In October 2017, a 39-year-old woman was involved in a car accident reporting an open contaminated elbow fracture-dislocation characterised by severe olecranon and posterior distal humeral condyle bone loss (). The soft tissue envelope was damaged with muscle and skin loss (IIIB Gustilo classification). Olecranon fracture was type IIIB, according to Mayo classification. She also reported ulnar nerve lesions with a complete ulnar deficit and elbow instability with an annular ligament lesion.
She had been initially referred to another hospital. She underwent damage control surgery for wound toilet, debridement, and unstable joint stabilisation by using a Kirschner wire (K-wire) for ulnar-trochlear temporary arthrodesis. Finally, a bridging external fixation (EF) was placed to provide bone stability ().
The patient refused amputation as a therapeutic solution based on the bone exposure and severe soft tissue damage.
Ten days after the trauma, she was referred to our hospital. Declaration of Helsinki and guidelines for good clinical practice were applied, and the patient expressed informed consent for surgery, photos, and clinical follow-up.
She underwent surgical exploration, toilet, and debridement (). Wound exploration showed an ulnar nerve gap of over 7 cm. Cultural examinations were performed along with broad-spectrum antibiotic therapy.
Three days later, a third multidisciplinary plastic and orthopaedic surgical approach was performed: necrotic tissues including bone were debrided once again. Metaphyseal ulnar fracture was reduced by resorbable cerclage wiring, and the triceps tendon, completely detached, was sutured into the remaining part of the olecranon, covering the posterior distal humeral bone loss to obtain stability. The K-wire was removed, and EF was replaced by a dynamic external fixator (DEF) to allow elbow flexion-extension movement. Vacuum-assisted closure (VAC) therapy was applied. Specific antibiotic and hyperbaric therapies were started.
Therefore, the reconstructive orthoplastic strategy was planned. The aims were firstly to provide an adequate soft tissue and skin coverage, and secondly to pursue elbow stability and bone gap restoration, in order to restore articular joint surface and mobility.
One month after the trauma, the infection was eradicated. She underwent plastic surgery to provide soft tissue coverage with a musculocutaneous latissimus dorsi rotational flap. Ulnar nerve gap was restored by harvesting the homolateral sural nerve, which was duplicated and end-to-end sutured, covered by the amniotic membrane ().
Hand and wrist splints were placed to prevent claw hand. Elbow active flexion-extension ROM was from 40 to 90° and ten days after surgery prono-supination was unlocked. An intensive rehabilitative physio-kinetic therapy program was started.
The patient underwent periodic clinical and functional examinations as an outpatient to assess flap taking, scar quality, articular finger wrist and elbow mobility, muscle tropism, musculotendinous retraction, and finger position. A constant improvement was registered.
Magnetotherapy was prescribed 8 hours/day for eight weeks.
Electromyography was conducted three months after trauma, showing ulnar axonotmesis.
Six months after the trauma, the second step of elbow reconstruction was started. At that time, elbow active ROM in flexion-extension was 30–100° and ROM in pronosupination 30–40° (). The quick disabilities of the arm, shoulder, and hand (DASH) questionnaire was performed, the result was 93.2 points. Due to young age, total elbow replacement was avoided.
Considering the olecranon bone loss, we planned the reconstructive phase by using a cadaver elbow allograft, proper sized with “ad hoc” harvesting by National Tissue Bank. Moreover, bilateral elbow CT was performed in view of the bone reconstruction surgery, 3D model production, and bone loss specific evaluation.
Being the percentage of olecranon articular surface bone loss was greater than 70%, a contralateral elbow was used to obtain affordable measures for ad hoc harvesting. For this purpose, we employed mirroring technique, producing a mirroring virtual model of the healthy elbow.
CT files of each elbow were imported on the software syngo.via Frontier (Siemens). We performed a semi-automatic segmentation by threshold and we exported each elbow 3D model for 3D printing ().
The healthy left elbow model was imported on the software Meshmixer (Autodesk) in order to use “mirror” function. Thus, the mirror image was produced with respect to the sagittal plane of the left elbow, i.e., obtaining a healthy copy of the right elbow ().
We printed the thermoplastic right elbow and mirrored elbow 3D models by 3D printer Fortus (250mc Stratasys) ( and ).
The duration of printing was 18.53 hours. The material cost was € 58.69.
The olecranon bone loss on VR was quantified by importing 3D models on software MiniMagics (Materialise) and Meshmixer. We chose landmarks to measure the healthy elbow 3D model ().
Finally, right injured 3D model and mirrored healthy 3D model were imported on the Meshmixer software to perform “Boolean subtraction,” thus producing a new 3D model subtracting the right injured 3D model from the mirrored healthy 3D model. The two geometries were overlapped by using landmarks on coronoid (). It allowed to obtain a proximal ulnar bone loss 3D model, in order to visualise the gap and to plan the graft surgery. () shows the bone loss measurement.
To avoid bone infection prior to performing the orthopaedic surgery, DEF was removed ten months after the trauma: during forearm flexion movements over arm and biceps contraction, the ulna was still anteriorly dislocated. The articulated brace was positioned, granting flexion-extension and prono-supination.
Three months later, with the choice of proper cadaveric allograft from the National Tissue Bank and the request of second check for the harvesting phase, the patient refused the treatment, reporting no limitations in no-articulated brace activities.
Thirteen months after the trauma, at clinical examination, she presented intrinsic hand muscle ipotrophy, good finger recovery, and elbow active ROM: flexion-extension reached 10–120°, prono-supination was 40–55°. X-rays were performed, showing complete healing of the fractures. Quick DASH score resulted 75 points and Broberg-Morrey score resulted 33.5 points.
The flap showed a steady morphological resemblance to the surrounding tissues, as it progressively integrated into the receiving area. There was an edema regression and a scar enhancement; despite that, the scar remained hypertrophic in the proximal forearm.
The patient about two years after the trauma underwent a flap-defatting revision surgery.
Eighteen months from the DEF removal and almost two and a half years from the trauma, she did not complain of elbow instability, lifting low weights easily and resuming daily activities. Elbow active ROM in flexion-extension reached 5–130° and pronosupination was 45–60°. Elbow radiographs showed initial humeroulnar signs of arthrosis and modicum proximal radioulnar diastasis ().
Quick DASH Score calculation was 93.2. Broberg-Morrey score was performed with a result of 71.5.


Case 1: A 58-year-old male patient, due to “binocular vision decline, right eye for 1 wk, and left eye for > 1 year,” visited the hospital. The patient had a history of hypertension, and oral drug was used to regulate the blood pressure. More than a year ago, he had left eye disease and was administered oral hormone, vitamins, and injected nerve growth factor after the treatment of stable visual acuity after discharge. The outpatient ophthalmological examination revealed that the best corrected visual acuity was 0.1 in the right eye and 0.5 in the left eye. Fundus: the right optic disc edema with hemorrhage of the optic disc, macular central light reflex disappeared; the left optic disc was light, the retinal artery was thin, and macular central light reflex disappeared. FFA: right optic disc edema and leakage and double late stage optic disc staining. Visual field and SD-OCT examination is described in Figures -.


Case 2: A 58-year-old female patient visited the hospital because of the requirement of fundus examination. She had a history of Sjögren’s syndrome and was orally administered hormones and immunosuppressive agents for a prolonged period and occasionally hydroxychloroquine. Ophthalmological examination: Best corrected visual acuity: Binocular 1.0, normal binocular vision field; SD-OCT examination: Bilateral mGCC and peripheral optic disc nerve fiber thickness slightly increased. After 8 mo, the patient revisited the hospital because of “left eye sudden inferior visual field occlusion for 2 mo.” After the onset of the disease, the patient did not show any significant improvement in the symptoms after treatment for 2 mo. Best corrected visual acuity: right eye 1.0, left eye 0.2. Medical records and color fundus images obtained from the outside hospital showed edema of the optic disc of the left eye with a small amount of bleeding. The diagnosis of AION by FFA late optic disc leakage staining was conclusive. The SD-OCT examination is described in Figure .


An 11-year-old boy presented with a 2-year history of dermatosis, characterized by multiple scaly erythematous lesions with extensive hypopigmentation. The initial lesions began as erythematous papular eruption on the trunk, and they later spread to the back, limbs, neck, and head. The lesion subsequently flattened and regressed over time, leaving the skin with hypopigmented macules covering almost his entire body (). On examination, numerous erythematous discrete papules with fine scales were seen within the area of hypopigmentation (). The hypopigmented macules were neither painful nor numb. The patient was otherwise healthy, with no significant past medical history. There was no other history of skin disease or atopy, recent infection, or relevant environmental exposure. Further examination revealed no hepatosplenomegaly and lymphadenopathy. Results of laboratory tests including full blood counts with differential tests as well as renal and hepatic functions were all within the normal range.
Retrospectively, the patient had visited seven clinics for medical treatment, but his skin condition persisted and progressively worsened. The initial stage of pruritic erythematous papules had evoked the diagnosis of early varicella infection. Subsequently, he was treated for atopic dermatitis and pityriasis rosea with various topical emollients and steroids, with no significant improvement. Later, several diagnoses such as tinea corporis, pityriasis alba, pityriasis versicolor, and post inflammatory hypopigmentation were made for the progressive hypopigmented lesions. Antifungals and steroids were also prescribed, but none effectively cured the condition. Then, he was referred to a dermatologist for expert evaluation.
A 4.0-mm punch biopsy was taken from two sites: an erythematous papule and a hypopigmented macule. Histopathological studies on the erythematous papule revealed marked acanthosis and mild parakeratosis with prominent epidermotropism of the dermis. The lymphocytes were atypical in appearance, some of which appeared cerebriform. Pautrier’s microabscess was occasionally seen. The papillary dermis had dense band-like lymphocytic infiltrates, with perivascular lymphocytic and histiocytic cells in the deep dermis (). Immunohistochemical staining demonstrated positivity for CD2+, CD3+, and CD5+ and negativity for CD30+ T-cells. CD8+ T-cell expression was more predominant than that of CD4+ T-cells (). T-cell receptor gamma gene rearrangement analysis was not performed in this case. Otherwise, biopsy of the hypopigmented macules showed features of post-inflammatory hypopigmentation.
In summary, our patient had clinical presentation of pityriasis lichenoides-like lesions exhibiting recurrent crops of erythematous and scaly papules, which then resulted in prominent post-inflammatory hypopigmentation. Nevertheless, the histopathology combined with immunochemical findings were consistent with those of MF. Therefore, the diagnosis of PL-like MF was established. Treatment thrice weekly with narrowband ultraviolet B (NBUVB) phototherapy, along with topical betamethasone valerate cream 0.05% once daily, was commenced. Significant clinical improvement was observed after completion of 30 phototherapy sessions. A long-term periodic follow-up was planned in order to detect any early symptoms and signs of relapse. The patient provided written consent for the publication of clinical details and images.


A 68-year-old Caucasian woman presented to the dermatology department with multiple erythematous nodules localized on the right thigh that had been slowly progressing for 9 months. The lesions were slightly tender on palpation, but no other general symptoms were reported. The patient’s comorbidities included obesity, hypertension, hypercholesterolemia, superficial venous insufficiency and memory impairment of unknown duration. Laboratory tests revealed a slightly elevated erythrocyte sedimentation rate (ESR) and positivity for cytomegalovirus (CMV), Epstein-Barr virus (EBV) and Borrelia burgdorferi immunoglobulin G. An excision biopsy was performed. The epidermis was hypotrophic with an infiltration of lymphocytes B, T and plasma cells, but mostly histiocytes with immunohistochemistry markers, including protein S-100, CD163, CD68, and an absence of CD1a and HLA-DR. The image was indicative of Rosai-Dorfman disease (Fig. ).
As no internal pathology was visible on the pan-computed tomography scan, on the lymph nodes and abdominal ultrasound and upon ophthalmological examination, we opted for the diagnosis of cutaneous form of Rosai-Dorfman disease.
The two most prominent nodules were surgically removed, and treatment with methotrexate (MTX) 10 mg subcutaneously (s.c.) per week with 10 mg of folic acid was started. On the first monthly follow-up we administered a total dose of 40 mg of methylprednisolone acetate suspension intralesionally. After 12 weeks, the MTX dose was increased to 15 mg s.c. once weekly, with the patient showing good tolerance; a visible flattening of the lesions was observed. After 11 months, 10 mg of prednisone once daily, taken by the oral route, was added to the treatment regimen. The lesions kept flattening and changed in color to violet-brown (Fig. ). The patient was regularly monitored for possible side effects of the treatment.
This case report was written after receiving oral and written consent from the patient and is compliant the ethical guidelines of the University Hospital. Written consent was also obtained from the patient for the publication of the photographs.


A 12-year-old girl presented to our clinic with a chief complaint of trismus. A few months ago, she noticed a bulge in the left maxillary gingiva and trismus. There was no spontaneous pain, but pressure pain was felt. She was afebrile, had no history of trauma or medications. During her first medical examination at our clinic, she was 164 cm tall, weighed 54 kg. Extraoral examination revealed a slight bulge in the left cheek with countenance, right and left asymmetry and trismus. The range of mouth opening was 18 mm, and there were no swollen lymph nodes that I could feel in the neck. Intraoral findings revealed a neoplastic lesion extending from the left maxillary first molar to the maxillary tuberosity (). It interfered with the occlusion on that side.
Panoramic radiography showed impaction of the left maxillary second molar and resorption of alveolar bone between the left maxillary molar area and the maxillary tuberosity ().
Computed tomography (CT) images showed a mass that extended from the left masticator space to the buccal space and the alveolar regions of the maxilla and mandible and pressure resorption of the anterior border of ramus, rear wall of the maxillary sinus and lateral plate of the pterygoid process. Involvement of the maxillary sinus was also suspected. Contrast-enhanced T1-weighted magnetic resonance imaging (MRI) showed a high signal in a range similar to CT (). Contrast-enhanced effects in the left cervical and retropharyngeal (Rouviere) lymph nodes were also detected. 18F-fluorodeoxyglucose (18FDG)-positron emission tomography/CT showed a mass measuring 63 × 38 × 45 mm (long axis × minor axis × height) located in the left maxillary gingiva, accompanied by abnormal accumulation of 18FDG (standardized uptake value [SUV] max, 8.3), and left cervical lymphadenopathy, accompanied by abnormal accumulation of 18FDG (SUVmax, 41.72), which was suspected as metastasis. Abnormal accumulation was not observed in the other organs.
The differential diagnosis for a malignant tumor of oral soft tissue includes squamous cell carcinoma, sarcoma and salivary gland malignant tumor. Ameloblastoma is considered in the differential diagnosis for a maxillary tumor with trismus. Ameloblastoma is a benign tumor that presents as a bulge on the jawbone and causes bone resorption. It has included extraosseous/peripheral ameloblastoma [].
Three days after the first medical examination, a biopsy of the lesion was performed in the left maxillary gingiva with the consent of the patient and parents to obtain a definitive diagnosis. The sectioned surface was milky-white with enhancing characteristics (). Histopathological examination showed proliferation of oval to spindle-shaped cells, with hyperchromatic nuclei and a high nuclear-cytoplasmic ratio, arranged in a fascicular pattern (). Mitotic figures were frequently observed. Focally, the tumor cells were arranged in small nests and in a pseudo-capillary pattern in the sclerotic collagenous stroma (). Immunohistochemical examination revealed that the tumor cells were positive for desmin, myoD1, myogenin, mammary serum antigen and glial fibrillary acidic protein (). The Ki67 proliferation index was ~30% per HPF (). The details of immunostaining are shown in . The patient was diagnosed with RMS classified as Group III according to the Intergroup Rhabdomyosarcoma Study (IRS) grouping system []. The left maxillary gingiva RMS was treated via proton beam irradiation at 59.4 Gy and with vacuum-assisted wound closure therapy with 14 cycles of vincristine, actinomycin D and cyclophosphamide. After chemoradiotherapy, a complete response was documented via image evaluation.


A 37-year-old otherwise healthy African-American male presented with 3 months of progressive right lower extremity weakness and numbness. The patient noticed that he had been walking with a limp and was unable to urinate or ejaculate despite preserved erection. On neurological examination, he had decreased strength in the right hip flexion (4/5), knee extension (4/5), foot dorsiflexion (3/5), extensor hallucis longus (2/5), and plantar flexion (2/5). He also reported decreased sensation in the right lower extremity in nondermatomal distribution.
Computed tomography (CT) imaging of the spine revealed a calcified T6-T7 paracentral disc eccentric to the right [ and ]. Magnetic resonance imaging (MRI) of his spine depicted again the T6-T7 paracentral disc with T2 signal change extending from T2 to T10 level [ and ]. Given that, the extent of T2 cord signal change was out of proportion to the disc disease, contrasted MRI was acquired afterward demonstrating intramedullary enhancement around the T6-T7 disc bulge [].
The patient was started on high-dose dexamethasone. The patient noticed significant improvement in his strength over the subsequent 3 days. Given the extent of T2 signal change and contrast enhancement in the spinal cord and response to steroids, the suspicion for another primary etiology was investigated. CT chest revealed diffuse mediastinal lymphadenopathy. Angiotensin-converting enzyme level was within normal limits. He underwent an ultrasound-guided endobronchial biopsy of the enlarged lymph nodes. Histopathological examination demonstrated noncaseating granulomas consistent with a diagnosis of sarcoidosis [].
The patient received 3 days of high-dose methylprednisolone therapy followed by prednisone (40 mg twice a day) at the time of discharge along with methotrexate and infliximab infusion. His right lower extremity returned to nearly full strength, with only mild weakness in the right extensor halluces longus and plantar flexion (4+/5) at his last follow-up visit.


A 62-year-old female who had undergone prior subtotal resection of a schwannoma of the cauda equina (5 years ago) newly presented with a 3-month history of low-back pain/dysesthesias radiating into her right lower extremity, anesthesia in her perineal region, and urinary retention. Her lower extremity examination revealed a partial paresis (4/5), hyporeflexia, and hypoesthesia of the lower limbs and perineal region.
A gadolinium-enhanced MR imaging (MRI) documented an intradural extramedullary solid lesion with marked gadolinium enhancement extending from L1 to L2, resulting in anterior compression/displacement of the cauda equina/ conus medullaris []. Due to the prior history, this was determined to likely be a recurrent schwannoma of the cauda equina.
She underwent bilateral laminectomies of L1-L2; following the durotomy, a well-defined (14 × 20 × 22 mm) solid yellowish lesion was visualized adjacent to the filum terminale; it was completely resected. Neuromonitoring potentials and electromyography remained unchanged. Next, a T11-L3 transpedicular screw-rod system was used to prevent mechanical instability in the thoracolumbar junction because of the multiple laminectomies performed at this level.
She was discharged three days postoperatively, having regained full neurological function except for residual hypoesthesia in the perineal region. In addition, the postoperative MRI scans confirmed complete tumor removal [].
Pathology revealed a fusocellular tumor that was compatible with the diagnosis of a schwannoma of the cauda equina []. It had a Ki67 <1%, positivity for S100 protein and smooth muscle actin, and negativity for desmin, DC34, and CD117.


A 63-year-old female, with poorly treated hypertension and morbid obesity (body mass index [BMI] of 58 kg/m2) was admitted in the emergency room (ER) with a history of 8 days of fatigue, cough without sputum, and hyporexia, which worsened 24 hours earlier. She had used azithromycin for 5 days and acetylcysteine. On examination, she was tachypneic, with 32 breaths per minute, but no complaints of dyspnea and had a saturation of 85% on room air. An oropharynx swab specimen was taken and the patient was admitted to an isolation ward with an intensive care unit (ICU) transfer solicitation. A chest computed tomography (CT) scan was taken () together with laboratorial examinations (). She was then started on oxygen 4 L/min, ceftriaxone 2 g to prevent bacterial superinfection, and anticoagulation with enoxaparin 1 mg/kg due to the high risk of thrombotic complications. After 24 hours, the patient was still waiting for ICU admission and had a worsening of hypoxemia, now, complaining of shortness of breath, being started on awake prone position strategy. The decision to administer tocilizumab was discussed with the patient and performed after a negative procalcitonin test. After admission in the ICU, the patient remained stable, with lower oxygen necessity. She complained, however, of a “new” cough with sputum on the fifth day of hospital stay. A control chest CT was made and piperacilin-tazobactam was started after blood sample for cultures and laboratory examinations. She was discharged to the ward 24 hours later, without signs of sepsis, and was sent home 2 days later. Her diagnosis was confirmed by detection of IgM (immunoglobulin M) and IgG antibodies in serum after a negative original RT-PCR (reverse transcriptase polymerase chain reaction) sample.


A 31-year-old, male, obese (BMI of 40.8 kg/m2) male, presented with a 6-day history of dry cough, headache, and fever, which worsened 3 days earlier with progressing dyspnea on exertion. On examination, he was febrile with 38.7 °C (101.6 °F), tachypneic, with a respiratory rate of 25 breaths per minute, and had an oxygen saturation of 88% on room air. A chest CT () and laboratorial examinations () were made. He was admitted to an isolation ward, an oropharynx swab specimen taken, which later tested positive, and he was started on supplementary oxygen 3 L/min, enoxaparin 1 mg/kg BID (twice a day) and ceftriaxone 2 g/day. On the fifth day, he had a worsening of hypoxemia, being mobilized in awake prone positioning. Methylprednisolone 1 mg/kg was administrated and he was transferred to the ICU with a pulse oximeter showing 88% saturation on a non-rebreather mask 10 L/min. On admission, the medical staffs decided to infuse tocilizumab after discussion with the patient and a negative procalcitonin test. The next day, the patient reported a relief in the shortness of breath sensation and tolerated O2 support reduction, being transferred to the ward on a 3 L/min catheter, 24 hours later. He progressed well, with a slow but steady supplemental oxygen weaning, being discharged home.


A 51-year-old, male patient, with hypertension, coronary disease with previous percutaneous revascularization, diabetes, and a BMI of 35 kg/m2 went to the ER with a history of 12 days of daily fever and anosmia. He had worsening of symptoms 24 hours before seeking medical assistance, when he developed intense fatigue and worsening of fever. He had used azithromycin, ivermectin, and corticosteroids since day 1 of fever. On examination, he had a respiratory rate of 16 breaths per minute and a heart rate of 110 beats per minute. His oxygen saturation was 88% on room air. He was admitted to an isolation ward, a swab specimen was collected, which came back positive, and blood was drawn for laboratory testing (). He was started on 3 L/min oxygen and unfractioned heparin 5000 mg TID (3 times a day). After about 24 hours, he had worsening of symptoms, now complaining of dyspnea and needing 15 L/min in a non-rebreather mask to maintain O2 saturation of 93%. A chest CT was performed (). He was transferred to the ICU, started on awake prone position, and a decision to infuse tocilizumab was made after a negative procalcitonin test. He progressed to a lower need for O2, being discharged to the ward 48 hours later breathing on room air and was sent home 3 days later.


A 31-year-old Caucasian woman was referred to the Endocrinology service with an 8-month history of secondary amenorrhea, fatigue, hirsutism and a 13-kg weight gain. She denied easy bruising and proximal myopathy and had no past medical history. On examination the patient was hypertensive and had a body mass index of 26.2 kg/m2. She exhibited marked clinical features of cortisol excess including dorsal skin thinning, hirsutism, facial flushing, characteristic moon facies, interscapular fat pad, central adiposity and purple abdominal striae.


It is about a 24-year-old male patient suffering a dental trauma at the level of the anterior upper teeth. The patient presented with fractured upper central teeth and a mobility of the coronal fragment of tooth 12 due to the trauma.
In this article, we focused on the maxillary right lateral incisor, with respect to the patient constent. Inspection revealed the presence of a healthy periodontium with pulpal exposure. The retro alveolar radiograph showed a long root of the tooth with no fracture and no apical radiolucency ( and ). After removing the coronal fragment, we noticed a lack of supragingival tooth structure required to guarantee a reliable long-lasting restoration. The next steps consisted in evaluating the radicular length, the absence of an apical curvature, and the width of the remaining radicular and coronal walls to discuss the feasible treatment options for saving the tooth.
After a global clinical examination, surgical tooth extrusion, consisting in crown lengthening technique, was performed to maintain a healthy supracrestal healthy tissue, thus offering to the patient a reliable long-term outcome. The clinical procedures involved, at first, endodontic treatment. It was conducted prior to surgical extrusion. Canal preparation was carried out using rotary instrumentation system (Revo S®, Micro Mega, France). It was accompanied by intracanal irrigation using 2.5% NaOCL and 17% EDTA as a final irrigation. At the same clinical consultation, the canal was dried with sterile paper points. The root canal was filled with gutta-percha (ProTaper Universal Gutta Percha Points, Meta Biomed, South Korea) and root canal sealer, using the lateral condensation technique. The coronal seal was provisional. After 1 week, the surgical extrusion procedure was performed.
After disinfection of the area using mouthwash of 0.12% of chlorhexidine (KLOREX fort, STODERMA, Tunisia), local anesthesia with 2% of lidocaine was administered. Syndesmotomy was performed using a syndesmotome, placed in both the buccal and palatal sides. A fine elevator was used to carry out tooth luxation. It was placed in the periodontal space and manipulated in a walking motion all around the tooth without causing surgical trauma. Minimally, traumatic luxation forces were applied just at the first 4 mm of the radicular structure to avoid periodontal ligament damage.
The tooth was carefully extruded to the desired situation using root forceps and it was placed at a level such that the fractured margin would be situated at least 3 mm from the alveolar crest, while being kept inside the socket. It is important to limit the extrusion quantity to preserve an adequate crown–root ratio that should always be inferior to 1.
 The tooth was maintained at the radicular portion, supposed to be kept in a supra-bony position after the procedure. A slight pressure was applied in a bucco-palatal direction, using a gauze, to obtain hemostasis and to keep the tooth in the right position. Simple interrupted sutures were placed to stabilize the tooth. A 0.3-mm diameter monofilament (violet braided of PGA Lac Synthetic Absorbable Suture, NEOFIL+) was used to achieve primary stabilization, thus obtaining a correct reorganization of the periodontal ligament fibers.
 After that, a semi-rigid splinting was placed using a flowable nano-hybrid composite (Reflectys Flow, ITENA, France) on the adjacent teeth. Special attention was exerted to release the interdental septum so that it would be easy for the patient to keep it clean. The patient was instructed to use a daily mouthwash with 0.12% of chlorhexidine for 1 week to thoroughly clean the area. Only analgesic was prescribed post-operatively (). The sutures were deposed after 10 days to avoid surgical site infection. In fact, microbes adhere to the suture filament and form biofilms. The knot is the principal site of infection. Typically, they should be left in place no longer than 2 weeks.
 Splinting was removed 15 days post-operatively. In fact, the risk of ankylosis increases when the splint is kept for more than 3 weeks.
 Actually, a slight mobility during the periodontal healing period is favorable.
 Six weeks later, the extruded tooth mobility was clinically acceptable. In fact, the periodontal ligament acquires its characteristics 45 days post-operatively.
 Then, a fiber post (Fiber Post Refill Dentoclic, ITENA Clinical Dental Post, France) was placed to ensure correct height to the core preparation. It was cemented with a dual core composite cement (Dentocore Body, Core Build-up, ITENA) that was utilized as a core build-up material to rebuild the missed coronal tooth structures (). A crown preparation was performed and a temporary crown was cemented. Six months post-operatively, impressions were taken and a final ceramic crown was placed ( and ). After 2-year follow-up, complete periapical bone formation is observed with a periodontal tissue repair ().


A 25-year-old unmarried man was presented to the psychiatry clinic in May 2020 with a three-month history of excessive concern about having contracted COVID-19 and fear of infecting other people. He had a family history of paranoid illness and was diagnosed with an anxiety disorder seven years ago, which precipitated after witnessing a seizure episode. He was treated with Escitalopram 10 mg for three years following which he improved and later discontinued the treatment. He functioned well despite intermittent mild episodes of anxiety.
He resigned from his job in February 2020 believing he had COVID-19 as he felt “uncomfortable” and he could feel mucous running from his nose into his throat. He reported to a COVID designated hospital where he was admitted for three days and tested negative for the virus. He was assessed by a psychiatrist and restarted on Escitalopram 10 mg/day for anxiety. After discharge, he quarantined himself at home for two weeks even though he did not have any COVID symptoms. He started gathering information incessantly about COVID-19, and believed he had all the symptoms despite the lack of objective evidence and multiple reassurances by doctors and family members. He believed he should rather die than infect others. Secondary to which, he went to a nearby river with suicidal intent, but did not act further. He was admitted in our hospital with a recent negative COVID report. He denied having pervasive sadness, anhedonia, and irrational unwanted thoughts which he could not resist, or any other psychotic symptoms.
In the hospital, he remained preoccupied with vague physical symptoms despite reassurances which he attributed to COVID-19 and believed he was spreading the infection to other patients. He drank turmeric–ginger water multiple times a day to kill the virus which was enabled by the caregiver. Physical examination and investigations such as complete blood count, inflammatory markers, chest X-ray, and electrocardiograph revealed no abnormalities which were reflected to him as the objective evidence of COVID-19 negative status. Nevertheless, he continued seeking further tests to prove his belief. He scored 72/210 on Positive and Negative Syndrome Scale, with positive, negative, and general psychopathology subscale scores being 22/49, 13/49, and 37/112, respectively. The modified Psychotic Symptom Rating Scales revealed a score of 22/24, with high scores on preoccupation, conviction, distress, and disruption. He scored high (22/24) on the Brown Assessment of Beliefs Scale too. These scales, both individually and collectively, confirmed high severity of his delusions and its vectors. He was diagnosed with delusional disorder (hypochondriacal) and anxiety disorder NOS as per ICD-10.
He was started on oral Risperidone for psychotic symptoms, which was gradually increased to 12 mg daily over eight weeks and Escitalopram up to 20 mg with short-term Clonazepam which reduced his anxiety. Despite compliance being monitored by nurses, there was no change in his conviction. Due to poor response and development of tremors, Risperidone was cross-tapered with Trifluoperazine 5 mg/day. Eight sessions of cognitive behavioral therapy (CBT) were provided, and his family was psycho-educated regarding his illness and treatment. With the combination of Trifluoperazine 5 mg and Risperidone 4 mg (stopped after three weeks), his subjective distress and conviction began reducing over two weeks prior to discharge. The delusions resolved almost completely after five months of treatment with Trifluoperazine.


A 68-year-old woman consulted because of a left vulvar lesion. As a pathological antecedent of interest, she had presented multifocal motor neuropathy in the left upper limb that was treated with rituximab.
During the gynaecological examination, a 2.5-cm irregular pigmented lesion was observed in the upper third of the left lower lip (Fig. ) with a raised and rough acetowhite lesion inside of it (Fig. ). There were no palpable inguinal nodes.
A vulvar biopsy was performed using a punch under local anaesthesia. The biopsy demonstrated a superficial spreading malignant melanoma. The Breslow index was 0.72 mm and Clark's level IV. The PET-CT examination did not show any metastatic lesion. Surgery consisted of vulvectomy with selective sentinel node biopsy technique. Surgery was carried out 5 days later under general anaesthesia with previous technetium 99m (Tc99m) injection. The resection limits were defined, as shown in Figure . Intraoperatively, permanent bladder catheterization was performed, and methylene blue was injected at the level of the lesion. A bilateral inguinal incision was made, but sentinel lymph nodes could not be identified because of the absence of Tc 99m or methylene blue, so inguinal lymphadenectomy was performed. Wide excision of the melanocytic lesion was performed, including the clitoral hood, the left lower vulvar lip, and a part of the left greater vulvar lip. The clitoris was subsequently exteriorized at the level of the upper pole. The resection of the mass and repair of the incision are shown in Figure . Subsequently, the left vulvar lip defect was covered with a left gluteal flap (Fig. ). The histopathologic study confirmed the diagnosis of vulvar melanoma of superficial extension with a Breslow of 0.89 mm and Clark level IV with ulceration (Fig. ). The resection margins were reported to be free of lesions. Six left inguinal lymph nodes and 5 right inguinal lymph nodes were obtained, all of which were negative for melanoma infiltration.
The postoperative evolution was satisfactory. No adjuvant therapy was indicated.


A 64-year-old patient consulted because she noted a vulvar lesion with hyperpigmentation. A 1-cm hyperpigmented lesion was observed in the right lower lip. The lesion was biopsied, confirming the diagnosis of malignant melanoma of superficial extension in situ. Right hemivulvectomy and sentinel node techniques were performed with Tc99m and infiltration of methylene blue in the lesion. A 3-cm right inguinal incision was made, and dissection was performed in planes up to the sentinel node, which was dissected. A sample with 2 secondary lymph nodes was sent for analysis. The resection margins were lesion-free. Lymph nodes had no evidence of metastasis; approximation of the surgical margins of the vulvar bed with 2 double points and skin closure of both surgical wounds.


A 40-year-old 25 weeks pregnant (patient) was admitted to our clinic presenting a large spontaneous periprosthetic fluid collection at the left breast, occurring 12 years following bilateral cosmetic sub-glandular implantation with a textured surface silicone gel-filled breast implant (). At the time of presentation, no palpable mass nor lymphadenopathy was observed.
She referred that clinical and instrumental (ultrasonography and magnetic resonance imaging) diagnosis of a left breast seroma dated back to 2 years before and had been treated conservatively through ago aspiration and anti-inflammatory drugs. Cultural test performed through fine needle aspiration 6 months before was negative for any bacterial/fungal infection and cytology test was negative for malignancy.
Fine needle aspiration was repeated during our first consultation and 50 mL of periprosthetic fluid sample was sent for cytological examination. Cell smear and cell blocks showed an infiltrate composed predominantly of large to medium-sized atypical cells with occasional mitotic figures and apoptotic debris in a fibrinous/necrotic background. By immunocytochemistry, the atypical cells were positive for CD30, CD4, IRF4, and negative for CD3, CD8, CD20, CD68, ALK (anaplastic lymphoma kinase) and EMA (epithelial membrane antigen) consistent with a diagnosis of BIA-ALCL ().
Once the diagnosis of BIA-ALCL was established, a multidisciplinary team including oncologist, pathologist, hematologist and gynecologist recommended a positron emission tomography computed tomography (PET/CT) scan for staging and surgical intervention when the patient would have reached full term pregnancy. Meanwhile, a breast and axillary ultrasonography was performed, which did not evidence focal alteration outside the periprosthetic capsule.
Twenty days after childbirth, PET/CT demonstrated an augmented glucose metabolism at the left breast with no associated capsular mass nor chest, lymph node or visceral involvement (stage IA according to the MD Anderson TNM classification) () [].
Surgical treatment with en bloc explantation of the implant and the surrounding fibrous capsule was performed bilaterally. Surgical specimens were oriented and inked for pathological processing as recently proposed []. Postoperative course was uneventful.
Histological examination showed the presence of CD30+, CD4+, CD3-, ALK- anaplastic large lymphoma cells admixed with abundant granular and necrotic material on the luminal surface of the left capsule confirming stage I disease. Lymphoma cells were not detected on the right capsule.
Patient is actually followed up according to National Comprehensive Cancer Network guidelines (history and physical every 3 to 6 months for 2 years and PET scan every 6 months for 2 years and then only if clinically indicated) [] in an outpatient setting and no tumor progression has been observed in 12 months of follow-up.


An 80-year-old female with no significant medical history presented with sudden onset, left-sided chest pain. Twelve-lead ECG () performed a few minutes after the onset of chest pain by the ambulance crew resulted in a diagnosis of acute anterior ST-elevation myocardial infarction. Upon arrival to our institution, she was administered oral loading doses of antiplatelet medications (aspirin 300 mg and ticagrelor 180 mg) and transferred to the cardiac catheter laboratory for emergency invasive coronary angiography with a view to percutaneous coronary intervention (PCI). Prior to angiography, a full cardiovascular examination excluded a murmur and there were no signs of a cardiac shunt.
Coronary angiography demonstrated mild, non-flow-limiting stenosis in the proximal left anterior descending (LAD) artery which was not felt to be unstable by the interventional cardiologist and hence intracoronary imaging and provocation testing were not performed (Video 1). The remaining arteries had minor, non-flow-limiting atheroma (). Left ventriculography showed apical ballooning consistent with TTC (Video 2) and in the absence of flow-limiting coronary artery disease and presence of laminar (Thrombolysis in Myocardial Infarction-3) flow, a decision was made not to proceed to PCI. The initial diagnosis of TTC was established by angiographic assessment.
Relevant admission blood tests are shown in . Serum Troponin-T was significantly elevated at 1940 ng/L. An angiotensin-converting enzyme-inhibitor and a beta-blocker were commenced. The following day, a physical examination revealed a new pansystolic murmur. After discussion with the patient’s primary care provider, there was no previously documented cardiac murmur. Urgent contrast-enhanced echocardiography performed the day after admission (Video 3) showed a significant apical septal defect suggestive of a ventricular septal defect (VSD). LV systolic function was moderately impaired with an ejection fraction of 40% in the presence of dyskinesis of all four apical LV segments resulting in apical ballooning. There was no LV outflow tract obstruction, systolic anterior motion of the mitral valve or mitral regurgitation. These echocardiographic findings could be consistent with TTC, however, the presence of a VSD raised the suspicion of an alternative diagnosis.
Repeat ECG on Day 2 () showed progressive deep T wave inversion in anterolateral leads. By Day 3, the patient developed urosepsis with atrial fibrillation, hyperactive delirium, and hyponatraemia. The patient became clinically unstable requiring intravenous antibiotics and careful fluid balance monitoring. Due to the development of a VSD, the diagnosis of TTC was re-evaluated. Cardiovascular magnetic resonance (CMR) imaging was performed on Day 10 once the patient was clinically stable and her delirium resolved, permitting safe and feasible CMR imaging.
CMR demonstrated transmural late gadolinium hyperenhancement (LGE) at the apical septal, apical anterior, and apical inferior LV segments with extension into the apical right ventricular (RV) which became subendocardial on extension into the mid-septal and mid-anterior segments, in keeping with acute transmural MI in the mid-LAD territory. There was resultant akinesis of the LV and RV apices and associated apical VSD measuring 9 mm × 12 mm with Qp:Qs 2.7 (RV stroke volume = 2.7 × LV stroke volume) in keeping with significant left-to-right shunting (). No significant valve dysfunction was present thus allowing this method of Qp:Qs calculation to be employed. Oedema imaging was not performed in order not to jeopardize the ability to perform LGE imaging as the patient struggled with breath-holding and tolerating the study.
Following joint cardiology and cardiothoracic surgery multidisciplinary team discussion, the diagnosis was revised to an anterior MI with spontaneous LAD recanalization. The prospect of surgical intervention was assessed. The P-Possum score was calculated; the predicted mortality was 26.7% and predicted morbidity 79.9%. The consensus was that percutaneous device closure would be the best option due to prohibitively high surgical risk.
Under general anaesthesia and transoesophageal echocardiographic () and fluoroscopic guidance, the VSD was found to be serpiginous. Successful percutaneous closure was achieved with the deployment of three Amplatzer Vascular Plugs-II: 9 mm × 22 mm, 12 mm × 9 mm, and 9 mm × 20 mm () with resultant significantly reduced shunting (). Following an uncomplicated recovery, the patient was discharged after 4 days, with recovery to her baseline functional status and mobilization with no cardiovascular symptoms. At clinic review 1-month later she remains well with no intrusive cardiovascular symptoms. ECG findings () showed the same T wave inversion anteriorly and no significant ST-segment changes. The patient was re-reviewed again in clinic after referral from her Primary Care Physician as she complained of mild breathlessness. A repeat CMR was arranged 4 months post-device closure. This showed a mildly dilated LV with thinned and akinetic apical segments. All other segments were normokinetic with uniformly normal wall thickness (max 8 mm basally). Mild LV systolic dysfunction with an ejection fraction of 60% (previously 50%) was present. All three VSD devices were well seated with only minimal residual shunting (). No valvular abnormalities noted apart from mild tricuspid regurgitation. The symptoms are stable and annual cardiology follow-up is being arranged.


The patient and her mother provided written informed consent to publish this report.
A 17-year-old girl (height, 170.8 cm; weight, 51.2 kg; body mass index, 17.55 kg/m2) was scheduled to undergo maxillary sinus floor elevation and tooth removal under general anesthesia. The patient was previously diagnosed with jaw deformity, excessive resorption of the maxillary alveolar ridge, and bilateral impacted mandibular wisdom teeth.
At the age of 15 years, the patient was diagnosed with hyperthyroidism which was being treated with 10 mg thiamazole orally. She had no reported drug or food allergies, but reported a history of administration of local anesthetic several times with no complications.
Initially, the surgery was postponed because of complications related to hyperthyroidism. During the preoperative examination, she was in a clinically euthyroid state. Laboratory tests showed a hemoglobin level of 10.2 g/dL (). No abnormalities were noted on other laboratory tests or chest radiographs. A 12-lead preoperative electrocardiogram showed normal sinus rhythm.
Given her hyperthyroidism, we planned to administer 3% prilocaine containing 0.03 IU/mL felypressin as a local anesthetic to avoid complications that may arise from adrenaline-containing drugs.
Her medications were continued orally until 14 h before surgery. Upon arrival in the operating room, her peripheral oxygen saturation (SpO2) on room air was 100%. General anesthesia was induced with 100 µg of fentanyl, target-controlled infusion of propofol with an initial target plasma concentration of 5.0 µg/mL, and 30 mg of rocuronium. The patient was intubated using a nasal endotracheal tube. Anesthesia was maintained using an intermittent bolus of fentanyl (total dose was 400 µg), propofol infusion (target plasma concentration of 2.8–3.2 µg/mL), and remifentanil (0.3–0.6 mg/h).
Approximately 61 min after inducing general anesthesia, the patient was administered 3.6 mL prilocaine with felypressin for infiltration anesthesia; the same dose was added 43 min later, which led to a gradual decrease in SpO2, even though the fraction of inspired oxygen was increased to 0.6 ().
Ninety-six minutes after the first administration of prilocaine, the SpO2 level decreased to 95%. Blood gas analysis showed that the MetHb value was 3.8% and fractional oxyhemoglobin was 93.9%, despite a partial pressure of oxygen of 327 mmHg (BGA#1 in ). Next, 50 mg of methylene blue was administered slowly, 127 min after the first administration of prilocaine. The SpO2 value improved gradually to 99%, and the MetHb value decreased to 1.2% (BGA#2 in ). SpO2remained above 99%, and the MetHb value 2.5 h after the administration of methylene blue was 1.6% (BGA#3 in ). No noteworthy adverse respiratory findings were observed during the perioperative period.
Upon returning to her room, the patient did not present with any symptoms of methemoglobinemia, and SpO2 remained above 99% for 2 h under oxygenation with a simple face mask at 3 L/min. After 2 h, she remained asymptomatic, and her SpO2 remained at 98% after the oxygen mask was removed. From that point until the next day, her SpO2 was measured intermittently and remained at 97%–98% on room air. The MetHb value 7 days after surgery was 1.2%, which is within normal limits, and congenital methemoglobinemia was ruled out.


An 80-year-old man, who experienced sudden chest pain, was transferred to our emergency unit. There was no indication of recent trauma.
He was in cardiogenic shock at the time of admission. Echocardiography revealed a moderate amount of pericardial effusion, while contrast-enhanced computed tomography (CT) revealed extravasation of contrast media from the distal ascending aorta; this created a massive hematoma in the anterior mediastinum and right hemothorax (). The ascending aorta was slightly dilated (37 mm). There was a focal contrast-filled outpouching on the anterior aspect of the aorta in the absence of a dissecting flap, false lumen, or aortic aneurysm. The bleeding point was surrounded by multiple calcified plaques (). Although the etiology of bleeding could not be determined, emergency surgery was performed.
The mediastinal space and right thoracic cavity were filled with fresh blood coagulation, but the pericardial space did not contain obvious blood. Upon coagulation removal, blood spurted from a 2-mm hole located on the anterior wall of the distal ascending aorta (). Although there were small lacerations in the adventitia, we did not observe any saccular aneurysm formations. Epiaortic echocardiography revealed a PAU (4 mm in diameter), with subsequent penetration into the media and adventitia, which resulted in a frank rupture of the aorta ().
We closed the pinhole directly with 3-0 interrupted sutures and Teflon felt strips (). After 8 months, follow-up CT showed no abnormality of the aortic wall at the repair site.


A 17-year-old male patient with DMD treated with corticosteroid (deflazacort) presented to a tertiary pediatric orthopedic spine clinic with severe low back pain that began while transferring from his wheelchair. Lumbar spine radiography and subsequent magnetic resonance imaging (MRI) demonstrated VCF of L1 vertebra with height loss of 50%, VCF of L3 vertebra with height loss of 40%, VCF of L4 vertebra with height loss of 40%, and minimal VCF of T12 vertebra with height loss of 5% (). Bone marrow edema was seen in the affected vertebrae on short-TI inversion recovery (STIR) MRI images, most extensively in L4. Treatment with calcium, vitamin D3, and appropriate opioid analgesics was initiated. The patient continued to have severe low back pain in the absence of radiculopathy. Treatment was augmented with bisphosphonate (pamidronate). With this treatment protocol, the patient regained his preinjury activity 6 months postinjury and was pain free. Bone mineral density (BMD) testing demonstrated decreased bone mass below the expected range for his age, with a Z score of −3.6 in the lumbar spine.
The patient then sustained another fall injury that resulted in an acute exacerbation of his symptoms and necessitated hospital admission for management, with a combination of medications prescribed including morphine 7 mg daily for breakthrough pain. He required bed immobilization and could not tolerate transfer to his wheelchair. Imaging studies found compression fractures of T12, L1, L3, L4, and new VCF of L5 () with height loss of 35% and extensive bone marrow edema in L5 on STIR images.
Considering the medications’ failure to alleviate symptoms and prevent osteoporosis progression, treatment with percutaneous vertebroplasty was proposed to ease his pain and improve mobilization.
The patient’s comorbidities were taken into account. In addition to DMD, his medical history included obesity and obstructive sleep apnea that required a continuous positive airway pressure machine. Pulmonary function examination demonstrated significant compromise (35% of predicted). For management planning, we sought input from anesthesiology and pediatric intensive care teams. There was documented concern that general anesthesia and intubation would cause the patient to become ventilator dependent. The patient was assigned American Society of Anesthesiologists (ASA) class IV (severe systemic disease that is a constant threat to life). Admission to the pediatric intensive care unit (PICU) was preplanned.
Vertebroplasty of T12-L5 vertebrae using a bipedicular approach was performed without complication (). The patient tolerated the procedure well and was successfully extubated. There were no respiratory or cardiac events reported.
The day after the procedure, while in the PICU, the patient was found to be tachycardic with oxygen saturation in the low 90% range with supplemental oxygen at 4 L/min. A computed tomographic pulmonary angiogram revealed bilateral atelectasis and consolidations in the lungs and a few tiny cement foci in pulmonary arteries. With oxygen supplementation at 5 L/min, the patient’s oxygen saturation increased to 98% to ~100%. Five days postprocedure oxygen supplementation was no longer required. At discharge, the patient was able to mobilize to his wheelchair and his analgesic needs decreased to hydromorphone 4 mg with a weaning schedule. Shortly after discharge, the patient and his family reported significant improvement in his symptoms and that he was being weaned from opioids.


A 7 year old male presented on account of whitish
speck noted in the right eye of about 5 years duration.
There was a history of the right eye being slightly
bigger than the left as well as poor vision in the right
eye. There was no history of eye protrusion, abnormal
skin pigmentation or seizures. There was no previous
ocular surgeries, nil significant medical illnesses or
previous hospitalization and no family history of
glaucoma.
Visual acuity was count fingers (CF) right eye and 6/5
left eye. Manifest refraction was +0.50DS/-2.75DC/
80 right eye and +0.25DS left eye. A relative afferent
pupillary defect (RAPD) was noted on the right eye.
Applanation intraocular pressures were 44mmHg and
18mmHg in the right and left eye respectively.
Slit lamp examination on the right eye showed a
buphthalmic globe, Haab's striae on the cornea with
corneal diameter of 16.5 x 15.5mm, deep anterior
chamber, round and sluggishly reactive pupil with
RAPD, clear lens and cupped disc with a cup-to-disc (CDR) 1.0. Finding in the left eye were essentially
normal with a pink disc of CDR 0.4.
An assessment of right infantile glaucoma was made
and was temporarily commenced on anti-glaucoma
medications (timolol and dorzolamide combination)
for the right eye. He subsequently had right
trabeculectomy with Mitomycin-C (MMC) under
general anaesthesia. Notable intraoperative event was
sudden shallowing of the anterior chamber upon entry.
Postoperatively, he developed hypotony (an IOP of
0mmHg) with a huge bleb on the 2nd post-operative
day and shallow anterior chamber with choroidal
detachment observed on the 4th post-operative day
(Fig. ).
An assessment of right overfiltration with choroidal
effusion status post trabeculectomy was made. He
initially had conservative management which included
maximum cycloplegia and reduction of the frequency
of topical steroid. This was to allow for deepening
of the anterior chamber by pulling of the iris-lens diaphragm back and for some healing around the
scleral flap and bleb to reduce the overfiltration. Upon
failed conservative management, he had a right anterior
chamber reformation with viscoelastic under general
anaesthesia on post-operative day 7 to augment the conser vative management. However, effusion
worsened progressively, with vision of light perception
(LP) and hypotony persisted as shown in figure 2 ( and ).
At the 11th day post-trabeculectomy, patient eventually
had a right compression suture, repeat anterior chamber
reformation with viscoelastic and sclerostomy with
drainage of effusion under general anaesthesia.
Intraoperative findings include thick tenon capsule and
sclera (which was unusual for an enlarged globe) and
straw coloured suprachoroidal fluid was drained.
Effusion resolved post-operatively with visual acuity
of CF and the retina remained flat as shown in figure
.


A 34-year-old male patient was brought to our emergency department by his neighbor after
sustaining a single stab wound to the neck and finding himself unable to walk. Physical
examination found him fully conscious, hemodynamically stable and without any neck
restraint. A single right-sided stab wound was noted in the lower anterior triangle of the
neck (), and air entry was
reduced over the right hemithorax. He could not move his lower limbs or feel sensation below
the waist, and his cervical spine was immobilized forthwith. A chest x-ray revealed a
right-sided pneumothorax, and an intercostal drain was inserted. A multidetector helical
computed tomography (CT) with angiography and contrast swallow ruled out vascular,
laryngotracheal, and pharyngo-oesophageal injuries. T2-weighted magnetic resonance imaging
(MRI) of the spine revealed a central intramedullary high signal lesion of the spinal cord
at the T2–T3 level as the cause of his acute paraplegia ().
Our urology department was consulted 5 h after admission with a complaint of persistent
erection of 4-h duration. He denied the use of antipsychotics, recreational drugs, or any
oral medication or self-injection for erectile dysfunction. He gave no history of
hematological diseases such as sickle cell anemia or leukemia. Further, examination revealed
no evidence of trauma to the pelvis, perineal, or genital area. A full blood count, liver,
renal and thyroid function tests and serum electrolytes were normal. No sickle cells were
detected on the peripheral smear. A tox screen was negative. Penile corporal blood gas
analysis demonstrated a high-flow, non-ischemic priapism with pH 7.42, pCO2
35.2 mmHg, and pO2 93.5 mmHg. Repeat penile corporal blood gas analysis
reaffirmed the priapism to be non-ischemic in nature, and it was decided to manage the
patient conservatively. The priapism resolved spontaneously 7 h after onset. The patient
reported two further episodes of unwanted erections, each lasting 30 min over the next 24 h.
He was transferred to a rehabilitation unit. He showed no demonstrable improvement in motor
and sensory function at follow-up 5 months later and no recurrence in priapism episodes.


An 89-year-old Caucasian female with a recent history of endometrial cancer and deep vein
thrombosis presented to the hospital emergency department with complaint of hematochezia.
She underwent total laparoscopic hysterectomy and lymph node dissection 1 month prior to
this current presentation. The endometrial cancer was characterized as a high-grade, poorly
differentiated adenocarcinoma stage 3b, strongly positive for estrogen receptor with a wild
type of p53. Three weeks after the surgery, she was diagnosed with proximal deep vein
thrombosis of the right lower extremity and was started on anticoagulation with apixaban.
Within a week of beginning the anticoagulation, she developed bleeding per rectum. She was
hemodynamically stable at the time of admission with a hemoglobin of 8 g/dL. The physical
examination was significant for right lower extremity swelling and bright red stool on
rectal examination. Esophagogastroduodenoscopy was unremarkable; however, the colonoscopy
revealed severe stricture in the distal sigmoid colon (), which was subsequently biopsied. The serum
carcinoembryonic antigen (CEA) levels were within the normal range. Colon biopsy
demonstrated metastatic endometrial adenocarcinoma, with immunohistochemistry (IHC) staining
positive for cytokeratin 7 (CK7), paired box gene 8 (Pax 8), and estrogen receptor (ER;
). The oncologist
referral was given to the patient for consideration of chemotherapy, but she decided to go
with palliative care.


A 20-year-old male visited our hospital because of pain in his left shoulder for 3 days. There was no relevant past or family history, including no history of side effects of vaccination, trauma, or viral illness. The patient was vaccinated against typhoid fever 6 days before in the left shoulder deltoid muscle, and there had been no other abnormal reactions. Vital signs were as follows: blood pressure, 127/82 mm Hg; pulse rate, 73 beats/min; respiratory rate, 16 breaths/min; and body temperature, 36.9°C. The patient complained of pain around the left shoulder joint. The pain intensity was reported as a visual analog scale (VAS) score of 9.
During physical examination, no heat sensation, edema, or direct tenderness was observed at the injection site. Passive range of motion of the left shoulder joint was limited (). The upper extremity muscle tone and deep tendon reflexes were normal.
Peripheral blood tests showed no unusual findings other than mild increased liver function: aspartate aminotransferase, 44 IU/L; alanine transaminase, 112 IU/L. There were no abnormal findings in the left shoulder joint and surrounding bone structure on simple X-ray. A mild atrophic change of the infraspinatus muscle was identified on shoulder magnetic resonance imaging (MRI) performed at the time of the visit ().
To examine sudden joint pain, muscle weakness, and atrophy, we conducted electromyography (EMG) and nerve conduction velocity for suspected Parsonage-Turner syndrome (). The results of the test revealed left upper trunk brachial plexopathy, which was diagnosed as Parsonage-Turner syndrome.
We initially administered a nerve block in the left C5 and upper brachial plexus using triamcinolone and lidocaine for pain control. Subsequently, pain decreased to 1 to 2 points on VAS. Initially, although steroids are usually available, we decided to administer intravenous immunoglobulin in consideration of autoimmune-related reactions. Intravenous immunoglobulin was administered for 5 days at a dose of 400 mg/kg/day as a treatment for neuropathy. There were no side effects during the immunoglobulin administration. From the fourth day of immunoglobulin administration, the abduction and adduction ranges of shoulder joint motion increased, and muscle strength began to improve ().
The patient was discharged with complete improvement in muscle strength without pain complaints on hospital day 21. He was also followed-up at our outpatient department a month after he was discharged from the hospital. Recurrence has not been observed.


The patient was a 11-month-old 7.8 kg-weighing female infant with hepatoblastoma. She was born at 39 weeks through normal full-term spontaneous delivery. At 7 months after birth, she started experiencing multiple vomiting. Thus, workup studies were performed. Imaging studies and percutaneous liver biopsy confirmed the diagnosis of hepatoblastoma (, ), which was classified as pediatric liver tumor staging (PRE-Treatment EXTent of tumor [PRETEXT] grouping system) stage IV. She underwent systemic chemotherapy (Children’s Oncology Group study AHEP0731). The tumor size was gradually reduced. However, some parts of the tumor remained due to partial responsiveness to systemic chemotherapy (, ). Thus, we decided to perform LDLT to remove the tumor completely.
The living donor was a 34-year-old mother of the patient. The whole LLS volume was measured to be 350 mL on computed tomography volumetry (), which was equivalent to a graft-to-recipient weight ratio (GRWR) of 4.5%. The ratio of graft thickness to the recipient abdominal cavity was 1.3. Although the abdominal cavity of the recipient was enlarged due to hepatomegaly with multiple hepatoblastomas, the whole LLS graft appeared to be too large for secure implantation. Thus, we planned to perform size reduction to obtain a reduced or hyper-reduced LLS graft.
Recipient liver dissection for total hepatectomy was performed according to standard procedures of pediatric LDLT. The residual tumor invaded the retrohepatic inferior vena cava (IVC) close to the common trunk of the middle and left hepatic veins.
In accordance with recipient operation, donor operation was performed to recover the LLS graft. After parenchymal transection, the LLS volume was assessed by manual palpation, which was comparable to the preoperatively-measured volume of 350 mL. Thus, in situ non-anatomical size reduction was performed to remove the flat lateral portion (). The resected liver parenchyma weighed 95 g. The reduced LLS graft was harvested according to the standard procedure. The weight of the graft was 235 g, which had a GRWR of 3.0%. The graft hepatic vein was single and measured 1.2 cm in diameter. Thus, incision-and-patch plasty using a small patch of iliac vein homograft was performed at the medial wall of the graft left hepatic vein, by which the diameter of the graft hepatic vein was enlarged to 2 cm.
Recipient hepatectomy was performed according to standard procedures of pediatric LDLT. After clamping of the supra- and infra-hepatic IVC portions, the IVC wall close to the tumor was additionally excised and a 2 cm × 1 cm-sized vein homograft patch was attached to the IVC defect. An external iliac vein conduit homograft was anastomosed to the hypoplastic recipient portal vein.
After finishing venoplasty in the recipient and the graft, the reduced LLS graft was temporarily placed at the abdomen to determine the implantation location. The graft was partially accommodated in the right subphrenic fossa, thus we decided to perform dextroplantation of the graft. The axial orientation of the graft was marked with 6-0 Prolene stay sutures. Afterwards, graft implantation was performed in the order of hepatic vein, portal vein, hepatic artery, and Roux-en-Y hepaticojejunostomy (). The graft portal vein was anastomosed with the interposed external iliac vein conduit homograft. The liver graft was not too large for the size of the recipient abdomen and it was partially accommodated in the right subphrenic fossa. Therefore, the abdominal wall wound was primarily closed under minimal tension.
The resected liver specimen showed multiple viable hepatoblastomas measuring up to 5 cm in size (). Necrosis and foam cell infiltration were identified in 60% of tumors. Lymphovascular invasion and perineural invasion were absent.
The patient recovered uneventfully (). Computed tomography images taken at four days after the transplantation revealed that the reduced LLS graft was accommodated within the right subphrenic fossa like the usual right liver graft. The patient has been doing well for the past 6 months. She is undergoing scheduled adjuvant chemotherapy.


A 31-year-old Filipino man with a history of cough variant asthma presented with a cough, fatigue, diarrhea, and fevers. An extensive history revealed a previous employment as a nurse in the Philippines; however, the patient admitted to a sedentary lifestyle, including approximately 18 h a day of playing video games in addition to a poor diet. The patient adapted this lifestyle after migrating from the Philippines to the USA for 6 months. A computed tomography (CT) scan of the abdomen and pelvis demonstrated bilateral psoas abscesses with extensive subcutaneous air tracking into the right flank. A subsequent magnetic resonance imaging (MRI) revealed early S1 osteomyelitis. Laboratory results included the following: white blood cell (WBC) 22.8 (85% neutrophils; reference range: 3.4 - 48), absolute lymphocytes 0.64 (reference range: 0.90 - 4.6 × 103/mm3), immature granulocytes absolute 0.2 × 103/µL (reference range: 0.0 - 0.1 × 103/µL), erythrocyte sedimentation rate (ESR) 61 (reference range: 0 - 15 mm/h), high-sensitivity C-reactive protein (hsCRP) 55 (reference range: 0 - 10 mg/L), HIV-1/2 Ag/Ab Combo negative, CD4+ helper 322 (26.8%; reference range: 359 - 1,519/µL), procalcitonin 0.09 (reference range: 0 - 2 ng/mL), QuantiFERON-TB Gold negative, and urine toxicology negative.
The patient was initially managed in the operating room for an incision and drainage of psoas abscess, with cultures revealing Escherichia coli, Streptococcus anginosus, and Bacteroides thetaiotaomicron. Medical management included ceftriaxone, vancomycin, and metronidazole for appropriate antibacterial coverage. The underlying etiology remained unclear as no colonic microperforations were appreciated on a CT scan. Any history of intravenous drug abuse was also denied by the patient. Living situations included living with his mother and aunt, who both happened to be nurses.
The hospital course was complicated by a pulmonary embolism (PE). The patient’s management included surgical debridement for the psoas abscess in conjunction with antibiotic therapy, as mentioned earlier, for antibiotic coverage. The patient was discharged with 6 - 8 weeks of outpatient antibiotics.


A 40-year-old female presented to her ophthalmologist’s office for evaluation of decreased visual acuity and bilateral flashers. She was diagnosed with bilateral panuveitis, started on cyclopentolate and prednisolone drops, and was referred to her primary care physician for further evaluation. Upon questioning, the patient also reported a pruritic rash of 3 weeks duration on both lower extremities and a genital ulcer 6 weeks prior that had since resolved.
She otherwise felt well with no complaints. The patient denied arthralgias, oral ulcers, photosensitivity, chest pain, or shortness of breath. She had no known exposures to tuberculosis. She was sexually active with one male partner, however questioned if he was monogamous. She had no prior history of sexually transmitted infections and never had been screened for human immunodeficiency virus (HIV). She had a past medical history of hypertension that was well controlled on amlodipine and was otherwise in excellent health. She had no family history of systemic autoimmune diseases or sarcoidosis.
Her physical exam was notable for copper colored/hyperpigmented macules on bilateral feet and ankles with overlying xerotic patches as shown in .
Rapid plasma reagin (RPR) was positive with a 1:64 titer and her treponemal antibody was reactive. HIV screen was negative. The patient was diagnosed with secondary syphilis and was admitted to the hospital for evaluation of neurosyphilis given concurrent uveitis. Upon admission she underwent a lumbar puncture (LP) with results as follows: two nucleated cells; 0 red blood cells (RBCs) (100% polymorphonuclears (PMNs)); protein 23, glucose 60; cerebrospinal fluid (CSF) Venereal Disease Research Laboratory (VDRL) non-reactive; herpes simplex virus (HSV) IgG and IgM negative.
The rash was biopsied which showed superficial and deep perivascular dermatitis with treponemal organisms consistent with cutaneous syphilis. Ophthalmologic exam revealed an inferior retinal hole in the left eye and bilateral panuveitis. Infectious disease was consulted and recommended 14 days of IV penicillin. Ophthalmology recommended concurrent use of topical cyclopentolate 1% and prednisolone 1%. The patient tolerated the treatment course well and had complete resolution of her rash and uveitis, without any long-term effects on visual acuity. As CSF findings were normal, no repeat LP was performed. Follow-up RPR titers checked at 6 months decreased to 1:32.


A 77-year-old woman presented with dyspnea, dry cough and right-sided chest pain for the previous 6 months. On physical examination, breath sounds were decreased on the right side. The skin examination showed no “cafe au lait” spots or subcutaneous tumors.
Contrast enhanced computed tomography (CT) scan of the chest revealed a well circumscribed heterogenous mass of the anterior mediastinum lateralized to the right measuring 11 cm in major axis without compression of the superior vena. This mass presents close contact with the ascending aorta and the right atrium with obvious pericardial thickening (). An interventional radiologist performed a transthoracic needle core biopsy, which revealed a mesenchymal lesion. An anterior mediastinotomy (Chamberlain procedure) was then performed to obtain adequate tissue for a precise diagnosis. On microscopic examination, the tumor consisted of neoplastic spindle cell proliferation arranged in interlacing bundles with large and irregular nuclei and frequent mitoses (around 10 mitoses per 10 fields) (). Immunohistochemistry (IHC) staining was performed. The panel of monoclonal antibodies consisted of cytokeratin 5, 6, 7, and 20, vimentin, smooth muscle actin, CD-117, thyroid transcription factor-1 (TTF1), epithelial membrane antigen (EMA), CD-34, and S-100 protein. Tumor cells were positive for vimentin strongly () and uniformly and negative for PS100 and other markers. This morphological and immunohistochemical aspect was compatible with high-grade MPNST. After pathological diagnosis was established, whole body CT scan was performed but did not reveal any tumor. The tumor was considered unresectable and the patient received three cycles of chemotherapy based on adriamycin 75 mg/m2. Chest CT scan performed thereafter showed partial response consisting of 30% decrease of the tumor volume allowing complete surgical excision of the tumor ().
Right posterolateral thoracotomy was performed over the fifth rib using double-lumen endotracheal tube to permit unilateral deflation of the right lung. Surgical exploration revealed firm, irregular, and completely encapsulated mass involving the right phrenic nerve, with conservation of the cleavage plane with the trachea, the superior vena cava, the ascending thoracic aorta, and lung. The tumor was completely resected and partial resection of the right phrenic nerve was performed ensuring R0 surgery (, ).
Final pathology confirmed the diagnosis of MPNST originating from the right intrathoracic phrenic nerve in an old female patient with no clinical evidence of Von Recklinghausen disease. No areas of hemorrhage or necrosis were seen.
The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. Six weeks later, the patient underwent adjuvant three-dimensional conformal external beam radiation to the surgical bed at the dose of 60 Gy in 30 fractions with mild acute side effects and overall a very good tolerance.
The patient remained free of recurrence 3 years after her treatment.


The patient was 16 years old when she developed periodic disfiguring blistering lesions of the face and arms that left scars. She graded disease activity subjectively as “8 out of 10,” being the worst during the first 1 - 3 years. The diagnosis of pemphigus foliaceus was made by physical examination and confirmed by indirect immunofluorescence of serum. The flaring attacks were affected only modestly by dapsone, so her dermatologist added oral prednisone between 5 and 10 mg per day for better control.
As a 19-year-old second-year college student, when her pemphigus activity was “at its worst,” she presented with myasthenia gravis because of problematic slurred speech and fatigability and weakness of leg muscles. Diagnosis was confirmed by repetitive nerve stimulation and by greatly elevated serum anti-AChR antibody. Imaging of the thymus did not show thymoma. She responded partially to oral pyridostigmine. The low-dose daily prednisone was not changed. She had no other autoimmune disorders.
At age 20, because of generalized myasthenia gravis, she underwent extended thymectomy by median sternotomy, with complete resection of mediastinal fat and exploration into the neck for ectopic thymic tissue. Preoperative anti-AChR antibody level by radioimmunoassay (RIA) was greatly elevated at 119 × 10-9 M (normal controls, < 0.16 × 10-9 M). Anti-pemphigus antibody by indirect immunofluorescence was positive at 1:320 dilution (normal, undetectable).
Serum was collected periodically for diagnostic purposes (before thymectomy and for 7 years thereafter), and an aliquot was stored frozen at -70 °C for later assay. Anti-AChR antibody was assayed by RIA using human AChR as antigen, and pemphigus antibody was assayed (by an older technique in the 1990s) by indirect immunofluorescence using squamous cell epithelium of monkey esophagus. For the construction of , all assays for each antibody were carried out simultaneously in single batches in order to lessen the between-test variance due to conditions of measurement.
For the 6 years after thymectomy, no change was made in her low-dose oral prednisone and dapsone; only the pyridostigmine (the only drug used for her myasthenia) was gradually decreased, and the topical medications for pemphigus were altered if there were flares. By 7 months after surgery, her “skin had improved markedly,” according to her dermatologist. The only short-lived rise in anti-pemphigus antibody months after thymectomy was temporally related to a brief flare in pemphigus symptoms after skin tanning exposure. Disease activity waned over time, and both lesions and flare activity became more manageable, in that there were fewer lesions on the face and much less discomfort. She needed to see her dermatologist only twice per year instead of the previous 4 - 8 visits. By 6 years after surgery, prednisone for pemphigus was tapered down to 10/0 mg on alternate days. By 10 years, prednisone was no longer used for pemphigus. By 16 years after surgery, when she had scant symptoms of pemphigus, she delivered a child who had transient neonatal pemphigus lasting for 1 week (but was normal for the next 13 years of life), indicating our patient still had circulating pemphigus antibody. Under vigilant surveillance for neonatal myasthenia, none developed. Likewise, the patient’s symptoms of myasthenia had gradually waned after thymectomy, so that even low-dose pyridostigmine was discontinued at 10 years as she became, and remains, asymptomatic, no longer requiring neurological care.


We present the case of a man, presenting with first-degree heart block, which progressed to CHB within hours and resolved promptly after receiving antibiotic to treat Lyme disease.
A 66-year-old man without prior cardiovascular issues presented in the first week of August with generalized body ache. The clinical examinations including skin examination and routine blood investigation were unremarkable then. An electrocardigram (ECG) had shown sinus rhythm, normal PR interval and a pre-existing right bundle branch block (RBBB).
He returned in early September complaining of light headedness, dizziness and breathlessness upon exertion for 6 - 7 days. A week earlier he had complained of fatigue and feeling unwell.
He was a Pittsburgh (USA) native, with schizophrenia and depression but no hypertension or diabetes. He was not on any medication causing heart block. The clinical examination at this time showed a regular pulse of 89 beats/min and blood pressure (BP) 134/92 mm Hg, temperature 36.6 °C (98.0 °F) and respiratory rate 18/min with O2 saturation of 94% on room air. The cardiac, pulmonary, neurological and abdominal examinations were unremarkable. No skin lesion or joint abnormality was present, except for trace ankle edema bilaterally.
A chest X-ray and routine blood investigations that included troponin-I were within normal limits, although erythrocyte sedimentation rate (ESR) 53 and C-reactive protein (CRP) 3 were elevated. Drug screen was unremarkable.
An initial ECG showed a new prolongation of PR interval to 320 ms with pre-existing RBBB. An ECG repeated due to non-conducted P waves seen on monitor showed several non-conducted P waves, without evidence of acute ischemic injury, which progressed to a CHB, with idioventricular rhythm at 32 bpm, and persistent RBBB in minutes on subsequent ECGs (). An echocardiogram showed normal valvular and systolic functions.
Further questioning in view of rapidly progressing heart block in absence of sign symptoms of acute myocardial or systemic disease revealed that the patient had been bitten by a tick in late May while walking his dog “in woods”. However, he never noticed any skin lesion.
Considering the possibility of Lyme carditis, 2 g of ceftriaxone was given intravenously, and pacemaker placement was deferred as the patient remained hemodynamically stable. Approximately 3 h after the antibiotic, sinus rhythm was restored, and PR shortened to 230 ms (). Later patient’s Lyme serology with Western blot yielded a positive result for both immunoglobulin G (IgG) and immunoglobulin M (IgM) along with Borrelia specific band.
Patient was treated with intravenous (IV) ceftriaxone for 3 days and then discharged on oral doxycyclin 100 mg twice a day for a total of 21 days of treatment. Two week of cardiac monitoring following discharge showed progressively decreasing PR interval, but persistent first-degree heart block without any arrhythmia. The ECG returned to the baseline with pre-existing RBBB and normal PR interval in approximately 6 weeks.


A 67-year-old woman diagnosed with breast cancer in 2017 was referred to our clinic for persistent right upper eyelid ptosis. She was previously treated by an ophthalmologist, who diagnosed an involutional ptosis. Upon presentation, her visual acuity (VA) was 20/200 in the right eye (OD), 20/40 with eyelid elevation, and 20/40 in the left eye (OS). There was a slight decrease in abduction OD. The margin reflex distance 1 (MRD 1) was −2 mm OD and 2 mm OS (). The margin reflex distance 2 (MRD 2) was normal in both eyes (OU). Levator function was 2 mm OD and 10 mm OS. There was fullness in the right superior sulcus relative to left; the right superior sulcus was non-tender and firm upon palpation. The remainder of the eye examination was normal.
Magnetic resonance imaging (MRI) of the orbit with and without contrast demonstrated an infiltrating enhancing soft tissue mass throughout the intraconal and extraconal space with extension to the orbital apex (). Abutment of the superior, medial, and inferior recti with associated encasement of the optic nerve was noted (). This likely contributed to the restriction of the right eye in lateral gaze. Within a week of presentation, a right anterior orbitotomy with biopsy via a lower lid transconjunctival approach was performed. A gray-white mass was visualized intraoperatively and biopsied. The biopsy demonstrated lobular carcinoma (). Our patient was referred to oncology and radiation therapy for further management and treatment.


A 50-year-old male known smoker, smoking 7-8 cigarettes/day for the last 10 years presented with complaints of intermittent hemoptysis for last 2 years. He denied any history of low-grade fever, loss of appetite, night sweats, weight loss, chest pain, trauma, or breathlessness. There was no history of exposure to any drugs (antiplatelets, anticoagulants) or bleeding disorder. His sputum for acid-fast bacilli (AFB) was negative. Diagnostic evaluation for his symptom on the previous occasions at other hospitals was inconclusive with a normal reported chest X-ray and computed tomography (CT) scan exam. Fiberoptic bronchoscopy findings reported blood in right and left main bronchial system. Presently, his physical examination revealed a temperature of 37°C, pulse rate of 82/min, blood pressure of 142/84 mmHg, respiratory rate of 12/min, oxygen saturation of 98%, normal respiratory sounds, and a normal chest X-ray. Laboratory investigations revealed a normal blood value including normal platelet count and coagulation parameters. His transthoracic echocardiography revealed normal right and left ventricular functions without any evidence of mitral stenosis/right-sided infective endocarditis or pulmonary hypertension. High-resolution CT scan showed localized pocket of air density medial to bronchus intermedius on axial [] and coronal sections [] suggesting accessory cardiac bronchus. No lung tissue was associated with accessory cardiac bronchus. Subsequent fiberoptic bronchoscopy confirmed accessory cardiac bronchus originating medially from bronchus intermedius opposite to the right upper lobe bronchus, whose lumen was partially obscured by small a clot. Bronchial and pulmonary angiography revealed no abnormality in tracheobronchial tree or pulmonary drainage.
A right thoracotomy was performed and accessory cardiac bronchus was identified. ACB extended 3 cm toward pericardium without any associated lobule. It was resected with preservation of vagus nerve. Bronchus intermedius was closed in two layers. Subsequent pathological examination revealed a tubular structure ending blindly with cartilage rings, inflamed and ulcerated mucosa with the collection of neutrophils and fibrous tissue. Hemoptysis was attributed to this inflamed vascularized accessory cardiac bronchus. The patient is asymptomatic currently with no recurrent hemoptysis at 6-month follow-up.


A 52-year-old male patient reported to the department of oral and maxillofacial surgery in view of a persistent diffuse swelling in the right lower face and neck region for 5–6 years []. The swelling remained stable in size for 4–5 years, after which it started increasing and reached the present size. The patient reported associated pain in winter season. History for associated or concurrent medical illness, trauma, fever, pus discharge, and any other similar swelling in any other part of the body was negative.
The swelling was irregular in shape with diffuse margins, compressible, and extending from mandibular attachment of right buccinator muscle to upper neck region. It extended anteroposteriorly from the left parasymphysis region to 2 cm beyond the right angle of the mandible and measured approximately 15 cm × 9 cm. Inferior border of the right mandible and submandibular lymph nodes could not be palpated. Overlying skin was normal in colour and temperature. Intraoral findings were insignificant, except for mild obliteration of the right buccal vestibule.
Fine-needle aspiration cytology of swelling showed clusters of mature adipocytes and fat globules. Ultrasonography of the right submandibular region was suggestive of abscess formation. Plain computed tomogram and contrast-enhanced computed tomogram of the neck study gave an impression of moderate to large-sized well-defined multiple septate lipomas measuring 11.5 cm × 10.5 cm × 6.5 cm involving submandibular region and anterior triangle of the right neck [Figure and ].
The patient's informed consent was obtained for the surgery and for using his images for the purpose of publication. Complete surgical excision was planned which was carried out extraorally through submandibular approach []. The excised mass measured 120 mm × 95 mm × 40 mm and weighed 104.70 g; more than 10 lobules were present []. The tissue when immersed in a jar filled with formalin was found to be floating – confirming its fatty nature, which was also confirmed by histopathological examination [].
The patient had an uneventful recovery and minimal scar with restored esthetics []. The patient was kept on follow-up for 6 months on monthly basis. No recurrence was observed. The patient was satisfied with the treatment.


Our patient is a 20-year-old female who initially presented to an outside hospital in July 2017 with a 1-month history of progressive low back pain. Initial magnetic resonance (MR) showed a destructive, osteolytic, expansile lesion measuring 4.8 × 3.8 cm centered in the left aspect of the sacrum at the level of S2–S3 with areas of anterior cortical destruction extending into the left sacral neural foramina from S2 to S4. There was also a heterogeneously enhancing soft tissue component that was measured at 6.4 × 3.7 cm that was along the left piriformis muscle. A CT-guided core needle biopsy performed in August 2017 yielded an initial diagnosis of a high-grade osteosarcoma. She was subsequently treated as an osteosarcoma patient with MAP chemotherapy. She completed a total of 12 weeks of chemotherapy, with cumulative doses of cisplatin 360 mg/m2, doxorubicin 225 mg/m2, and methotrexate 24 g/m2. Surgical intervention was determined to result in substantial morbidity, and therefore, the patient underwent proton beam radiation in three fractions for a total dose of 54 Gy. However, due to the lack of increased bone mineralization in response to chemotherapy, the question of osteoblastoma rather than osteosarcoma was raised.
After reviewing the initial pathology, a second pathologist described the tissue specimen as a cellular tumor composed of proliferating osteoblasts with atypia and frequent mitotic figures associated with trabecule of woven bone. Neoplastic cells demonstrated mild cytologic atypia and scattered mitoses of normal configuration. In different areas, the tumors had undergone secondary hemorrhagic and cystic changes. Although difficult to definitively differentiate between the two, an overall impression of osteoblastoma was favored. As a result, a second biopsy was later obtained in December 2017. It in fact demonstrated no neoplastic cells, but instead a cystic wall with bland-appearing spindle cell proliferation, hemosiderin deposition, lamellar and woven bone with osteoclast-type giant cells along with a foci of fibrous tissue with plasmacytoid and epithelioid osteoblasts, with surrounding osteoid, all of which was consistent with an ABC. The specimen was negative for reportable single nucleotide variants, as well as negative for EWSR1/FUS/SS18/STAT6 rearrangements. After having three separate pathology consultations, the final diagnosis of an osteoblastoma with secondary ABC was made.
Based on the revised diagnosis of osteoblastoma, the decision was made to change her therapy to denosumab as surgery was still deemed to be too morbid. In May 2018, she was started on denosumab 120 mg every week for 4 weeks, and then monthly. At the time of writing this report, she has received 24 doses. Surveillance imaging throughout her treatment showed a decrease in the number and size of the cystic components, and an overall plain radiographic appearance of mineralization along with decreased FDG avidity on PET scan, suggestive of a treatment response ( and ). After nearly 24 months of treatment with denosumab, her latest MRI has continued to show stable to slightly decreased size of the lesion and loss of fluid level in the lesion (). Additionally, her pain control has drastically improved and she was able to completely titrate off all pain medications within 3 months of starting denosumab.


A 31-year-old patient (G2P1) presented to our center for routine prenatal examination at the 22nd wk of gestation.
The patient was healthy, and her previous pregnancy resulted in laboring a healthy child.
The patient received regular prenatal examinations beginning at the 6th wk of gestation, and US screening of the first trimester was unremarkable. During US screening, 2DUS examination showed normal results for fetal status. In the coronal lip-nostril plane, the fetus's lips, nose tip, nostrils, and mandible could be identified, and the edge of the upper lip appeared continuous. However, the oral commissures appeared asymmetric in the coronal plane, and a cleft was identified at the left oral commissure which extended to the left cheek (Figure and ). The cleft was significantly enlarged while the mouth was open. The mid-sagittal plane was normal, while the left oblique-coronal section indicated the facial cleft extending from the left oral commissure through the left cheek towards the left ear (Figure and ). Subsequently, the 3D surface rendering images were taken for further clarification, and the result showed the left lateral facial cleft, which resulted in unilateral macrostomia (Figure ). No other defects, e.g., signs of amniotic band syndrome, were identified on further investigations.