A 52-year-old female presented with swelling in the neck, in the thyroid region, of 3 months duration. She complained of difficulty in swallowing and pain in the swelling for the last fifteen days. Clinically, she was euthyroid and there was no past history of exposure to radiation. Routine blood examination and serum chemistry revealed no abnormalities. Serum T3, T4 and TSH levels were normal. Renal function and liver function tests were normal.
There was no family history of thyroid disease. She was a known hypertensive on treatment. On examination a 3 × 2 cm lump was palpable in the lower part of neck, more so on the right side. This swelling moved with deglutition. No lymph nodes were palpable in the neck. No clinical evidence of abnormal parathyroid activity, Cushing syndrome, subcutaneous nodules or mucosal neuromas was present.
Computerized tomography (CT) scan neck showed a 3.5 × 2.5 cm hyper dense lesion in the right lobe of the thyroid without any associated lymphadenopathy. Fine needle aspiration cytology (FNAC) was suggestive of a poorly differentiated carcinoma. On laryngoscopic examination, bilateral vocal cords were mobile. Near total thyroidectomy was done without lymph node dissection. Post-operative period was uneventful. Unfortunately, serum calcitonin level was not estimated preoperatively but postoperative serum calcium and calcitonin levels were within normal limits. Thyroid weighed 24 gm and thyroid capsule was intact. Cut surface showed a single nodule measuring 3.1 × 2.2 × 1.1 cm within the right lobe of thyroid. Nodule was partially encapsulated but well demarcated from adjacent normal appearing thyroid. Cut section of nodule was soft homogeneously black in color with grey white foci (Fig ). No satellite nodule was seen in the rest of the thyroid. Lymph nodes were not found in the specimen.
Tissue was fixed in 10% neutral buffered formalin, routinely processed and paraffin embedded. Five micron thick sections were cut for hematoxylin and eosin staining and immunohistochemistry. Immunohistochemical staining was done by streptavidin-biotin peroxidase complex method and a panel of antibodies was used to characterize the tumor. These include thyroglobulin (dil 1:50), thyroid transcription factor (TTF, dil 1:100), synaptophysin (dil 1:50), carcinoembryonic antigen(CEA, dil 1:100), melan A(dil 1: 100), epithelial membrane antigen (EMA, dil 1:50), pancytokeratin (CK; dil 1:100), cytokeratin 19 (dil 1:100), S-100 protein (dil 1:100), vimentin (dil 1:100), chromogranin (dil 1:50), calcitonin (dil 1:50), HMB 45 (dil:100), p53 (dil 1:50), bcl-2 (dil 1:50) and MIB-1 (dil 1:50). All antibodies were obtained from M/s Dako Patts, Denmark except p53 and TTF which were procured from M/s Novocastra UK and M/s Neomarker, USA respectively. High temperature antigen retrieval using microwave was carried out by immersing the sections in 10 mM citrate buffer (pH 6.0) and heating inside a 750 watt microwave oven in full power for 30 minutes except for chromogranin, HMB-45, S-100 and EMA.
MIB-LI was calculated as percentage positive nuclei in the highest labeled areas. For electron microscopy, the tissue was fixed in 2.5% glutaraldehyde, post-fixed with 1% osmic acid and embedded in epoxy resin. Routine thick sections were cut to select representative area for ultra-thin sectioning. Ultra-thin sections were double stained with uranyl acetate and lead citrate and examined under a transmission electron microscope (TEM, Morgagni 268, Holland). Microscopic examination showed a cellular tumor arranged in solid sheets, nests and trabecular pattern with few residual normal thyroid follicles (Fig ). Tumor cells were polygonal, round to oval, at places showing spindling. Cellular outlines were indistinct with moderate to abundant amphophilic cytoplasm. Nuclei were vesicular and showed moderate pleomorphism, multi-nucleation and conspicuous nucleoli. Frequent mitoses were present but necrosis was not seen. Scant perivascular eosinophilic amorphous material was present which was reactive to Congo red stain and showed apple green birefringence on polarization. Brown-black, coarse intracytoplasmic pigment was present in the tumor cells (Fig. ) which bleached with Masson-Fontana stain and it was negative for iron stain. Melanin was present in all types of tumor cells. Tumor cells showed diffuse immunopositivity for calcitonin, HMB-45, carcinoembryonic antigen, synaptophysin, chromogranin, vimentin and epithelial membrane antigen but focal paranuclear dot-like positivity for cytokeratin (Fig ), and were negative for thyroglobulin, S-100, melan-A and TTF (Table ). Electron microscopy revealed abundant compound melanosomes, premelanosomes in various stages of melanogenesis and sparse membrane bound dense core neurosecretory granules measuring 50–200 nm along with intermediate filaments (Fig ). Patient was discharged on fourth post operative day and was doing well.
Follow up: However in the follow up, she developed local recurrence twice after 10 months and 18 months of operation in the soft tissue of neck. Serum calcitonin levels were within normal range. Excision of recurrent nodules showed medullary carcinoma without pigment production. After 3 months of second recurrence, she developed multiple nodules at the same site and surgical excision was done in another hospital. After this surgery she had multiple metastases to the scalp and died after 24 months of first surgery. Mutational analysis for ret oncogene could not be done.


A previously healthy 63-year-old man was admitted with a two week history of wounds over his sternum. Twenty days before hospital admission, he had developed fever and sore throat. Oral amoxicillin was given. Six days later he noted an erythematous skin lesion over his sternum. One week later his sore throat resolved but the skin lesion worsened. He presented to a dermatologist and was diagnosed with erysipelas and received oral amoxicillin again. Over the next two days, the skin lesion evolved to form vesicles that were drained in the emergency department of another hospital. The lesion progressed to ulceration over the next five days.
The patient had no history of immunosuppressive disease or treatment.
On admission he was afebrile (temperature of 37,2°C), and hemodynamically stable. Physical examination revealed two sloughy necrotic ulcerations of the skin over the sternum with hyperemic margins. These lesions measured about 6 × 4 cm. and 2 × 1 cm. (Figure ). The white blood cell count was 12.700/mm3, the hemoglobin level was 10.8 g/dL, and the platelet count was 561.000/mm3. The erythrocyte sedimentation rate was 78 mm/hour, the serum C-reactive protein level was 5,6 mg/L (range 0 – 5 mg/L). Liver function tests, blood urea nitrogen and serum creatinine levels and chest radiographs were normal.
Blood cultures were taken. A skin biopsy with culture was performed. While the results of cultures were pending, antibiotic therapy with imipenem (500 mg. IV every 6 hours) was initiated. Pathological examination of the biopsy material revealed ulcerated inflammatory cell infiltration, vascular proliferation and wide necrosis characteristic of ecthyma gangrenosum (Figure ). Blood cultures remained sterile, but a culture of the biopsy material grew Pseudomonas aeruginosa. Antibiotic treatment was continued for 14 days, after which the patient was admitted to the Department of Plastic Surgery for skin grafting. Two months later, the skin lesion had healed. One year later, he remains healthy.


A 44-year-old woman presented to the otolaryngology outpatient clinic with an asymptomatic anterior midline neck mass. The tumor had developed over 6 months. Physical examination revealed a 2 × 2 cm mass on the anterior part of the neck between the thyroid cartilage and hyoid. She was in good health otherwise and her past medical history was unremarkable.
A cervical ultrasound showed a lesion which appeared to be a TGDC and surgical resection by means of Sistrunk's procedure was performed. The histopathologic diagnosis was a papillary carcinoma evolving from a TGDC, confined to the thyroglossal cyst with a tumor diameter of 2 cm (Figure ). The patient was referred to the surgery department for further investigation. Thyroid scintigraphy, ultrasound and cervical CT scans were performed. The thyroid scintigraphy was normal. The cervical ultrasound showed multiple cervical lymph nodes which were of different sizes ranging from 8 mm to 17 mm. A cervical CT revealed bilateral cervical lymph nodes less than 2 cm in diameter. The patient's thyroid function tests were within normal limits. Total thyroidectomy and bilateral neck dissection were performed. The final postoperative pathology reported an 8 mm papillary cancer in the left lobe of the thyroid without any metastasis to the cervical lymph nodes (Figure ). The patient was treated with radioactive iodide and thyroid suppresion therapy was given as an adjuvant treatment. The patient has been following without any metastasis for two years.


A seven year old male presented with a painless, firm 3 cm mass overlying his sternum. He was clinically well, apyrexial with no history of weight loss. Initial investigations revealed an elevated CRP (27.5), ESR (90), white cell count (22.3) with a neutrophilia (17.0) and a hypochromic microcytic anaemia (Hb: 9.3). Technecium99 bone scan (Figure ) revealed increased uptake in the sternum, L1 vertebra, the left sacro-iliac joint and the right acetabulum.
A CT scan of the chest (Figure ) and sternum confirmed the presence of a sternal mass with no underlying soft tissue involvement. A fine needle biopsy of the sternal mass showed an inflammatory infiltrate. Bone marrow aspirates and trephine from the sternum showed a reactive marrow with no evidence of malignancy. Both ultrasound of the abdomen and echocardiogram were normal. On the basis of these results a provisional diagnosis of multi-focal osteomyelitis was made and the patient was started on antibiotic treatment (Benzylpenicillin, Flucloxacillin and Fusidic Acid). Despite this treatment his white cell count and inflammatory markers continued to rise.
Five weeks after discharge he represented because of an enlarging sternal mass and the development of back pain with no associated neurology (Figure ). He remained well with no weight loss or signs and symptoms of systemic disease. An open biopsy of the chest wall mass and a CT guided biopsy of the L1 spinal lesion were performed. These revealed macroscopically caseous material. Mantoux and Heaf tests were negative. An MRI scan of the lumbar spine (Figure ) showed loss of height of L1 with disease extending bilaterally to the pedicles of T12 and L2. There was a soft tissue mass anterior and posterior to L1 causing spinal stenosis and impingement on the conus. Radiologically this was thought to resemble Potts disease and the macroscopic appearance of the lumbar specimen suggested a diagnosis of tuberculosis. Triple therapy was commenced (Rifampicin, Isoniazid and Pyrazinamide). The specimens were negative for acid fast bacilli, Ziehl-Neelson stain for TB was negative and no organisms were cultured. Subsequent histology from the sternal mass showed Hodgkin's lymphoma (Figure ). Cells within the specimen were positive for CD30 and CD20 (Figure ).
Treatment with chemotherapy was started following the current UKCCSG (United Kingdom Childrens Cancer Survey Guidelines) for Hodgkin's disease, and antituberculous treatment was stopped. Staging showed no lymphadenopathy in the chest or abdomen. Two weeks after commencement of chemotherapy a dramatic decrease in soft tissue involvement around the spinal cord was seen on a repeat MRI. (Figure ). The time from presentation to diagnosis was two months.


A 28-year-old female patient presented to AIC Kijabe Hospital (KH) with a large, ulcerated mass on her left thigh which had been present for the previous 6 months.
Nine months prior to presentation, she had suffered traumatic avulsion of skin of the anteromedial aspect of her left leg, measuring about 5 cm by 8 cm. The resulting wound became infected and was initially managed with daily dressings. Debridement and split thickness skin grafting (STSG) were finally performed three months after the trauma. The skin graft had been harvested from her left thigh, and whereas the recipient site healed completely, the donor site failed to heal, and instead rapidly developed into a large ulcerated mass with a purulent, foul-smelling discharge. It bled frequently, both spontaneously and on mild trauma. (Figure ) Severe pain had kept her bedridden for two months prior to her presentation to KH. She had not used any traditional therapies.
The mass was covered by a thick creamy-white exudate. It had a purplish-grey hue around the rolled edges, and measured 25 × 15 × 5 cm. Old blood clots spread across the mass indicated past bleeding episodes. The proximal edge was continuous with the healed skin donor site. She had a healed scar on her leg, and was otherwise in good health.
An excision of the mass with a margin of 20 mm was performed, and the defect was covered with a STSG. The biopsy was reported as a giant lobular capillary hemangioma (Figure ). Bacterial colonization was only present on the surface of the lesion, and there was no evidence of mycobacterial or fungal infection.
This unusual history, presentation and diagnosis prompted a search for a possible cause. An ELISA for HIV-1 proved positive. Both the donor and the recipient sites healed completely, with no evidence of recurrence at 5 months (Figure ).


A 55 year old, non-smoker, Caucasian man presented to the emergency room with left sided hemiparesis. The patient also had bloody diarrhoea (12 times a day). A diagnosis of ulcerative colitis had been made five years previously and the patient had been maintained on mesalazine only. The patient had been evaluated in the out-patient department three days earlier with an exacerbation of his UC and was started on prednisolone 40 mg daily only. There was no history of vascular disease. On examination the patient was normotensive (blood pressure 111/80 mmHg) and afebrile. Cardiovascular examination revealed normal heart sounds, and no carotid bruits. Abdominal examination revealed tenderness in the left iliac fossa and reduced bowel sounds. A dense left sided hemiplegia was noted. Blood tests showed a raised white cell count of 11.5 × 109/L (NR 4–11) and C-reactive protein (CRP) of 29.6 mg/L (NR 0–5) and a thrombocytosis of 566 × 109/L (NR 150–400). Fasting cholesterol of 3.3 mmol/L (NR 1.3–5.2) and blood glucose of 3.3 mmol/L (NR 3.3–5.8) were both normal. Stool cultures were negative. An electrocardiogram demonstrated normal sinus rhythm. No evidence of cardiomegaly was noted on a chest radiograph. Trans-thoracic echocardiogram and carotid dopplers were normal. Computed tomography (Figure ) of the brain confirmed an ischaemic infarct in the right parietal lobe.
Flexible sigmoidoscopy demonstrated an inflamed granular mucosa with loss of the vascular pattern to the proximal sigmoid colon. He was commenced on intravenous hydrocortisone (100 mg QDS) and subcutaneous low molecular weight heparin (LMWH). Total parenteral nutrition was also commenced because of the likelihood of poor enteral absorption. After 14 days of treatment with hydrocortisone he underwent a total colectomy because of poor symptom control and worsening abdominal pain. Postoperative recovery was unremarkable. A thrombophilia screen (anti-thrombin, protein C and S, factor V leiden) was negative Twelve months post surgery the patient is mobilising independently with only mild weakness of the left upper limb.


A 24 year old Caucasian woman presented to the emergency room with a left sided headache, confusion and increased bowel frequency (8 times per day). UC had been diagnosed six months earlier at colonoscopy and subsequently treated with mesalazine 800 mg BD and prednisolone 10 mg OD. On examination the patient was afebrile and normotensive (BP 119/80 mmHg). A global aphasia was noted with no other neurological deficits. Blood tests revealed a raised white cell count of 20.1 × 109/L and CRP at 185 mg/L, and a thrombocytosis of 641 × 109/L. Trans thoracic echocardiogram and carotid dopplers were normal. CT of the brain demonstrated an ischaemic infarct of the left middle cerebral artery territory. A thrombophilia screen was negative. The patient was managed conservatively and made an uneventful recovery with no residual neurological deficit but subsequently developed epilepsy. Her colitis has remained well controlled with azathioprine.


The patient was a 40-year-old female who developed dysarthria and ataxia in late 2006. These symptoms lasted for two months after which she made a complete recovery. Unfortunately she relapsed in March 2007, presenting with impaired coordination, speech difficulties and ataxia and was soon after confined to a wheelchair. Breast examination was normal, and neurological examination confirmed the presence of ataxia, dysarthria and impaired coordination.
MRI scans of the spine and brain were normal and blood tests were positive for anti-Yo antibodies. A subsequent whole body PET CT although showed no clear primary lesion, indicated an avid node in the left axilla. Bilateral mammograms were normal and ultrasound of both breasts was normal except for the pathological node in the left axilla. Fine needle aspiration of the left axillary lymph node showed metastatic carcinoma, although extensive immunocytochemical studies could not confirm or exclude breast or lung carcinoma. MRI scan of the breast showed a single 6 mm nodular lesion and a targeted ultrasound of the left breast showed several hypoechoic nodules. Core biopsies of two of the visualised nodules showed high-grade ductal carcinoma in situ and poorly differentiated invasive carcinoma (Figure ).
The patient underwent a left skin-sparing mastectomy combined with implant-based immediate reconstruction plus axillary node clearance. Histological analysis showed a 4 cm area of grade 3 invasive ductal carcinoma and DCIS associated with extensive immunological response that had broken the tumour into small islands (Figure ). There was no lymphovascular invasion, and 3 of 8 lymph nodes were positive for cancer. The tumour was negative for oestrogen and progesterone receptors and positive for HER2.
The patient made a good postoperative recovery and was subsequently referred for adjuvant chemotherapy and herceptin treatment and post-mastectomy radiation. Her neurological condition remained stable during treatment.


A 34-year-old man presented with a 3-month history of paresthesia of his left foot. On examination, he had impairment of dorsal column sensation in both feet, with intactness of other modalities of sensation, and preserved motor and bladder functions. He had no other comorbidities in the form of diabetes or coagulation disorders. He had not undergone any previous surgical procedures. He was on a short course of gabapentin prior to the diagnosis. A magnetic resonance imaging (MRI) scan revealed an intradural extramedullary lesion arising from the T8 root on the left side compressing the spinal cord.
He underwent surgery for excision of the tumor. Under general anesthesia, a subspinous laminectomy was performed from T7 to T9, and the tumor was approached intradurally on the left side.
In subspinous laminectomy, the interspinous ligament on the distal limit of the laminectomy is cut and the spinous processes of the desired vertebrae are cut using angled bone-cutting forceps and turned proximally by preserving the interspinous ligament on the proximal limit of the laminectomy. On completion of the procedure, the spinous processes are sutured back.
A radicular vessel was seen dorsal to the tumor which was preserved. Intracapsular debulking was performed and the tumor was excised following resection of the dorsal nerve root from which the capsule was seen to arise. The tumor was yellowish-grey and bilobed and was sent for histopathologic examination. The dura was closed in the standard fashion and gel foam and a dural patch were placed epidurally. A subfascial gravity drain was placed. No suction was applied, as is the standard procedure following durotomy. Adequate hemostasis was achieved. The patient recovered from anesthesia with normal neurology. He was progressing well for the first 2 days following surgery. He was kept on log rolling (i.e. simultaneous turning of shoulder, back and pelvis with assistance) and assisted with movements of the limbs.
On the first postoperative day (POD), the drain collected 150 ml which was predominantly altered blood. During the second POD, the drain collected 200 ml which contained cerebrospinal fluid (CSF) mixed with altered blood. On the third POD, drain was 150 ml of clear CSF, indicating that hemostasis was adequate in the immediate postoperative period.
After 72 hours, our patient experienced stabbing pain in his back with radiation to the legs following repeated unassisted voluntary twisting of the body, despite being advised of the need for strict log rolling. A fresh streak of blood was observed in the drain by the attending clinician when the pain was experienced. Gradually, the patient complained of progressive numbness of both his lower limbs with deterioration in motor power to grade 3 with sensory impairment from T10 downwards. The time interval from the onset of pain to neurological deterioration was 2 hours. His motor power deteriorated further to grade 0, with complete anesthesia below T10, within a further short period of about 1 hour. By this time, the drain showed the collection of more fresh blood. This alerted us to the possibility of a bleed producing a neurological deficit. The patient was started on methylprednisolone as per the NASCIS 3 protocol []. His coagulation profile was checked and was found to be normal.
Emergency spinal imaging was advised. Although MRI is the investigation of choice, it could not be carried out due to technical faults in the machinery. Hence, an emergency computed tomography (CT) scan with reconstruction was performed which showed a large extradural hematoma (Figure ) at the level of the surgical laminectomy. The patient underwent emergency re-exploration 3 hours following the onset of neurological deficit. There was a large hematoma (4.5 cm × 7 cm × 5 cm and approximately 150 ml) on the right side, extending into the epidural space and compressing the cord (Figure ). The blood clot had pushed away the sutured spinous process superiorly and to the left. The hematoma was evacuated. It was bright red in color suggesting a fresh arterial source. While removing the clot, active arterial spurting from vessels in the right paraspinal muscles was observed at two sites and these were promptly coagulated. No active bleeding from the epidural space was seen. The dura was reopened, but there was no blood collection inside. Neural tissues were found to be normal. Dural closure was performed. Cord pulsation was felt. Spinous processes were removed and paraspinal muscle closure was performed over an epidural drain. A second drain was used in the supramuscular plane. The skin was approximated using subcuticular sutures.
Immediately postoperatively, the patient regained motor power and sensations. He had grade 4 power of both lower limbs and mild paresthesia. He showed good motor and sensory recovery during the following week. Methylprednisolone was continued for 24 hours. He was mobilized cautiously with particular instruction not to strain. He had an uneventful recovery.


A 20-year-old man was tackled whilst playing football. He felt a pop in the right knee and was subsequently unable to bear weight on it. He had a palpable bony lump in the anterolateral aspect of his knee and tenderness along the lateral joint line (Figure ). The range of movement in his knee joint was limited. He had no effusion and there were no signs of ligament injury. Anterior-posterior and lateral X-rays of the knee revealed anterolateral dislocation of the proximal tibiofibular joint (Figure ). Comparison views confirmed the anterolateral dislocation.
A closed reduction was attempted with the knee flexed, ankle dorsiflexed and everted without any benefit. He also had a failed manipulation under anaesthesia and the joint needed an open reduction in which the fibular head was levered back into place. Operative findings revealed a horizontal type of joint. There was no bone or ligamentous injury. We attribute the failure of the closed reduction to the presence of the projection of the lateral tibial edge as seen in cadaveric study by Ogden []. The knee was immobilised for a week and the patient had a good functional outcome.


A 77 year old lady was referred to our breast clinic as she noticed a hard non painful lump at the upper inner quadrant of the left breast and another lump at the left posterior axillary fold for 3 weeks. Patient recalled having a recent trauma to the breast after having a fall. The patient had no previous breast problems and has no family history of breast cancer. Past medical history included having total thyroidectomy and bilateral neck dissection followed by radiotherapy 10 months earlier for high grade metastatic Hurthle cell carcinoma.
On examination, there was bruising overlying the left breast due to the trauma the patient had earlier but no obvious lump, tethering of the skin or peau d' orange. Palpation of left breast revealed a mobile lump at the 11 o'clock position (upper inner quadrant). Examination of the left axilla confirmed a 2 cm lump overlying the lattismus dorsi. Mammography of the left breast showed an 11 mm dense lobulated nodule at the upper inner quadrant (figure ). Ultrasound scan demonstrated the breast lesion as well as the axillary lesion as similar and relatively avascular and highly suspicious of metastasis from her thyroid tumour. Core biopsies and Fine needle aspiration cytology of both lesions confirmed secondary deposit of carcinoma.
The patient underwent wide local excision of the left breast nodule and excision of the left posterior axillary fold lump. Histology of both lesions showed large pleomorphic cells with abundant eosinophilic cytoplasm which confirmed metastases from the previously diagnosed Hurthle cell carcinoma of the thyroid (Figure ).


A 50-year-old man was admitted with a suspicion of an acute coronary syndrome because of progressive dyspnea and positive Troponin I (9.5 ng/ml). A two-dimensional echocardiogram revealed severe left ventricular hypokinesis with an ejection fraction of 27%. Upon coronary angiography, coronary artery disease was excluded. Because of a white blood cell count of 17000/mm3 with 41% eosinophils, endomyocardial biopsies were taken from the left ventricle. Histological evaluation showed marked endomyocardial eosinophilic infiltration and areas of myocyte necrosis (Figure ). Further evaluation revealed no evidence of secondary hypereosinophilia (malignant diseases, allergy, vasculitis, parasitic infection). The patient was diagnosed with hypereosinophilic myocarditis due to idiopathic hypereosinophilic syndrome. Medication with steroids and heart failure was initiated promptly and the patient improved rapidly.
CMR-studies at presentation and a follow-up study 3 weeks later showed diffuse subendocardial LGE in the whole left ventricle with involvement of the papillary muscles. Upon 3 months follow up, however, subendocardial LGE has markedly decreased in parallel with further clinical improvement (Figures ). Ejection fraction has improved from 27% at baseline to 35% after 3 months and end diastolic volumes have decreased from 195 ml to 161 ml. There was no evidence of mural thrombi at baseline and during follow-up studies and there were no signs of restrictive filling patterns in Doppler and tissue-Doppler echocardiography. NT-pro-BNP decreased from initially 16319 pg/ml to 5305 pg/ml at 3 weeks and to 1926 pg/ml at 3 months.
In conclusion, diagnosis of eosinophilic myocarditis due to idiopathic hypereosinophilic syndrome was made in the early stage. Upon treatment with steroids, CMR-studies revealed marked reduction of subendocardial LGE representing acute inflammation and necrosis. Treatment with steroids in the early stage might have prevented further progression to the intermediate thrombotic-necrotic stage with mural thrombi and the fibrotic stage which has been postulated as the final stage in the time course of eosinophilic myocarditis [-].
This case highlights the clinical importance of CMR which is the only noninvasive method to visualize the extent of endomyocardial involvement in the diagnosis and treatment of eosinophilic myocarditis.


A 21-year-old male, a mechanic by profession, presented to the accident and emergency department with a 5-day history of fever, jaundice and generalized abdominal pain and a 2-day history of altered conscious state. There was no significant past medical history nor was there a history of substance abuse.
Clinical examination at the time of presentation revealed a young man who was drowsy but arousable, conscious and oriented. He was febrile (101.5°F), had icterus and exhibited a flapping tremor. He was hemodynamically stable. Systemic examination was unremarkable except for generalized tenderness and mild hepatosplenomegaly on abdominal examination. Investigations on admission are summarized in Table . Of note were anaemia (Hb 7.2 gm/dl), thrombocytopaenia (35,000/cumm), renal failure (serum creatinine 5.8 mg/dl) and marked hyperbilirubinaemia (total bilirubin 53.6 mg/dl). Peripheral blood smear was positive for Plasmodium falciparum and Plasmodium vivax gametocytes and ring stages, with marked parasitaemia of 45%. A diagnosis of severe falciparum malaria was made and treatment was initiated with intravenous artesunate (140 mg at admission and at 12 hours, dose calculated based on an estimated weight of 65 kg) and oral doxycycline therapy (100-mg twice daily) in the emergency department. The dose of artesunate was increased to 180 mg intravenously daily in the intensive care unit. Broad-spectrum antibiotics (intravenous cefepime 1-gm twice daily) were added to cover for a co-existent gram negative sepsis. In view of the high parasitic index and severe anaemia at presentation, three units of packed red cells were administered to the patient and 250 ml of blood removed from the patient in a partial exchange transfusion. A complete ml to ml exchange transfusion was not performed as the haemoglobin value reduced after the first exchange to 5.2 g%. The three units of packed cells and the partial exchange transfusion reduced the parasitaemia from 45% at admission to 3.5% in 24 hours (Figure ).
He was admitted to the intensive care unit (ICU) for treatment and monitoring. In the ICU, his acute renal failure was initially managed conservatively by achieving adequate filling pressures (central venous pressure), maintenance of blood pressure and measures to correct hyperkalemia. However, in view of persistent renal failure and hyperkaliaemia that were refractory to medical therapy, dialysis was initiated and continued till renal recovery. On the second day following ICU admission, his abdominal pain worsened with the development of abdominal guarding and rigidity. Investigations suggested a diagnosis of acute pancreatitis with serum amylase and lipase levels of 1712 U/L (Reference range 0–200 U/L) and 5217 U/L (reference range 0–190 U/L) respectively. A non-contrast computed tomography (CT) scan of the abdomen showed bulky pancreas with significant peri-pancreatic fat stranding (Figure ). C-reactive protein was > 190 (Reference range-0–6 mg/L). There was no evidence of a hollow viscus perforation.
The acute pancreatitis was managed with analgesics, hydration and supportive therapy. A naso-jejunal tube was inserted to facilitate nutritional supplementation and antibiotics were changed to imipenem in view of severe pancreatitis. However, fever persisted even after ten days of artesunate therapy with the presence of ring forms of falciparum malaria (parasitemia not quantifiable) on the peripheral smear. He was initiated on intravenous quinine therapy on the suspicion of artesunate resistance/failure. Following initiation of quinine therapy, the ring forms were not demonstrable on the peripheral smear. His course was further complicated by urinary tract infection, with > 100000 colonies/ml of Escherichia coli and Pseudomonas aeruginosa grown from a catheter specimen of urine.
On Day 17, the patient developed one episode of generalized tonic clonic seizures with post-ictal drowsiness. A CT scan of the brain showed features of acute bi fronto-temporal subdural haematoma with no mass effect (Figure ). He was initiated on gabapentin 300 mg twice daily (subsequently increased to 300 mg thrice daily), in addition to clobazam 10 mg once a day, at the advice of the neurologist. The subdural haematomas were surgically drained by the neurosurgeons. His consciousness improved and he had no further seizures.
However, his fever did not resolve despite appropriate anti-biotic therapy. Search for a cause for fever including nosocomial infections and sepsis were negative. A diagnosis of drug fever was proposed and all medications were ceased. After 38-days of admission, on becoming afebrile, and free of ring stages on peripheral smear, he was discharged on a fourteen-day course of primaquine.


A non-smoking 53-year-old woman on vacation in the French Alps was admitted to a hospital in July 2005 because of sudden and severe dyspnea at rest and chest pain. These symptoms were improved by anteflexion. She also had a one week history of fever (39°C), asthenia and abdominal pain. An electrocardiogram showed depression of the PR segment, moderate sinus tachycardia and diffuse ST segment elevation, which was concave upwards, was present in the anterior leads. A transthoracic echocardiograph revealed a large posterior pericardial effusion. A chest x-ray and a computed tomography scan showed cardiac enlargement, pleural effusion and interstitial pneumonia. A urine test for Legionella pneumophila 1 was negative. Serological tests for Coxiella burnetii, Bartonella spp., Chlamydia spp., L. pneumophila, Brucella spp., Mycoplasma pneumoniae, Borrelia burgdorferi, Toxoplasma gondii, cytomegalovirus, human immunodeficiency virus, hepatitis C and enterovirus were performed and were all negative. The patient's serum C-reactive protein level and erythrocyte sedimentation rate (first hour) were high at 186 mg/liter and 130 mm/hour, respectively, and her white blood cell count was 12 g/liter. Empirical treatment with amoxicillin, 6 g per day, and ofloxacin, 10 mg/kg per day, was initiated. The fever resolved completely within 2 weeks and the volume of pericardial fluid decreased significantly.
Serological tests, performed on a second serum sample 2 months later during a consultation at the Department of Clinical Microbiology in Marseilles, showed a seroconversion in antibody titers to F. tularensis (IgG titer = 400) and L. pneumophila (IgG titer = 512). F. tularensis was identified by Western immunoblotting following cross-adsorption (Figure ). The patient retrospectively reported close contact with rabbits 2 weeks prior to the beginning of the symptoms of pericarditis.


About 2 years ago a 5-year-old girl
with recurrent urinary infection was admitted in another hospital and checked.
A 2° grade active right vesicoureteral reflux was found by voiding
cystourethrography. She was treated by assuming orally a long-term
antibacterial therapy: a prophylactic evening dose of trimethoprim-sulfa
combination. After one year vesicoureteral reflux remained unchanged by X-ray
check and she had a urinary infection relapse for a temporary break in
antibacterial therapy. The parents took her to another urological department and
were advised to submit their daughter to ureteral reimplantation surgery.
They were not persuaded and took
their little girl to our outpatients' department.
She was a little girl presenting
normal somatic characteristic for her age, quite shy and affectively deeply
attached and dependent from her mother who accompanied her. Her physical
objectivity did not signal anything which could lead to urological pathologies.
Looking at the cystourethrography () we observed a large vesical
capacity, abnormal for the patient's age; an ultrasound exam of the urinary
tract confirmed this observation: her bladder contained a volume of 500 cc.
The girl seemed calm with no need of
urinating. Finally, persuaded by her mother she had an uroflowmetry test; the
girl completely emptied her bladder, urinated 500 mL, with a normal flow.
Searching in the remote pathological
anamnesis we found that the girl had always urinated rarely, twice or three
times a day, remaining sometimes for more than 12 hours without urinating.
She had often refused to urinate in
the evening before going to sleep, saying she did not need to.
Her mother did not attribute any
importance to this habit and she did not insist. In both of them it was clear a
fear of urinating in bathrooms out of their home because of the scarce hygiene
conditions and the past urinary infections of the girl.
The patient refused every kind of
invasive diagnostic approach such as urodynamic examination, cystoscopy. We could proceed in the diagnosis only by asking a micturition diary
which has confirmed our clinical suspect of Lazy Bladder Syndrome.
From a therapeutic point of view,
the girl has been directed to a bladder training therapy.
We only used behavioral therapy
notifying to the girl a strict daily micturition scheme to modify the child's
voiding habit and achieve a different behavior which included more frequent
micturition and a new conception of the use of public toilettes. Consulting did
not prescribe any other approach considering the good level of cooperation of
the girl.
The absence of evident
postmicturition residuals enabled us to avoid anticolinergic-alpha-adrenergic
blockade therapies
or invasive procedures such as intermittent catheterization or endovesical
electrical stimulation.
After 9-month follow-up the patient
seems to have changed her micturition habits; she is still following a
prophylactic antibacterical therapy.
The last ultrasonographic evaluation
does not show any negative evidence of the upper urinary tract.
The cystography check done 9 months later than the
previous one and after 6 months of behavioral therapy pointed out the
disappearance of the vesicouretheral reflux.


A 52 year-old Caucasian male was admitted, on emergency basis to the orthopaedic department with six weeks history of increasing mid thoracic pain, change in gait, poor balance, subjective weakness, numbness of the lower trunk and legs. He didn't report any neurogenic bladder or bowel disturbances and he was otherwise fit and well.
The patient had a right sided orchidectomy 3 years ago, for stage one well differentiated Leydig cell tumour. He was diagnosed having an enlarged right testis. No adjuvant therapy was given perioperatively. Afterwards, he followed up periodically and Computer Tomography (CT) scans of the chest, abdomen and pelvis were performed on the basis of evaluation and potential metastasizing of the neoplasm.
Two years following the primary operation the patient complained of back pain. Plain films of the spine showed an "ivory" vertebra at T4. CT scan depicted a definite abnormality in the body of T4 with no evidence of general metastatic disease. There was no soft tissue extension and no vertebral body collapse. None of the visceral organs was involved and this was the only detectable pathological sign. The bones scan showed intense uptake in T4 and no other sights of increasing radioisotope uptake. The blood tests, including tumour markers, didn't show any abnormality. At that stage, the oncologists decided against biopsy as they felt it was potentially hazardous and the patient will have little to gain from it. Accordingly, in absence of symptoms and tenderness, a "wait and see" policy was adopted.
Nine months later the patient admitted to the Spinal Unit in an emergency base complaining of increasing mid thoracic pain, change in gait, poor balance, subjective weakness, numbness of the lower trunk and legs. Examination revealed a broad base gait, able to walk in toes and heel, absence of tenderness or masses over T4 level, hypo aesthesia below T5 level more pronounced over the left side, exaggerated tendon reflexes in the lower limbs, un-sustained ankle clonus bilaterally and normal plantar reflexes. No objective motor weakness detected and intact perianal sensations were recorded.
X-rays of the thoracic spine revealed a sclerotic appearance of the T4 vertebral body (Figure &) and an urgent Magnetic Resonance Imaging (MRI) showed quite dramatic change in the appearance of T4 compare to the previous CT despite the maintenance of vertebral body height. Furthermore, T5 vertebral body was also involved, but to a lesser extent. There was a soft tissue expansion into the extradural space causing spinal cord compression (Figure ).
Blood test, including inflammatory and tumour markers, were within normal values and a dose of 16 mg Dexamethasone daily was started. A CT guided biopsy was performed and the histological appearance of the lesion was identical to the primary tumour.
After discussion with the patient, a decision was made to perform urgent T4 and T5 corpectomies, decompression of the spinal cord and reconstruction of the vertebral bodies. Anterior surgery was contemplated as the compression was coming only from the front and the tension band of the posterior elements, at the involved level, were intact.
Surgery was performed through a right subscapular 3rd rib thoracotomy, and the cord function was monitored by Somatosensory Evoked Potentials (SSEPs) throughout the procedure. After complete canal decompression, reconstruction was achieved by a Synmesh packed with bone graft obtained from the excised rib. Anterior Universal Spine System (USS) II system was added to augment the construct (Figure ).
The patient was then transferred to Intensive Therapy Unit (ITU) and had an uneventful recovery. He discharged one week following operation with clear neurological improvement. Three weeks postoperatively, he developed a right-sided pneumonia, which resolved with antibiotics. The histological evaluation of the excised tumour was identical to the primary.
Because it was a solitary metastasis and eradication of the tumour wasn't feasible by surgical excision alone as it had already extended beyond the bony limits, postoperative radiotherapy with radical intent was applied. The duration of the radiotherapy was a daily 5 weeks course and the dose was 50 Gy in 25 fractions to the area of T4/T5. Neither side effect from radiotherapy nor skin reactions was reported.
The patient was followed up periodically by Technetium bone scans and CT scans of chest, abdomen and pelvis. At the last follow-up visit-two years and six months postoperatively he was disease-free based according to the results of repeated scans. He complained only for a minimal numbness of the right foot and slight winging of the right scapula.


A 66 year old Irish male, non-smoker, presented to the emergency department complaining of left sided pleuritic chest pain, associated with non productive cough for two days. His past medical history included hypertension, hypercholesterolemia, varicose veins, and migraine. Five years previously he was admitted for "chest pain" and all of his investigations including coronary angiography were normal. Seven months prior to this presentation he suffered an anaphylactic reaction to a Wasp sting. His chest X-Ray was normal. He had significant family history of heart disease as both parents suffered from myocardial infarction.
His ECG revealed T wave flattening in leads III and AVF (old changes), chest x-ray showed left lower lobe consolidation. Routine bloods including full blood count, urea and electrolytes, and liver function tests were all within normal range. Arterial blood gas was normal. CRP was elevated at 79.9 mg/L. The patient was commenced on intravenous antibiotics and a CT thorax was requested. It showed an elliptical well defined shadow (figure ), with mixed internal density lying above the diaphragm and closely related to the left cardiac margin, most likely representing a pericardial cyst. An MRI of the thorax (figure ) showed the cyst to be 7.9 cm × 3.6 cm × 6.0 cm. The patient remained symptomatic and was therefore referred to the cardiothoracic team for excision of the cyst, which was performed successfully.


A 45-year-old man with a medical history of epilepsy presented to the emergency room with complaints of vertigo, gait disturbance, dizziness, slurred speech and diplopia. He had been using CBZ (Karazepin®) 400 mg three times per day for 4 years and levetiracetam (Keppra®) 500 mg twice daily for 1 year. No other toxin, alcohol, herbal products or drugs were reported except for a history of 2 days simethicone (Metsil®) usage for abdominal distention. He had a blood pressure of 115/70 mmHg, a pulse rate of 88 beats per minute and a respiratory rate of 18 breaths per minute. The patient had a normal mental status and was able to give a reliable history. There were no signs of dehydration. He reported no history of vomiting or diarrhea. He denied trauma, extra drug dosage or suicidal attempt. In his neurological examination, the pathological findings were bilateral nystagmus, dysarthria, diplopia and ataxic walking. He had a serum CBZ level reported as 10.5 μg/ml 2 days earlier (blood sampled 10 to 11 hours after the last dose of CBZ; normal reference range 4 to 11 μg/ml), confirmed in the neurology outpatient clinic.
The initial laboratory findings were as follows: hematocrit, 41.5; prothrombin time, 12.3 seconds (reference range 11 to 13 seconds); international normalized ratio, 1.02; creatinine, 0.97 mg/dl (reference range 0.5 to 1.10 mg/dl); glucose, 102 mg/dl (reference range 70 to 110 mg/dl); serum alanine aminotransferase, 16 U/L (reference range 10 to 37 U/l); aspartate aminotransferase, 17 U/l (reference range 10 to 40 U/l); alkaline phosphatase, 238 U/l (reference range 0 to 270 U/l); γ-glutamyltransferase, 46 U/l (reference range 7 to 49 U/l); total bilirubin, 0.54 mg/dl (reference range 0.2 to 1.0 mg/dl); and CBZ serum level, 34.2 μg/ml (blood taken 8 to 9 hours after the last dose of CBZ).
Cranial computed tomography scan was normal. Confirming the simethicone levels would have been helpful in confirming the patient's report, but this test was not available.
The patient was taken to the neurology in-patient unit with a diagnosis of CBZ intoxication. CBZ was withdrawn. Treatment for intoxication comprised intravenous hydration and cardiac monitoring. After 36 hours his serum CBZ level had normalized (17.6 μg/ml at 24 hours; 11.4 μg/ml at 36 hours) and neurological exam was intact. In a follow-up visit the patient was warned about simethicone use, and there have been no further problems in the following 6 months.


An 80-year-old woman presented to the emergency department with a 24-hour history of sudden onset, severe right upper quadrant pain. The pain was sharp and constant in nature. It was relieved by sitting up and exacerbated by movement and deep inspiration. She felt nauseous but had not vomited and her bowels had opened normally the day before. Her past surgical history included an appendicectomy, a hysterectomy and bilateral salpingo-oophorectomy and a left inguinal hernia repair. In addition, she suffered from hypertension and osteoarthritis.
On examination, she was afebrile and her vital signs were all within normal limits. Abdominal examination revealed a tender mass in the right upper quadrant (Figures and ). Her white cell count was raised at 12.85 × 109/litre, with a neutrophil count of 10.3 × 109/litre. The rest of her blood test results were entirely normal, including liver function tests. An ultrasound scan of her abdomen was organised and this showed a distended gallbladder with a thickened wall suggestive of cholecystitis. However, no stones were seen and there was no intra or extrahepatic biliary duct dilatation.
Her clinical picture did not improve despite intravenous antibiotics and fluids so an abdominal computerised tomography (CT) scan was carried out. CT demonstrated focal thickening around the neck of the gallbladder as well as a small amount of pericholecystic fluid that had extended into the right anterior perihepatic space.
As the patient's condition was not improving (her white cell count had also increased to 15.4 × 109/litre) she was scheduled for an open cholecystectomy, as the surgeon was more familiar with the open rather than the laparoscopic approach. At operation, there was free, bile-stained fluid on opening the peritoneal cavity and the gallbladder was gangrenous and grossly distended. On closer scrutiny, the gallbladder had undergone a complete anticlockwise torsion. A routine cholecystectomy followed the initial detorsion and decompression. The patient recovered without incident and was discharged from hospital within a week.


A 40-year old nulligravida was referred to our outpatient clinic because of menorrhagia and irregular bleeding since 2 years, unresponsive to oral contraceptives. Her general practitioner obtained a Papanicolaou (Pap) smear at initial presentation of symptoms, which revealed no abnormalities. Inspection of the cervix showed no lesions, polyps or unusual bleeding. By vaginal ultrasound an intramural fibroid was seen in the fundus, measuring 4,5 cm × 4,5 cm and no further uterine anomalies. The next day, a Mirena® was inserted. She returned to our clinic 2 weeks later due to abdominal cramping. The Mirena® was in place. She was treated with antibiotics and painkillers on a presumptive diagnosis of pelvic inflammatory disease. Two months later at follow-up, the Mirena® was still in place and irregular bleeding continued. As this is a common symptom in the first 3 months of Mirena® use, she was reassured and instructed to make a new appointment if the bleeding were to persist.
Seven months after initial referral, she was seen for a cyst of Bartholin. During follow-up of the cyst, inspection by speculum revealed inflammation of the cervix. A Pap smear was performed, and during colposcopic examination, a lesion suspicious for neoplasia with abnormal vessels was seen. Two biopsies were taken and revealed a moderately differentiated squamous cell carcinoma. The Pap smear was reported as squamous cell carcinoma. Revision of the initial smear showed that due to blood staining it was difficult to interpret, but in retrospect it was suspect of malignancy. Clinical staging allocated our patient to cervical cancer stage IB. She was referred to a centre for Oncology for a radical hysterectomy with pelvic node dissection.


A 29-year-old woman was referred by her general practitioner 2 months after delivery of her first child for insertion of a Mirena®. Her medical history revealed no prior gynaecological problems and she had no history of abnormal cervical cytology. Examination by speculum and ultrasound prior to insertion of the Mirena® revealed no abnormalities. Due to ongoing irregular bleeding and abdominal pains since insertion, the Mirena® was removed several months later and oral contraception was prescribed. The irregular bleeding was attributed to the Mirena® and no Pap smear was obtained in this period. Nine months after initial referral, she was referred again by her general practitioner due to persisting irregular bleeding and rebound tenderness during bimanual palpation. An ulcerative lesion on the cervix was seen by speculum, suspect for malignancy. Cervical cytology revealed moderate dysplasia, biopsies a micro-invasive squamous cell carcinoma of the cervix. Clinical staging allocated her to stage IIA cervical cancer. Assessment of new biopsies revealed adenosquamous carcinoma. She was also referred to a centre for Oncology for a radical hysterectomy with pelvic node dissection. During surgery, however, the procedure was aborted due to tumour extension into the vesicouterine fold. Lymph nodes were negative and she was treated by radiotherapy with brachytherapy.


A 60 year old non-smoking male presented to the Emergency Department with a non-productive cough and cold symptoms. For the past week he had been confined to bed and reported severe bodily pain, a troublesome cough and shortness of breath when showering and toileting. His temperature was 38.6°C. Physical examination of the chest was unremarkable and chest radiograph showed increased bronchial markings centrally. Arterial Blood Gas results breathing room air were: pH 7.46, pCO2 4.6 kPa, pO2 6.9 kPa. He was commenced on oral roxithromycin 150 mg bd, inhaled salbutamol 100 ug 2 puffs qid, and analgesia, and continued pre-existing carbamazepine 300 mg bd for controlled epilepsy (a recent onset condition) and thyroxine 50/100 mcg on alternative days for hypothyroidism which had developed five years prior. He was subsequently changed to oral azithromycin 500 mg, improved and was discharged on day 5. Acute and convalescent serology confirmed recent infection with Mycoplasma pneumoniae (antibody titre 1:1280 (ref range < 1:40).
At a seven week follow-up visit he described persistent cough, inspiratory dyspnoea, voice changes (characteristics common to paradoxical vocal cord movement (PVCM) and EAHR disorders) and fatigue. Hypertonic saline provocation test was requested and conducted 2 months later.
Spirometry was FEV1 84% predicted, FVC 86% predicted, FEV1/FVC 78%; and FIF50% 5.22 L/sec. Hypertonic (4.5%) saline provocation challenge identified EAHR with attenuation of the inspiratory flow curve. The FIF50% decreased by 39% to 3.20 L/s at a cumulative saline dose of 10.59 mL (figure , solid line). The fall in FEV1 (12%) was within normal limits. A trial of fluticasone/salmeterol and nedocromil sodium was commenced.
The patient's cough and dyspnoea had greatly improved by three months. One year later the cough had resolved completely and an inspiratory/expiratory flow volume curve was normal. There was no EAHR or bronchial hyperresponsiveness after repeat hypertonic saline challenge (figure , dotted line), fall in FEV1 remained within normal limits (8%) and laryngoscopy showed no posterior chinking during inspiration and no paradoxical vocal cord movement (PVCM).


An 38-year-old woman with a medical history of asthma presented with a mass rising in the left breast without any pain. Physical examination at admission revealed a mobile mass in her right breast, estimated to be at least 8 cm. The mass was not attached to the sternum or the underlying rib. No axillary lymphadenopathy was detected on physical examination. The left breast was unremarkable. On mammography, the mass was well demarcated and partially calcified. An incisional biopsy was performed, the histological exam showed abundant cartilaginous proliferation varied from mature cartilage to poorly differentiated areas. Immunohistochemical studie was performed, immunoreactivity was detected for vimentine but not for for AE1/AE3, CK7, CK20, estrogen and progesterone receptors. There was also no overexpression of the HER-2/neu oncoprotein.
Liver echography, chest radiography and bone scan were normal. The patient underwent simple mastectomy, just after she presented dyspnea.
Chest radiography revealed a diffuse reticulonodular infiltration describing metastatic disease to the lung wich was confirmed by CT-scann.
The patient was treated by association of doxorubicin 50 mg per square meter and cisplatinium 100 mg per square meter every 21 day. The evaluation of the response basing on the CT scann showed a partial response after the third cycle and progression of the disease after the sixth cycle. The patient dead two months later.


The mother was an unbooked, 24 year old primigravida, with an uneventful antenatal period. There was no history of consanguinity or family history of any malformations. There was no history of intake of drugs other than hematinics and calcium during the pregnancy. No antenatal ultrasonogram had been done. She had been clinically diagnosed to have polyhydramnios prior to being referred to our institute. At 36 weeks of gestation, she was admitted with preterm onset of labour and delivered a stillborn fetus weighing 1900 g.
On external examination, the placenta was normal; the umbilical cord was short; two umbilical arteries and one umbilical vein were present in the cord. The head and facies were normal. There was amelia of the left upper limb. There was a large defect in the body wall involving the thorax and the abdomen. The sternum, the anterior costal parts of the ribs on the left side and the diaphragm were absent. There was ectopia cordis, evisceration of the lungs, stomach, liver, spleen and intestines [Figure ].
At autopsy, the above mentioned findings were confirmed. Dissection of the heart revealed a patent foramen ovale. The arch of the aorta gave rise to the right brachiocephalic trunk and a small left common carotid artery. The left subclavian artery was absent. The right lung was normal, but the left was firm, hypoplastic and without lobations. The thymus was normal. The intestines were nonrotated, with the small intestine on the right and the large intestine on the left side. The small intestine was dilated and distended with thick meconium forming a cast of the intestine. The terminal ileum was stenosed. The large intestine was short, stenosed and ended in a blind pouch; the terminal part of the large intestine and the rectum were atretic; the anal canal was patent and the anal opening normal. The liver was trilobulated and the gall bladder was absent. The pancreas and spleen were normal. The kidneys and ureters were normal but the bladder was found to have a vesicourachal diverticulum arising from its apex. The external genitalia were male and both testes were intraabdominal. The cranial contents were normal. Scoliosis of the spine was present [Figure ]. Microscopic examination of the organs was not contributory.


An eighteen year old unmarried female presented with progressive distension of abdomen and swelling in left gluteal region for last ten months. It was associated with mild dull aching pain in lower abdomen and bilateral flanks. She was having normal menstrual history. Examination revealed distended abdomen and a non-tender, diffuse, firm and dull mass was felt all over abdomen. Free fluid in peritoneum could not be demonstrated. There was another 10 × 8 cm boggy swelling on upper postero-medial aspect of left thigh having cross fluctuation with abdominal swelling. On ultrasonography 30 × 18 × 16 cm complex cystic mass was found occupying whole abdomen and pelvis with internal septations and echoes displacing bowel loops posteriorly with mild right sided hydro-ureteronephrosis. CECT scan (Figure ) showed heterogeneous soft tissue mass, adjacent to coccyx, involving left gluteal region and extending superiorly into pelvis and abdomen with anterolateral displacement of urinary bladder and lateral displacement of bowel with right hydronephrosis. Rectum was displaced anteriorly and to the right. The lesion was complex with variable soft tissue attenuation (+23.0 HU). Fat plane between the mass lesion and pelvic musculature and abdominal wall muscles was intact. Fine needle aspiration cytology was inconclusive and trucut needle biopsy showed round to spindle shaped cells in a loose to fibrous stroma with fair number of intervening vessels, suggestive of spindle cell tumor.
Patient underwent laparotomy and the tumor was excised. The tumor was found to be bilobed, weighing about 15 Kg. (Figure ). Rectum was displaced anteriorly and to right. Right ureter was displaced laterally with hydroureter. Tumor was extending into thigh through left obturator foramen. Urinary bladder was adherent to mass and displaced anteriorly. Uterus and fallopian tubes were normal, tumor was found to be originating from rectovaginal septum. Liver was normal and there was no ascites or lymphadenopathy.
The histopathology of the specimen showed capillary and cavernous vascular spaces stuffed with blood and separated by edematous fibrous and myxomatous tissue. The fibrous tissue is in form of interlacing or parallel bands of collagen with edema. The myxomatous tissue comprise of stellate cells with fibrillary in mucinous setting (Figure ). Immuno-histochemistry was positive for vimentin and desmin while negative for actin and myosin. These findings were consistent with the diagnosis of aggressive angiomyxoma.


A 39-year-old man was admitted in October 2006 with a 2-week history of sharp, non-radiating pain of the right shoulder blade with associated dyspnea upon exertion and 5 kg loss of weight. He denied fever, chills, night sweats or cough. His symptoms did not interfere with his occupation as a gardener. Vitals demonstrated a normotensive, afebrile 155 cm, 100 kg man with an oxygen saturation of 96% on room air.
Physical examination was normal with the exception of decreased breath sounds half way up the right lung field along with dullness to percussion and without tactile fremitus. A chest radiograph showed a moderately sized, right pleural effusion (Figure ). The right thoracentesis fluid analysis showed a slightly cloudy and yellow fluid. Cell count results were 1,164 nucleated cells, 12% polymorphonuclear leukocytes, 80% lymphocytes, 7% monocytes, 1% eosinophils, glucose 123 mg/dl, lactate dehydrogenase (LDH) 103 units/l, and protein 5.3 g/dl (pleural to serum protein ratio, 0.8; pleural to serum LDH ratio, 0.7). Bacterial Gram stain and culture, acid-fast bacilli smears, fungal culture and cytology were all negative. Histopathological evaluation of the pleural biopsy noted granulomatous inflammation and fungal elements consistent with coccidioides (Figure ). Cultures for tuberculosis remained negative even after 7 weeks. Purified protein-derivative skin test to the right forearm produced a 0 mm induration. Tests for human immunodeficiency virus were negative by both enzyme-linked immunosorbent assay and Western blot. Serum coccidioidomycosis complement fixation was normal (< 1:2). A post-thoracentesis chest radiograph did not reveal any evidence of parenchymal infiltrate. After several weeks of fluconazole therapy, the patient improved clinically, and follow-up chest radiograph showed near-complete resolution of the pleural effusion.


A 55-year-old man presented with fever and abdominal pain. Abdominal CT showed swelling of the right kidney and low attenuation areas (Figure ). Laboratory tests and renal CT imaging were suggestive of pyelonephritis. However, multiple cavitary lesions were also found on the routine chest radiography performed on admission. VATS (Video-Assisted Thoracic Surgery) lung biopsy confirmed the diagnosis of metastatic adenocarcinoma presumably from the kidney. Therefore, a renal tumor with multiple pulmonary metastases, was considered. At the time, transitional cell carcinoma (TCC) was suspected, which later proved to be a misdiagnosis, and chemotherapy with MVAC (methotrexate, vinblastine, adriamycin, and cisplatin) was given. However, the chemotherapy was not effective, and the patient died of respiratory failure 2 months later. On autopsy, the primary tumor was found to be a collecting duct carcinoma, and there were lung, liver, spleen, bone marrow, right adrenal gland, and para-aortic lymph node metastases. CT done while the patient was alive detected lung (Figure ), liver (Figure ), and para-aortic lymph node (Figure ) metastases.


A 77-year-old man was admitted to our department after developing a fever and backache. Based on CT findings (Figure ) and laboratory test results, pyelonephritis was initially suspected. Antibiotic therapy improved his symptoms and laboratory indicators of inflammation. One year later, he complained of backache. CT revealed a progressively enlarging renal lesion, multiple liver masses, enlargement of the para-aortic lymph nodes, and multiple osteoblastic and osteoclastic lesions (Figure ). A renal tumor with multiple metastases was suspected considering the clinical course and imaging findings retrospectively. At the time, TCC was suspected, which later proved to be a misdiagnosis. MVAC therapy was given without effect, and 1 year later the patient died of cardiac failure that was unrelated to the treatment. On autopsy, the primary tumor was found to be a collecting duct carcinoma, and liver, right adrenal gland, right upper ureter, bone marrow, para-aortic and mediastinal lymph node, and bone metastases were found.


The patient, Natalie, is an eighteen year old single female.
Natalie self referred to a private mental health out-patient service specializing in the treatment of psychological trauma in January 2007. She reported labile mood that often resulted in a transient low mood accompanied by anger. During these transient periods Natalie would engage in DSH; typically cutting herself on her inner thighs.
Natalie reported that, on a descriptive scale of 0 – 10 (where 0 is no anger and 10 is intense anger) that she would cut her self when her anger level reached 8. She reported a number of triggers for her anger, but that these triggers would always relate in some way to events from her past that she remained very angry about. In essence, the presenting event combined with her past life events led to her anger rising to the point where she would cut to relieve herself of this distress.
During the initial assessment Natalie reported an uneventful childhood in relation to her emotional and physical health, her school life or family life. She is the eldest of three children and is currently studying at University.
In the fourth year of post-primary education, around the age of 14 years Natalie reports that her best friend "turned on her". This led to a prolonged period of bullying by this girl on Natalie. Subsequently, and as a direct result of this bullying, Natalie reports becoming depressed and starting to engage in cutting herself. She also reported one incident of tying a scarf around her neck.
Following this incident Natalie was referred to her General Practitioner who prescribed Amitryptaline and made arrangements for her to be seen by her local Child and Adolescent Mental Health Services (CAMHS).
She reports that the input from the CAMHS service was initially beneficial and that their input coupled with the antidepressant medication resulted in an improvement in her mood and a cessation of self cutting.
Aged 16 years, Natalie embarked upon a relationship for two years that, on reflection, she now reports was "unhealthy". She states for example, that her alcohol consumption was a times around 80 units per week. This relationship was also characterized by humiliation and bullying of Natalie. She ended the relationship when she was 18 years of age.
Also, at age 18 years Natalie was discharged from the CAMHS services and no further referral to adult services were made. Natalie stopped taking her medication and started to resume cutting herself as a reaction to the bullying she had experienced during her adolescent years.


A 24-year-old Iranian-balooch man was admitted in the ICU because of head injury. He had not any history of medical or surgical diseases before the accident. His CT scan showed generalized brain edema, the Glasgow coma scale score (GCS) on arrival was 4. In the ICU the patient was sedated by remifentanil and midazolam to decrease the brain edema via hyperventilation and decreasing blood pressure. Twenty four hours later, the CSI was appeared with fluctuations that correlated to muscular twitching in the facial muscles. The CSI had also fluctuations parallel to EMG activities which appeared on the CSM screen with a short time delay, less than one minute (figure ) . When EMG activity reached to 100%, CSI became 100, and when it went down to 25%, CSM also became 25–30. All of the CSI data was recorded automatically and wirelessly by the company's standard software. Because of the patient's brain condition; it was very important to evaluate the level of consciousness. So, atracurium 25 mg intravenously was injected at 00:36 a.m leading to disappearing EMG activity three minutes later except sporadic surges. Concomitant with decreasing EMG, CSI was decreased from 100 to 70. An interesting finding was increasing burst suppression (BS) from zero to about 10% after first injection of atracurium. After returning EMG at o1:34 a.m, the second dose of atracurium was injected 15 mg intravenously at 1:36 leading to complete EMG recession and increasing BS to 20–30% and decreasing CSI to 20–40. All of the time GCS was 7 and Richmond Agitation-Sedation Scale remained between 0 to 1.


A 53-year-old man, obese and smoker, was admitted to the cardiology unit of our hospital for shock associated with a third-degree atrioventricular block. Upon admission, five sets of peripheral blood cultures were systematically drawn; however, antibiotics were not initiated because the patient was afebrile. In the cardiology unit, he had two episodes of ventricular fibrillation treated by external cardioversion. Coronarography was performed and showed an occlusion of the right main coronary artery that disappeared spontaneously whereas the left main coronary artery was normal. Ventriculography was normal and aortography revealed the absence of aortic dissection. Due to persisting cardiogenic shock, the patient was then transferred to the medical intensive care unit on the same day where he received inotropic drugs. Because of leukocytosis (white blood cell count of 16,000 cells/mm3) and hypothermia (body temperature at 35.3°C), an antibiotic treatment with cefotaxime (3 g daily) was started. A transoesophageal echocardiography revealed right atrial and ventricular massive dilatation and an acute right ventricular dysfunction. A diagnosis of cardiogenic shock due to transient occlusion of the right main coronary artery was made. In the unit, his evolution was rapidly unfavourable with the occurrence of multiple and repeated episodes of ventricular fibrillation. The patient died four days later in a context of multiple organ failure associated with persistent cardiogenic shock and right ventricular failure.
The day after of the patient's death (i.e. five days of incubation), four out of five BacT/Alert® blood culture anaerobic bottles (bioMérieux, Marcy l'Etoile, France), yielded a Gram-negative spiral-shaped bacterium, suggesting a spirochete. After three days, the isolate was subcultured on 5% horse blood-containing agar plates under anaerobic conditions at 37°C and the growth appeared as a thin film with weak β-hemolysis. Phenotypically, all biochemical tests except hippurate were negative using the API 20 ANA and ID 32 ANA strips (bioMérieux). In addition, the isolate yielded a positive reaction for oxidase test and negative reactions for catalase and indole production tests.
Accurate identification of the clinical isolate was achieved by 16S rRNA sequence analysis, as previously described []. The 16S rRNA nucleotide sequence of the clinical isolate was then compared to deposited sequences available from GenBank using the BLAST program. The sequence of the clinical isolate was 100% identical with those of B. pilosicoli ATCC 51139 and P43/6/78 strains (GenBank accession no. and , respectively).
Disk diffusion susceptibility testing was performed on Mueller-Hinton agar supplemented with 5% defibrinated horse blood according to the recommendations of the Antibiogram Committee of the French Society for Microbiology . The strain was fully resistant to penicillin, amoxicillin, ticarcillin and piperacillin by producing a β-lactamase (cefinase test positive). It was also resistant to erythromycin, spiramycin, rifampin, vancomycin and colistin, and susceptible to amoxicillin/clavulanate, piperacillin/tazobactam, cefoxitin, cefotaxime, imipenem, clindamycin, pristinamycin, tetracyclin, chloramphenicol and metronidazole.


A 66-year-old man was referred to the Haematological and Transfusional Medicine Department of an urban general hospital in December for persistent fever and night sweating. The patient was affected by hypertension, diverticulosis, haemorrhoidal bleeding and by chronic obstructive pulmonary disease with periodic exacerbations.
Starting in June, the patient reported weakness, increased blood glucose serum levels and decreased body weight. In November, swelling of superficial lymph nodes, fever and nocturnal sweating had occurred. The laboratory test results showed normocytic normochromic anaemia (haemoglobin, Hb, 9.5 g/dl), white blood cell count (WBC) was 7170/mm3 with 85% neutrophils and 11% lymphocytes, 7.13 mg/dl C-reactive protein (CRP) with normal values < 0.8 mg/dl, erythrocyte sedimentation rate (ESR) of 59 mm/hour, fibrinogen 597 mg/dl (normal range 150–450) and beta 2-microglobulin 5.21 mg/litre (normal values 1.42–3.21 mg/litre). Levels of Ca 15.3, Ca 19.9, PSA, TPA, alpha-fetoprotein, FT3, FT4, TSH, vitamin B12 and folic acid were in the normal range. Serological tests for CMV, Toxoplasma gondii, VZV, Brucella, HBV, HCV and HIV were negative. The Tuberculin Sensitivity Test with 5 IU of Purified Protein Derivative (PPD) was performed with negative results. Markers for autoimmune diseases (ANA, APCA, ASMA, and ENA) were in the normal range.
In December, because of persistent fever, weakness, nocturnal sweating and loss of 7 kg in body weight, the patient was referred to the Haematological Department. Blood examinations documented a persistent increase in ESR (90 mm/hour) and CRP (6.7 mg/dl) levels and a progressive haemoglobin decrease (nadir 8 g/dl); dosage of cytokines showed increased levels of IL-6 (12.7 pg/ml, normal values < 4.1), IL-10 (20.5 pg/ml, normal values < 9.1) and TNF-alpha (32.4 pg/ml, normal values < 8.1); the study of B- and T-lymphocyte subpopulations by RT-PCR (CD5, CD19, CD20, Sig, CD3, CD7, TCR) gave normal results. Blood transfusions and iron therapy were performed. In January, total body computed tomography (CT) scanning showed cardio- and splenomegaly. Non-complicated diverticulosis in the descending colon and sigmoid colon and anal haemorrhoids were revealed by colonoscopy. A trans-oesophageal echocardiogram showed mitral prolapse with regurgitation but no valvular vegetation was found. A dental X-ray was negative for dental abscess or caries.
In February, the patient was referred to the Infectious Disease Department. On admission, four consecutive blood cultures were performed. Gram-positive aerobic-anaerobic coccobacillary bacteria were isolated from all specimens and identified as Leuconostoc spp. resistant to vancomycin and trimethoprim-sulphamethoxazole. Therapy with parenteral levofloxacin (500 mg intravenous bid) was started. After 2 weeks of parenteral therapy, the patient's conditions improved, but because of persistence of fever and increased levels of ESR (59 mm/hour), the therapy was continued with oral moxifloxacin. A blood culture specimen was examined with PCR for sequencing of 16S ribosomal RNA. The molecular analysis did not confirm the previous diagnosis and the microorganism was identified as Lactobacillus casei.
In March, haemorrhoidectomy was performed. During the postoperative period, the patient developed respiratory failure with an increased ESR (100 mm/hour). Chest CT scanning revealed multifocal pneumonia. Blood and sputum culture results were negative. A 7-day course of parenteral therapy with amoxicillin-clavulanate (2 g bid) was added to the moxifloxacin. In April, after 6 weeks of fluoroquinolone therapy, the patient was feeling well: fever, weakness and nocturnal sweating had resolved, the haemoglobin and CRP serum levels were in the normal range, ESR was reduced (51 mm/hour) and antimicrobial therapy was stopped.
Three months after the end of antibiotic therapy, the patient was hospitalized because of a new episode of multifocal pneumonia, likely to be secondary to a previous upper respiratory tract infection. During the hospitalization, an abdomen CT scan demonstrated normalization of spleen size. A trans-thoracic echocardiogram confirmed the presence of cardiomegaly and mitral prolapse with regurgitation. Blood and sputum cultures were negative. The patient was successfully treated with intravenous ampicillin-sulbactam (2/1 g tid) and oral levofloxacin (500 mg qd). No microorganisms were isolated in blood, sputum or urine.
Six months after the bloodstream infection with Lactobacillus casei, the patient reported a marked increase in body weight with complete normalization of ESR (8 mm/hour), CRP (0.5 mg/dl), and Hb values (13 g/dl). Now the patient is on the waiting list for cardiac valvular replacement.


F.R., a 58 year old Hispanic male, DOB 1/10/1937, sustained an acute inferior-posterior myocardial infarction on 9/25/1996. Coronary angiography demonstrated a totally occluded circumflex coronary artery filling via collaterals, with patent left anterior descending and right coronary vessels. Echocardiography showed inferior-posterior akinesis, inferior wall aneurysm, and an ejection fraction about 40%.
Because of recurrent ventricular tachycardia with syncope, he received a permanent defibrillator implant about two weeks after the acute MI. One week later he was readmitted with syncope and physical signs of cardiac tamponade. Emergent cardiac catheterization and ventriculography indicated ventricular rupture with extravasation into the pericardium. At surgery this diagnosis was confirmed and the ventricular defect was closed with a Teflon patch. No coronary bypass grafting was done. Postoperative echocardiography revealed the patch and a small residual pericardial effusion. Ten years after surgical repair, the patient is asymptomatic on a secondary prevention regimen of an aspirin, ace inhibitor, a statin, and a beta-blocker. His favorable course illustrates that myocardial rupture after acute MI, although most often rapidly fatal, can occasionally be diagnosed in time for a surgical repair to be performed. In this case, the patient has survived and has been well for ten years, despite the additional co-morbidity of recurrent ventricular tachycardia requiring an implantable defibrillator. We believe that the long term favorable course in our case is attributable to preserved ventricular function. As in the case of infarction complicated by ventricular septal or papillary muscle rupture, survival after repair of the mechanical complication depends on adequate ventricular function. In our patient, with a current ejection fraction of 50 %, he has not only survived for ten years- but is asymptomatic and fully active.


A 58 year old white male presented in our department with mucusuria, recurrent bacteriuria and lower urinary tract symptoms. He had been treated in the past for recurrent episodes of prostatitis. He also reported mucusuria that had been present since childhood and for that reason thought it was not unusual. He did not report any hematuria. Abdominal examination revealed a round, smooth, firm, non-tender, suprapubic mass. The prostate gland was soft, painless and of normal size. Biochemical and haematological analysis was normal. An abdominal computerised tomography (CT scan) revealed a 7 × 6 cm round supravesical, midline cyst, with extension into the bladder (figure ). Antegrade cystography did not reveal any communication between the bladder and the cyst. Rigid cystoscopy under general anaesthesia showed a round and smooth protrusion at the level of the dome and presence of an orifice. The cyst was filled with mucous and there were multiple papillary lesions on the inner surface of the cyst that was biopsied. Histology revealed a urachal adenoma, with no signs of malignancy. The patient underwent an open transperitoneal removal of the cyst (figure ) and partial cystectomy. Histological examination of the specimen revealed an invasive mucus adenocarcinoma with positive surgical margins. The patient was further evaluated with a pulmonary CT and bone scan which were both negative for metastatic disease. Subsequently he underwent a radical cystectomy and pelvic lymph node dissection with orthotopic neobladder construction.


A 65-year-old Greek man presented with a 9-month history of gradually progressive intermittent dysphagia. He also reported significant weight loss but no haemetemesis or melaena. The rest of his medical history was not significant. No specific abnormality was revealed during the physical examination.
Radiologic work-up with oesophagogram showed a dilated oesophagus, air bubbles with a mottled appearance, and contrast-filling defects from the cervical oesophagus to the upper body of the stomach (Figure ). The computed tomography (CT) scan revealed a soft-tissue lesion in the oesophagus, extending from the level of the cervical oesophagus to the level of the upper body of the stomach (Figure ). The lesion appeared as a relatively smooth, sausage-shaped intraluminal mass with bulbous distal tip.
CT with multiplanar reformatting provided valuable information regarding the location of the lesion as well as the size and anatomical attachment proximally, which was pivotal in directing surgery (Figure ). The intraluminal polyp showed soft tissue densities and a central area with attenuation identical to that of fat (Figure ). Endoscopy revealed a smooth submucosal mass occluding the oesophageal lumen. Endoscopic ultrasound-guided fine-needle aspiration was performed and cytological examination revealed benign fibro-fatty elements. The lesion was diagnosed as a submucosal FVP of the oesophagus, originating from the cervical oesophagus.
A biapproach surgical technique was selected. The origin of the pedicle was attached to the anterior wall of the hypopharynx. The broad base of the stalk was divided by performing cervical vertical oesophagostomy. However, the head of the polyp was too large to be removed through pharyngotomy; therefore, the entire polyp was removed via gastrostomy (Figure ). The length of the tumour was 16 cm and histopathology revealed an oesophageal mucosa-covered polypoidal lesion composed of lymphocytes and plasma cells interspersed with fibroblasts and blood vessels. No hyperplasia of the mucosal epithelium was evident. The final diagnosis was FVP of the proximal oesophagus. The patient recovered uneventfully and was cured of his dysphagia.


A 77-year-old Caucasian man visited his orthopedic surgeon and complained about persistent right knee pain for the last 2 months. The patient did not remember a specific traumatic event in the past. Upon clinical examination, the surgeon suspected a degenerative meniscus lesion. Since the patient had a pacemaker, further evaluation with magnetic resonance imaging was contraindicated. Intra-articular steroid injection did not lead to a substantial improvement in the symptoms. Based on the available data, it cannot be definitely ruled out that CRPS was absent at that time. The clinical presentation however makes this scenario unlikely.
Since the surgeon supposed that the pain was due to a degenerative meniscus tear, he performed an arthroscopic partial medial and lateral meniscectomy. Shortly thereafter, the patient complained of a dramatic increase in pain intensity and on inspection the surgeon described a newly developed soft tissue swelling, skin color change and hyperhidrosis. He referred the patient to our institution for further evaluation and treatment because he suspected a case of CRPS 1.
Upon examination, the patient was afebrile and complained of consistent pain and soft tissue swelling over the right knee. Due to pain, the patient used two crutches for independent ambulation and was able to walk approximately 30 m. The right knee showed vasomotor (slight rubor, locally increased skin temperature) and sudomotor changes (slight hyperhidrosis) (Figure ). Active and passive range of motion was painfully limited to flexion/extension of 40°/20°/0°. He demonstrated tenderness on palpation of the medial femoral condyle. Ligamentous stability and meniscal integrity could not be examined due to the pain.
Laboratory testing showed the following results: Hb of 12.2 g/dl (<14.0–18.0), ESR 83 mm/hour (8), AP 106 U/liter (40–129), CRP 38.9 mg/liter (<5). Plain radiographs revealed moderate degenerative changes and a moderate intra-articular effusion. Computed tomography (CT) showed some nonspecific trabecular changes in the medial and lateral femoral condyle. Finally, triple phase bone scan with Tc-99m-DPD revealed an increased activity inflow into the distal femoral diaphysis and epiphysis during the perfusion stage. During the second and third phase of the bone scan, multiple enhancements in the distal femur, the right tibia and right hemipelvis were detected (Figure ). Based on these findings, we concluded that a metastatic process caused the painful swelling and dysfunction. Further evaluation with a biopsy of the femur and cystoscopy revealed the diagnosis of a metastatic urothelial carcinoma. The location of the primary tumor remained unclear and was not further investigated due to the progressive worsening of the patient. After initiating palliative chemotherapy, the patient's condition rapidly deteriorated and he passed away within a few weeks.


A 32-year old male patient, working for a building enterprise, broke down on the job. As the patient experienced strong pain and was tachycardic and hypotensive, he was transferred intubated by helicopter to our institution for primary care. On admission the patient was in hemodynamically stabilised condition, though an ambigiuous shot-wound like entry wound in the upper left quadrant of about 5 mm in diameter was mentioned. By computerized tomography an unique metalic fragment in the upper pole of the left kidney with subcapsular bleeding was evidenced [Figure ]. Abdominal free air was indicative for a hollow organ perforation. A lesion of the pancreatic tail was suspected. The liver and spleen were also free of signs for injury in the pre-surgical diagnostic procedures. The presence of fluid within the subhepatic space, Morrison's pouch, was suspicious for blood. It was decided to perform an exploratory laparotomy.
Exploration revealed about 400 ml fresh, partly coagulated blood. Perforations of the ventral (entrance wound) and dorsal (exit wound) gastric wall respectively (5 mm in diameter) were identified and closed by single suturetechnique utilising resorbable material. Broad exposure of the bursa omentalis showed a wound correspondending to the dorsal stomach lesion. After mobilisation of the spleen and the pancreatic tail, a tangential injury of the pancreas could be demonstrated. The major pancreatic duct was not lacerated by the metal fragment. The adipose capsule of the kidney was completely blood-filled. We split Gerota's fascia and mobilized the kidney. The upper pole showed an entrance hole on the anterior side without an exit wound. A metal fragment was removed guided by x-ray fluoroscopy. The pancreatic and the renal injuries were treated without sutures, but drained adequately transcutaneously with soft silastic drains. The exocrine pancreas was blocked by subcutaneous application of 100 μg per die octreotide for the following seven days to minimize the development of post-operative pancreas-fistula.
After surgery, the patient was transferred to our intermediate care unit for 11 days. Retrospectively the mechanism of injury was reconstructed. Not involved in the trenching of a dilapidated building with a special wire, the worker was hurt while walking by in a distance of about 12 meters to a diamond wire divice in motion in the moment of wire rupture. A fragment hit the person by maximum speed and penetrated into the abdomen.
The patient further stabilized under antibiotic coverage by Piperacillin and Sulbactam with declining infection signs in clinical chemistry. A low output pancreatic fistula closed 8 weeks after endoscopic retrograde pancreaticoscopy with placement of a decompressing stent to the common duct four days after surgery [Figure ]. The patient was transferred to regular ward and discharged from hospital in good condition and closed wounds after closure of the pancreatic fistula. The stent could be removed on an outpatient basis without any complications after 4 month.


A 72-year-old man presented to our hospital with a 2-week history of lower abdominal pain, constipation, and weight loss of 7.3 kg. One month earlier, he had presented to another institution with a 1-month history of fatigue and dyspnea. On that occasion, he was found to be anemic (hemoglobin: 76 g/L), for which an endoscopy and colonoscopy were performed. Those tests failed to reveal any cause for the anemia. Physical exam demonstrated a firm, slightly tender, palpable mass in the upper abdomen, but no hepatomegaly or splenomegaly. There was also no jaundice or systemic evidence of liver disease, and no palpable lymphadenopathy. No rales, wheezes, or areas of reduced air entry were observed on auscultation. He had a performance status of 2.
Imaging of the abdomen by ct showed a large heterogeneous mass appearing to arise from the small bowel mesentery, measuring 15.7 × 26.3 × 22 cm, and partly encasing loops of small bowel [(A)]. No adenopathy or other significant intra-abdominal pathology was observed. Imaging of the chest by ct demonstrated a single 2.2 × 2.1-cm subpleural lesion in the left lower lobe of the lung, abutting the inner aspect of the thoracic wall, appearing to arise from the abdomen, with no intrathoracic adenopathy. A ct-guided biopsy of the abdominal mass demonstrated a poorly differentiated neuroendocrine carcinoma with features of a small-cell carcinoma. A bone marrow biopsy revealed no malignant cells. A bone scan and imaging of the head by ct were negative for bone and brain metastases respectively. A diagnosis of epsmcc was made, and after prompt placement of a peripherally inserted central catheter, treatment with etoposide (100 mg/m, days 1 to 3) and cisplatin (80 mg/m, day 1) began, with planned cycles of 21 days.
From day 1 to day 6 of chemotherapy, the patient developed recurring fever spikes (maximum: 38.8°C), but preliminary investigations did not reveal a source. On day 6, he developed worsening abdominal pain, somnolence, tachycardia, and hypotension. Peritoneal signs were present on physical exam. Imaging of the abdomen by ct showed small pockets of gas bubbles at the site of the tumour, consistent with tumour necrosis [(B)].
Broad-spectrum antibiotics were instituted, and surgical consultation was requested. Surgical intervention was refused because of a high perioperative risk and impending neutropenia anticipated from the chemotherapy.
Over the following 4 days, the patient’s clinical picture remained tenuous. He developed acute renal failure (creatinine rose to 188 μmol/L from a baseline of about 110 μmol/L) and anasarca. Antibiotics were added, ultimately including imipenem, vancomycin, metronidazole, ciprofloxacin, and fluconazole. With these interventions, the patient’s hemodynamics and overall clinical picture normalized by day 10.
The patient recovered well from the foregoing events and received his 2nd cycle of chemotherapy on schedule. In light of the renal failure and gross edema, to which the cisplatin may have contributed because of its nephrotoxicity and the large fluid volumes given with the drug, cisplatin was replaced with carboplatin (area under the curve: 6). Antibiotics were discontinued, adequate diuresis was achieved, and the patient was discharged home on day 8 of cycle 2.
The patient returned to clinic on day 16 of cycle 2 with complaints of fatigue and dyspnea. He received 2 units of packed red blood cells because of a hemoglobin level of 85 g/L, and repeat ct imaging of the abdomen was requested to evaluate tumour response. On the patient’s return to the clinic 1 week later (day 22), his symptoms had not improved. Fever and worsening abdominal pain were now present. The abdominal ct demonstrated a large 25 × 16-cm cystic abdominal mass with air–fluid levels at the site of the previous tumour [(C)], and leucocytosis was found (17.8 × 10). The patient was sent for urgent ct-guided abdominal drainage, which removed more than 4 L purulent material, and intravenous antibiotics were administered. Symptoms improved immediately with drainage. The abdominal exudate grew Klebsiella, Bacteroides, Enterococcus, and Staphylococcus aureus.
After 24 hours of observation in the emergency room, the patient was discharged home with a prescription for 2 weeks of oral antibiotics consisting of ciprofloxacin, metronidazole, and amoxicillin with clavulanic acid. The drain was removed after 8 days. Imaging by ct on the day before drain removal showed complete resolution of the abscess and significant reduction in tumour size ((D)].
The patient’s 3rd cycle of chemotherapy occurred on schedule and without incident, and at the time of writing, he was beginning a 4th cycle.


A 4-months old male infant was referred to our department because of progressive/painless bulging over the right parietal bone. He was the first child to non-consanguineous parents. The mother was a 28-year gravida 1 abortus 0 married to a 31-year-old unrelated man. He was a product of uneventful gestation. At birth his weight, length and head circumference were around the 50 th percentile. Recently, his parents noticed a hard/painless mass over his right parietal bone. Clinical examination showed a 4-months old child with no associated dysmorphic facial features or any associated craniofacial disfigurement, apart from a hard mass over the right parietal bone. Hearing and vision were normal. Neurological examination was normal. Skin showed no peculiar stigmata. Anteroposterior skull radiographs showed a multicystic lesion with slightly sclerotic margin in the right parietal bone, associated with significant outward bulging of the outer table without destruction of the inner table in tangential view of the right parietal bone (fig ). Lateral radiograph of the skull showed large osteolytic/multicystic lesion associated with thick sclerotic rind in the right parietal bone (fig ). T1 weighted image of the skull showed expansile lesion within the parietal bone. The lesion is larger than appreciated on the radiograph. There is mixed hyper and hypointenstities. It is significantly expanded with well-defined margins (fig ). Sagittal T1-weighted MR image showed significant expansile lesion associated with a dense zone of calcification within the mass-arrow (fig ). Skeletal survey of the child showed no other bones involved. The child underwent a series of investigations, included complete blood cell counts, urine biochemistry, chromosomal analysis and metabolic tests, which aimed to test calcium, phosphorous, and vitamin D metabolism, all were normal. Hormonal investigations included thyroid hormones were normal.


A 46 year old Caucasian woman was seen in the breast clinic in Tralee General Hospital, Tralee, County Kerry, Republic of Ireland (March, 95) with a 3 × 2 cms right breast lump. Bilateral mammography followed by open biopsy confirmed an adenocarcinoma in the upper outer quadrant of the right breast. Left breast was normal. The patient underwent simple mastectomy followed by radiotherapy to right chest wall, axilla and supra-clavicular fossa and chemotherapy with Cyclophosphamide, Methotrexate and 5-FU. In February 2001 the same patient presented with a lump in the contralateral breast. The lump, present for 6 months, was non-tender and slow growing. Mammography figures as shown (Figures and ) Overlying skin tethering was present (Figure ). No nipple discharge or axillary lymphadenopathy was noted.
Cytology was graded as C1. Trucut specimen histology showed cellular connective tissue with fibroblasts and enlarged, hyperchromatic nuclei. Amid those desmoplasia were single histiocytes with granular foamy nuclei. There was also cellular dense collagen involving adipose tissue. Fibroblast proliferation accompanied by collagen necrosis was extensive and was reported as post radiation change.
The lump was excised. Specimen revealed a 3.2 cm central tumor with a cyst 2 cm in dimension within. The tumor arose in the soft tissue underlying the skin. A central cystic cavity surrounded by extensive tumor necrosis was noted along with a vascular tumor with fibrocellular nodules surrounded by a network of collagen fibres. Some of the nodules were hypercellular containing frequent mitoses. There was an irregular infiltrating edge to the tumor into the adipose tissue. The tumour was classified as a malignant fibrous histiocytoma arising from the breast stroma/subcutaneous tissue.
This was based on the finding of predominant storiform pattern, and presence of epithelioid along with tumor giant cells. The tumor had 2 parts, majority of low grade differentiation. 1/3 rd was of high grade with >3 mitoses/high power field. The patient was underwent left mastectomy and axillary clearance. Histology confirmed tumour clearance and no evidence of axillary node metastasis. Body scan revealed no distant metastases.


A 32-year-old woman presented with a door handle stuck into her left non-dominant hand. While trying to move an old door at home, it accidentally fell on her injuring the left hand. The handle had passed through the dorsal aspect of the first web space and had exited though the volar aspect of the hand. She was able to move her fingers and had no distal neurovascular deficit at presentation. The capillary refill time was less then 2 seconds and the fingers showed no discoloration. There was minimal bleeding from the wound and there were no other associated injuries. After a preliminary assessment she was immediately taken to theatre. Clinical photographs (Figure ) and radiographs (Figure and ) were taken preoperatively. Tetanus toxoid and intravenous antibiotics were administered. A tourniquet was used at appropriate pressure to aid the procedure. Intraoperative findings showed some 'paint' debris in the deeper tissues and the wound was washed with normal saline. The wound involved the capsule of the first metacarpophalangeal joint, which was repaired with 4-0 vicryl sutures. The integrity of tendons, nerves and blood vessels was confirmed and appropriate debridement and washout was performed. The wound was then reviewed after 48 hours and a delayed primary closure performed. The patient had regained good hand function and the wound healed unremarkably at follow-up.