point in the left lateral pharyngeal wall was carefully widened a little by using a blunt probe, and the head was gradually disimpacted. After that, the toothbrush was removed by gently pulling, as well as rotating it slightly in either direction to free it from the surrounding soft tissue. It was done slowly with utmost care to avoid injury to the adjacent important structures. On measurement, the toothbrush was found to be 5.4 cm long including the broken part of the handle and 1.8 cm broad at the head [].
After removal of the toothbrush, the wound in the left lateral pharyngeal wall was carefully inspected. There was no significant injury to the other adjacent important structures. The wound was apposed by applying stitches with absorbable suture material.
To eliminate the risk of respiratory obstruction in the postoperative period, a tracheostomy was done as a preventive measure. A Ryle's tube was introduced for feeding in the postoperative period.
The patient was kept on intravenous fluid on the day of operation. Ryle's tube feeding was started from the next day. The patient recovered quickly. On the fifth postoperative day, the tracheostomy tube was removed, and the wound was closed. The Ryle's tube was also removed on the same day, and the patient was allowed oral feeding. The patient was discharged 7 days after the operation.


A 32-year-old male patient reported to our center with the complaint of swollen gums in lower anterior region. The clinical examination revealed gingival overgrowth on the labial aspect from distal of 33 extending to distal of 43 region with periodontal probing depth of around 6 mm, OPG revealed deep caries in 11 and 12 and root stumps in 18 []. His medical history revealed a history of epilepsy since 14 days of his birth with frequent epileptic episodes. His medications included Eptoin 100 mg, Sodium Valproate 500 mg, and Levetiracetam 500 mg, thrice daily. He was considered a high risk patient for any dental procedures under local anesthesia as he had poor control of the disease, in spite of taking the maximum recommended dosage of anticonvulsants. So, conscious sedation was considered a safe technique as it reduces the risk of stress-induced epilepsy.
After obtaining the medical fitness and informed consent of the patient, the treatment plan included gingivectomy in relation to lower anteriors, crown lengthening in relation to 11 and 12, endodontic therapy in relation to 11 and 12, and extraction of 18 in single sitting under conscious sedation.


A 41-year-old woman was referred for vaginal bleeding. The previous day, she underwent a TOT procedure in a private gynecologic clinic. She urinated without difficulty and was discharged from the clinic. However, she presented with abdominal pain and voiding difficulty at the next day. She went to original clinic, they inserted foley catheter into her bladder to drain, she urinated 1,000 mL after foley catheter insertion. The original surgeon found hematoma on the vaginal wall and undertook hematoma removal. However, the vaginal bleeding persisted. Her hemoglobin dropped from a preoperative level of 15 to 9.6 g/dL. After packing with vaginal gauze, she was sent to our emergency care center. After arrival, she appeared pale and acute illness. Her blood pressure was 104/66 mmHg with tachycardia at 100/min. The left vaginal wall was found to be edematous and active bleeding. However, it was difficult to identify focus of bleeding. On the laboratory findings, the hemoglobin was 8.1 g/dL after two units of packed red cell transfusion, and coagulation factors, electrolytes, chemical batteries were within normal range. The patient was taken to angiographic room for embolization. Angiography showed extravasation of contrast from the upper vaginal branch of left internal iliac artery (). After super selection via microcatheter, selective embolization with glue were undertaken. Then extravasation of contrast was stopped. After embolization, vaginal bleeding was decreased and her vital signs stabilized. On post operation day 3, no evidence of active bleeding after embolization was observed on abdomen and pelvis computed tomography (CT). On post operative day 4, she reported no vaginal bleeding, she was discharged. Twelve days after her completed operation, she went to the emergency room, complaining of lower abdominal pain. Through the abdomen and pelvis CT scan, it turned out that the size of residual hematoma had decreased and extravasation didn't show up on the contrasted CT. She was discharged from the emergency room after receiving pain modulation. Fourteen days after the operation, we conducted a follow-up consultation and her abnormal pain had been mitigated. She did not show signs of any of the specific abnormalities. Her stress incontinence symptoms also improved in a follow-up consultation conducted in 3 months later.


A 43-year-old woman was referred for low abdominal pain after TOT procedure in a private gynecologic clinic. Abdominal pain lasted for 7 hours after procedure and she went to our emergency care center. On arrival, she appeared pale and acute illness. Her blood pressure was 102/75 mmHg and heart rate was 95/min. She complained lower abdominal tenderness and rebound tenderness. Vagina and cervix were no specific findings in pelvic examination. Vaginal bleeding was scanty. After arrival, her hemoglobin was 12.6 g/dL and coagulation factors, electrolytes, chemical batteries were within normal range. Abdomen and pelvis CT showed a 10-cm-sized hematoma in left pelvic cavity with extravasation of contrast. Abruptly, her blood pressure dropped to 96/63 mmHg. Hemoglobin dropped from 12.6 to 10.9 g/dL. During resuscitated with intravenous fluid and two units of packed red blood cells, we made a diagnosis as retroperitoneal pelvic hematoma with active bleeding. She was taken to operation room for evacuation of hematoma and bleeding control. We found a large amount of hematoma in abdominal cavity and undertook hematoma removal. Although we tried to find bleeding focus but we couldn't, and bleeding persisted at pelvic wall. We sent her to our angiographic room for embolization to confirm pelvic vessel injury. Left iliac artery angiography showed extravasation of contrast from pubic branch of Left obturator artery (). After use of glue, post embolization angiography showed remained bleeding foci. Left external iliac artery angiography showed extravasation of contrast from Left inferior epigastric artery (). After insertion of microcoil and use of gelfoam, extravasation of contrast was stopped. After embolization, her vital signs stabilized and hemoglobin was 11.4 g/dL. Patient was given 8 units of packed red cells during her hospitalization. Since the overall amount of vaginal bleeding diminished, she had no longer complained of leakage symptom. She was discharged on postoperative day 5 without any complications. On postoperative day 11, she went to our emergency care center because she presented with lower abdominal pain. Abdomen and pelvis CT showed a size of residual hematoma decreased from 10 to 7 cm without contrast extravasation. On post operative day 13, she had no further symptoms.


A 43-year-old woman underwent a TVT-S procedure in our gynecologic clinic. During operation, we found hematoma on the left anterior vaginal wall and active bleeding were observed from the incision in the suburethral portion. We undertook hematoma removal and tried to find bleeding focus. However we couldn't find a definitive bleeding focus, and bleeding persisted at vaginal wall. Patient was given 8 units of packed red cells and 3 units fresh frozen plasma during operation. We decided to undergo embolization for treatment of pelvic vessel injury. The patient was taken to angiographic room for embolization. No definite bleeding focus on left internal and left common iliac arterial angiography. Embolization of anterior trunk of left iliac artery using gelfoam was done. After embolization, the vaginal bleeding was stopped and her vital signs remained stable. On the following day, no vaginal bleeding was observed. She was discharged on postoperative day 7 without any complications.


A 35-year-old male, manual laborer by occupation, with left hand dominance, presented to the casuality department, sustaining an accidental injury due to entrapment of his left upper limb in concrete mixer while working. He presented after a delay of 24 h as the patient was referred from primary health center. The patient was transiently hypotensive with blood pressure below 90 but responded well to intravenous fluid.
He sustained severe crush injury of the left forearm, wrist and hand. There were multiple lacerated wounds, around 15-20 in number, criss-cross in shape, each approximately 3 cm × 2 cm in size serially longitudinally arranged on both volar and dorsal aspect of forearm, wrist and hand, on the radial side of limb, sustained due to entrapment of limb in rotating concrete mixer, caused by the rotating motor blades. The skin and muscles were severely crushed over the radial side of forearm, wrist and palmer aspect of the thenar eminence. The thumb was attached with skin tags only. The tendons and muscles were normal over hypothenar area. Multiple small bone pieces of the radius were seen and can be palpated from the wound, whereas surprisingly the ulna was felt intact. The wound was grossly contaminated. Surprisingly all active finger movements were present though reduced, in all four fingers except the thumb. Ulnar pulse was palpable whereas radial pulsations were absent clinically as well as on color doppler. Capillary reflow was sluggish on the radial side. Hypoesthesia was present only on dorsum in first web space, whereas ulnar and median nerves were intact. The elbow, arm and the shoulder were normal. The mangled extremity severity score (MESS) of the limb was 8 (age group – 30-50 [1 point], shock group - transiently hypotensive [1 point], skeletal/soft tissue group - medium energy injury [2 point], ischemia group – moderate [2 point], ischaemia time >6 h [2 point]).
Primarily, gross contamination was removed by thorough irrigation of the wound and primary splintage done, which was followed by administration of third-generation cephalosporin antibiotics and tenatus toxoid. Thus after stabilizing the patient haemo-dynamically, anteroposterior (AP) and lateral radiographs of the entire affected forearm, wrist and hand were taken, which showed severely comminuted fracture with multiple bony pieces arranged in criss-cross pattern in middle and distal third radius (bag of bones), along with intraarticular extension. Ulna and all the carpals were intact with maintenance of the inter-carpal relation. The radiological examination of the hand showed comminuted fracture of 1st and 2nd metacarpal, with crushed thumb and severely comminuted fracture of the proximal and distal phalanx of the thumb [].
Although MESS score of the patient was >7 a score validate for amputation, we, on the contrary, planned the patient for limb salvage reconstructive surgery. Under brachial block, in the supine position, initial debridement along with thorough irrigation of the wound was done, with removal of all dead necrotic tissues and refreshing the muscles and skin, till fresh bleeding points. The free loose bone pieces seen, were removed. As the thumb was severely crushed and was attached with only skin tag, which was impossible to reconstruction and hence the thumb was amputated from the metacarpophalangeal joint. After the debridement and thumb amputation, multiple lacerated wounds on the volar and dorsal aspect were closed in layers, whereas the wound on the dorso-radial surface of the wrist and hand was left open for regular dressing as it was not possible to close it primarily. This was followed by stabilization of the fractures, by application of a radio-metacarpal distracter maintaining the length of radius by passing two 3 mm schanz pins proximal to the fracture, in middle third radius at mid forearm between the brachioradialis and extensor carpi radialis brevis muscles and the two schanz pin distally, in the neck of the 2nd metacarpal, as the base of the 2nd metacarpal was also fractured [].
Regular dressing and antibiotics continued till 5 days and as the dorso-radial wound improved, split skin grafting was done. Sutures were removed after 2 weeks. Patient continued on radio-metacarpal distracter till 6 weeks followed by below elbow cast for further 4 weeks. Range of motion (ROM) exercises for elbow and fingers started with below elbow cast in place. ROM exercises for wrist also started after cast removal. Sound bony union was seen at 7 months with wound healing with no signs of infection, although with some amount of malunion and ulnar variance []. Elbow had full ROM whereas wrist had 30° of each palmar-flexion and dorsi-flexion. Fingers had near normal ROM. Pronation of the limb was about 70° and supination was restricted to 50°. Grip strength was about 75% compared to contra lateral side even without the thumb as tested objectively with dynamometer. Patient is being considered for policisation of the index finger for better functioning of the hand. At final followup of 7 months, both the dorsal and palmar sensation was intact except at dorsal first web space. Further, as thumb was amputated the strength, prehension ability and performance was reduced.


A 53-year-old woman visited a local obstetrics and gynecology clinic for a routine examination. Ultrasonography demonstrated a right ovarian cystic mass. The patient was referred to the Department of Obstetrics and Gynecology at Chosun University Hospital for further evaluation and treatment. The patient had a history of laparoscopic left salpingo-oophorectomy and adhesiolysis due to left ovarian teratoma and intestinal adhesion seven years earlier. She had also experienced an intracranial hemorrhage 3 years earlier, and had suffered from medication-controlled hypothyroidism for 5 years.
Abdominal computed tomography revealed a 5.5-cm cystic mass in her right ovary (). The cyst was unilocular with fluid attenuation, and there was no contrast-enhancing solid mass. Laparoscopy findings revealed a fluid-containing cystic mass that had a smooth surface with focal hemorrhage (). Laparoscopic right salpingo-oophorectomy and adhesiolysis was undertaken under the clinical impression of benign cystadenoma.
Gross findings revealed a previously collapsed cystic mass measuring 5 cm×4.5 cm×2.5 cm. The mass showed a 2.3 cm×1.2 cm solid part on one side. Histologic examination revealed benign and borderline CCAFs, endometriosis, atypical endometriotic cysts, and CCAC. The solid portion consisted of benign and borderline CCAF, CCAC, and endometriosis in descending order of prevalence. The cystic portion was merged into the solid portion of CCAF and CCAC, and consisted of benign and atypical endometriotic cysts.
The benign CCAF constituted a major portion of the tumor and demonstrated a compact arrangement of variably sized tubulocystic structures in the cellular stroma with no nuclear atypia. Flattened indiscernible, flat cuboidal, and polygonal cells with relatively abundant cytoplasm and no nuclear atypia lined the mass (). The glands in the borderline CCAF showed a greater degree of crowding and variation in size and shape compared with the benign CCAF. Focal nuclear atypia was observed in the glandular linings. The glands were delineated with one to three layers of cells with abundant cytoplasm and mildly pleomorphic, hyperchromatic nuclei. In some areas, stratified epithelium showed tiny buds with atypical nuclei. However, the glands in many areas were lined with non-atypical flat to cuboidal epithelium ().
The CCAC had a tubulocystic pattern with hobnail, cuboidal or flat atypical cell lining, characterized by nuclear enlargement and hyperchromasia. The glands were separated by fibrous stroma, and foci of altered stromal responses were noted. There was crowding of tubules with a slightly haphazard arrangement in some areas. The borderline CCAF had microinvasion characterized by a few cells scattered haphazardly in the surrounding stroma. The borderline CCAF and CCAC were scattered, and a histologic continuum between borderline CCAF and CCAC was found within the same tumor ().
The benign endometriotic cysts had a predominantly cystic gross appearance. Typical endometriotic cysts showed minimally stratified tubal-type epithelium overlying the scant endometrial-type stroma. This endometriotic epithelium gradually showed greater nuclear atypia, demonstrating a multilayered epithelium with hyperchromatic, enlarged and irregular nuclei with prominent nucleoli as it merged with possible intraepithelial carcinomatous areas ().
The presence of benign and borderline CCAFs, borderline CCAF with microinvasion, CCAC, endometriosis, and benign and atypical endometriotic cysts within this single ovarian mass suggests a histologic continuum among endometriosis, CCAF and CCAC.


A 10-year-old male presented with complaints of gait disturbance and vomiting for 2 weeks. On examination, he was drowsy and had left sided cerebellar signs and a weak gag reflex on left side. Magnetic resonance imaging (MRI) [] revealed solid-cystic lesion in left anterior cerebellum and cerebellar peduncle that was hypointense on T1-weighted (T1W), hyperintense on T2-weighted (T2W), had heterogenous contrast enhancement with surrounding edema. Midline suboccipital craniotomy was performed for tumor excision. Histology was suggestive of low-grade glioma. Thereafter, patient was lost to follow-up and presented 3 months later in unconscious state with a large recurrence and hydrocephalus. A critical review of previous biopsy showed few elements of atypical cells with high mitotic activity. The patient underwent a ventriculoperitoneal shunt followed by reexploration. Intraoperatively the tumor was vascular, infiltrating surrounding cerebellum with areas of necrosis. Histopathology revealed glioblastoma (World Health Organization [WHO] Grade IV) with highly cellular tumor showing nuclear pleomorphism and endocapillary proliferation. The patient did not gain consciousness after surgery. Computed tomography (CT) was suggestive of hypodensity and edema in brainstem. Further neurological deterioration was noticed next day with episodes of tachycardia and apnea. The patient finally succumbed to illness due to brainstem edema after 2 days.


A 9-year-old female presented with complaint of diplopia on far vision and facial deviation for 1 week. Examination revealed gait ataxia, left gaze, facial paresis, and subtle left cerebellar signs. MRI [] revealed a left peduncular lesion which was hypointense on T1W, hyperintense on T2W and had heterogenous enhancement on contrast. Two days later, she became unconscious, when a repeat CT showed intratumoral bleed again with mass effect. She underwent midline subocciptal craniotomy and had a friable, vascular tumor with necrosis. Histopathology revealed small cell glioblastoma (WHO Grade IV) with highly cellular tumor showing palisading necrosis, nuclear pleomorphism. Tumor cells stained positive for glial fibrillary acidic protein. Despite adequate decompression, the patient did not show clinical improvement. CT was suggestive of brainstem edema. There were scarce spontaneous respiratory efforts, pupil reaction was absent, and stimulus yielded minimal flexion response. She finally succumbed to illness after 1 month due to brainstem edema.


A 30-year-old male patient presented with complaint of gait ataxia and visual blurring for 3 weeks. Examination revealed left cerebellar signs and a brun's nystagmus with coarse component to left. CT head demonstrated a hyperdense lesion in left anterior cerebellum spreading to middle cerebellar peduncle. MRI [] demonstrated lesion that was hypointense on T1W, iso- to hyper-intense on T2W with necrotic foci at inferior end. Taking into consideration the close approximation to vital brainstem area, he was taken up for stereotactic biopsy. Histopathology revealed medulloblastoma (Grade IV) with high mitotic activity, high nuclear: Cytoplasmic ratio, and round cells. The tumor stained positive for synaptophysin and neuron-specific enolase. He received adjuvant radiotherapy and concurrent chemotherapy with cisplatin and etoposide. After ten weeks, he presented with headache and vomiting. Repeat MRI revealed slight increase in edema and hydrocephalus for which a ventriculoperitoneal shunt was performed. At follow-up of 6 months, he is conscious and independent for daily routine activities.


A 55-year-old lady presented to the emergency department with complaints of worsening weakness, vomiting, abdominal pain, and bleeding gums. In her last visit, a week ago, she was started on daily dose of tablet cholorambucil 10 mg on outpatient basis. Her complete blood profile showed haemoglobin of 5.3 g/dl, white blood cell (WBC) count of 42,000/mm3, and platelet count of 27,000/mm3. The differential leukocyte count showed 60% blasts and 15% lymphocytes. The blasts had high nucleo-cytoplasmic ratio, immature nuclear chromatin with 1–2 prominent nucleoli, and scant amount of agranular basophilic cytoplasm [Figure and ]. Flow cytometry performed [Figure and ] on the peripheral blood showed that the blasts were positive for CD10 (62.9%), CD19 (69.9%), CD20 (65.0%), CD34 (93.2%), and Tdt (70.2%) suggesting the diagnosis of B-cell acute lymphoblastic leukemia (Calla- Common acute lymphoblastic leukemia antigen positive B-cell [ALL]).
Patient's past medical history includes presentation to outpatient service with complaints of generalized weakness and fatigue about 8 months ago. Her examination then revealed splenomegaly, palpable 5 cm below the left coastal margin. There was no associated hepatomegaly or lymphadenopathy. Patient's complete blood count showed hemoglobin of 9.5 g/dl, WBC count of 40,000/mm3, and platelet count of 60,000/mm3. The differential leukocyte count showed 95% lymphocytes (absolute lymphocyte count of 38,000/mm3). Bone marrow aspirate showed hypercellular marrow with sheets of mature lymphocytes and few prolymphocytes (12% of the total nucleated cells) along with depressed erythropoiesis, granulopoeisis, and megakaryopoiesis. Final diagnosis of CLL was made and she was started on tablet chlorambucil 10 mg/day. After 2 months of chemotherapy, the patient stopped therapy and started taking medications on her own that she could not recall. Over a period of next 8 months, the patient was on regular hematological follow-up which showed persistent lymphocytosis (85–95% lymphocytes, absolute lymphocyte count of 16,920/mm3), bicytopenia (anemia and thrombocytopenia), and nucleated red blood cells (15/100 WBC counted). No abnormal/atypical cells were seen on the peripheral blood film examination. No flow cytometry evidence of this time was available.


A 45-year-old male presented with intermittent right lower quadrant abdominal pain for one month. There was no positive sign for physical examination. Abdominal enhanced computed tomography (CT) scan was performed and ileo-ileal intussusception was found. The ileal lipoma was diagnosed as the possible leading point. [Figure and ]. Single-incision laparoscopic surgery was performed with the approval of the patient.
The patient was placed in supine position under general anaesthesia. The conventional laparoscopic instruments were used. After pneumoperitonium was established, a 10-mm trocar was placed in the umbilical incision for camera access. An ileo-ileal intussusception was found through careful laparoscopic inspection []. The umbilical incision was then enlarged to 3 cm without cutting the anterior sheath of the rectus abdominis or linea alba in case of air leakage. Two other 5-mm trocars were implanted in the same incision []. The ileocecal region was identified first and the small bowel was gently detected to locate the lesion using two atraumatic forceps.
The ileo-ileal intussusception was located 60 cm away from the ileocecal region. Attempts to reduce the intussusception failed []. The holes for trocar access were connected to make a 3-cm incision. A disposable incision protector (Qingdao Huaren Mecial Product Co. Ltd, Qingdao, China) was inserted into the incision and the involved ileum was pulled out of the incision []. Ileal resection was performed the same as open procedures. An approximately 20-cm-long involved ileum was removed. After the anastomosis, the ileum was returned to the abdominal cavity. After careful inspection of the abdominal cavity for leakage or blooding, the umbilical incision was closed carefully using absorbable monofilament sutures.
The operation time was 65 min and the blood lost was 10 mL. The post-operative time before the patient left the bed was 6 h and 40 mg parecoxib was used after the surgery. Bowel function recovered and the gastric tube was removed the following morning. The patient was discharged on post-operative day 3 without any complication. A microscopic examination revealed inflammatory polyp [Figure and ]. The patient was extremely satisfied with the cosmetic results [Figure and ].


A 46-year-old female presented with the complaint of diffuse soft-tissue swelling in the back. The swelling was present since the last 2 years and was gradually increasing in size. It was nontender.
On examination, the mass was present in the right inferior subscapular region. It measured 8 cm × 6 cm in size. The surface of the swelling was smooth []. The routine hematological and biochemical examinations were within normal limits. The MRI was reported as showing focal ill-defined altered signal intensity lesion in right posterolateral chest wall deep to serratus anterior muscle [Figure –]. The patient underwent fine needle aspiration (FNA) cytology examination that was reported as lipoma. Following this, she underwent excisional biopsy. Grossly, the lesion was irregular, not capsulated, and measured 7 cm × 5 cm in size. The cut section was firm with grayish-white areas [].
Microscopically, the lesion was poorly circumscribed and showed an admixture of collagenous tissue with mature adipocytes. The striking feature in the lesion was the presence of numerous elastic fibers. The elastic fibers were large, coarse, and deeply eosinophilic in nature. Additionally, there were many fragmented ones, which gave the appearance of beads on a string. There was no area of necrosis or increased mitotic activity [Figure and ]. The Verhoeff's elastic stain confirmed the elastic nature of the fibers [Figure and ].
Based on the characteristic histopathological features and histochemical staining with Verhoeff's stain highlighting elastic fibers, the lesion was diagnosed as a case of elastofibroma. The patient had an uneventful postoperative period.


A 54-year-old healthy male, presented with multiple, variably sized, nonhealing ulcers over his right lower leg since 3 months. It started as a single coin-sized ulcer over the shin, which rapidly increased in size with the simultaneous appearance of multiple new similar lesions and swelling over the right leg. The patient had received multiple courses of oral and intravenous antibiotics despite of which his disease was progressing. There was no history of apparent trauma or evidence of an immunocompromised state. History of excursion to Amazon rain forest 1-month prior to the onset of ulceration was present.
Cutaneous examination revealed irregularly shaped ulcers ranging in size from pinpoint to 9 cm × 5 cm, covered with seropurulent slough [] distributed nonlinearly over the extensor aspect of the right leg. Few of them were herpetiform in morphology. The involved limb presented a cellulitic picture with diffuse erythema and induration. There was no evidence of any preceding nodulation. A single thickened lymphatic cord was palpable on the medial aspect of the thigh in the later course of his disease.
All the hematological and biochemical investigations were normal except for a raised erythrocyte sedimentation rate (45 mm/h). Magnetic resonance imaging lower leg showed findings consistent with cellulitis with no deep extension, abscess, osteomyelitis, or muscular involvement.
Histopathology and tissue culture samples were sent with a differential diagnosis of pyoderma gangrenosum, mycobacterial infection, cutaneous leishmaniasis, and deep fungal infection. Repeated cultures for the same were negative. Histopathology revealed multiple, poorly formed, epithelioid cell granulomas along with diffuse infiltrates of lympho-histiocytes, plasma cells, and neutrophils in the deeper dermis. Special stain (periodic acid-Schiff [PAS] and Gomori Methenamine silver stain) showed small budding and occasional elongated yeast cells in the dermis []. PAS stain from tissue imprints revealed cigar-shaped bodies suggesting Sprorothrix infection.
Patient was started on itraconazole capsules 200 mg twice daily monotherapy, with only marginal response. He developed multiple subcutaneous nodules and an ulcer over the right thigh even after 6 weeks of treatment. Thus, saturated solution of potassium iodide (SSKI) was added with complete clearance of the lesions in 10 weeks.


The patient was a 65-year-old male who experienced exertional dyspnea (Modified Medical Research Council [mMRC] grade 2) and palpitation in recent 3 months. A chest X-ray showed a nodular lesion in left upper field (Fig. A), and computed tomography (CT) revealed convolution and dilation of pulmonary vessels (Fig. B and C). Three-dimensional CT revealed convolution and aneurysm of bronchial artery (Fig. D). Bronchial arteriography demonstrated 4-mm dilated convolution and 20-mm sized pooling of contrast injection at segment 1 + 2 in the left upper lobe. Outflow from the vascular lesion into pulmonary artery of 1 + 2 was also present during the early arterial phase, suggesting the presence of fistula between bronchial and pulmonary artery, (i.e. BPAF) (Fig. E). Pulmonary arteriography revealed a decrease in filling of contrast injection into A 1 + 2 (Fig. F). The decrease in filling of contrast injection into pulmonary artery appeared to be explained by a possibility that higher blood pressure of the BPAF disturbed depiction of pulmonary arteriography. There was no fistulous tract between pulmonary artery and vein. Bronchoscopic study was not performed because of the patient's anxiety about airway bleeding.
Since 20-mm sized aneurysm of bronchial artery and BPAF coexisted, the patient underwent left video-associated thoracotomy, and then ligation of the bronchial arterial aneurysm and upper lobectomy were taken. Because the aberrant bronchial artery lesion reached to the lingular bronchus, it was hypothesized that upper lobectomy rather than upper division segmentectomy appeared to be the appropriate treatment. He was discharged home without any incident on postoperative day 5 and resolved his exertional dyspnea. No overt appearance of new aneurysm in bronchial artery was seen in follow-up CT 1 year later.
Pathological examination revealed irregular thickness of media and abrupt calcification in the vascular wall of dilated bronchial arteries. No findings of vasculitis, including inflammatory infiltration and plexiform lesion, were seen (Fig. ).
There was no history of infection, foreign body ingestion, trauma, upper respiratory bleeding or travel, and no teleangiectasia was seen on physical examination. There was no familial history of coagulopathy, vascular malformation, epistaxis, stroke, or respiratory illness.