An 11-year-old girl diagnosed as having PS with features of hemihypertrophy of the right side, scoliosis, macrodactyly accompanied by exostoses in digits and hands, subcutaneous tumors, and connective tissue nevi was scheduled for removal of a mass of the external auditory canal and mastoidectomy with tympanoplasty on the right side (). She had previously undergone tonsillectomy and adenoidectomy under general anesthesia with no events at the age of 2.
In preoperative assessment, she had facial and skull asymmetry, hypoplastic and carious teeth, a degree of mandibular prognathism and mild limitation of neck movement due to torticolis. Chest X-ray showed thoracolumbar scoliosis, but there was no deviation or stenosis of the trachea and no active lung lesion (). She presented good mouth opening and belonged to Mallampati class 2. However, computed tomography (CT) showed nasopharyngeal mucosal hypertrophy with adenoid vegetation and a deviated nasal septum to the right side (). Therefore, flexible FOB was prepared for use when tracheal intubation was difficult or failed using a laryngoscope. Laboratory results were within normal ranges.
Her height was 155 cm, weight was 46.8 kg, blood pressure, heart rate, and oxygen saturation were 105/60 mmHg, 105 beats/min, and 99%, respectively. Glycopyrrolate 0.2 mg was administered for premedication. General anesthesia was induced with 200 mg of thiopental, 30 mg of rocuronium and continuous infusion of remifentanil. Observation of the larynx by direct laryngoscopy was unsuccessful despite complete muscle relaxation induced by rocuronium administered after confirming mask ventilation was not difficult. Cormack and Lehane (CL) grade obtained by laryngoscope was 3. Torticollis and restricted joint mobility added to difficulties. Prepared FOB was used immediately. A 6.0-mm-internal-diameter reinforced endotracheal tube was inserted orally into her trachea using FOB and fixed at the 21 cm mark over the right side of her lips after adequate positioning of the tube was confirmed by FOB. The view of FOB showed multiple polyp-like masses in the supraglottic region and her epiglottis was enlarged. The surface of the tracheal wall was rugged as there were a number of small nodules (). Despite the rugged wall, a 6.0-mm-internal-diameter tube was inserted smoothly. Anesthesia was maintained with sevoflurane (inspired 2.0 vol%) with a mixture of air/O2, continuous IV infusion of remifentanil. The surgery lasted for 5 hours under general anesthesia and she was sent to the recovery room after extubation with no problem. There were no anesthetic complications or problems in the recovery room and she was sent to the general ward.


The first case is a 44-year-old Caucasian male who presented with recurrent episodes of gastrointestinal bleeding was found to have a mass in the ampulla of Vater. Patient underwent laparoscopic small-bowel resection with primary stapled side-to-side functional end-to-end enteroenterostomy. Pathology was consistent with GIST that was c-KIT positive and DOG-1 positive, and high mitotic rate. In the immediate postoperative period after the small bowel resection, patient was found to have a thrombus in the superior mesenteric vein (SMV) and portal vein (PV) leading to hepatic infarct in segment 7. Patient was treated with lovenox for 4 months. Follow-up MRI after 2 months of lovenox treatment showed no evidence of the thrombi in the SMV and PV as well as the resolution of the perfusion defects seen in the segment 7 of the liver. The patient was offered adjuvant therapy with imatinib 400 mg daily. Liver function tests (LFTs) were monitored twice a month for one month and then every four weeks. Baseline LFTs prior to imatinib initiation were normal. Approximately three months after treatment, a gradual incline in total bilirubin was noticed. Further workup was negative for hepatitis B, C, and HIV. He had minimal alcohol intake (he used to drink one drink once or twice a month but declined any use since his diagnosis) and was not taking any hepatotoxic medication (over-the-counter [OTC], recreational drugs or herbal supplements). Hemolysis parameters were normal as evidenced by normal levels serum lactate dehydrogenase, haptoglobulin, reticulocyte counts were normal as well as lack of abnormal cells on peripheral smear. Repeat MRI showed resolution of the density in the liver and no evidence of biliary obstruction or metastases.


The second case is a 65-year-old Caucasian male who presented with multiple episodes of gastrointestinal bleeding was subsequently found to have a 3-4 cm submucosal jejunal mass. Pathology was consistent with stage II (pT2pG2N0M0) jejunal GIST (CK positive, and Ki 67 positive) with high mitotic rate. Patient had a laparoscopic jejunectomy followed by a small bowel resection. Adjuvant therapy with imatinib (400 mg daily) was started with baseline normal LFTS prior to initiation. A dose reduction to imatinib 200 mg occurred within two months of treatment due to neutropenia and rash. Patient tolerated the medication without further side effects; however, laboratory results were significant for total bilirubin of 1.9 mg/dL. Hepatitis A, B, C serologies were negative and alcohol intake was limited to 1-2 beers per weekends only. He did not have any evidence of hemolysis as serum lactate dehydrogenase, haptoglobulin, reticulocyte counts were normal and no spherocytosis seen on peripheral blood smear.


RF is a 66-year-old male with a history of ischemic cardiomyopathy. The patient had a HeartMate II LVAD placed 3 years prior to presentation for medically refractory heart failure. He was on warfarin and aspirin for his LVAD with goal INR of 1.5–2.0. He presented to the emergency department with light-headedness and hematochezia for several days. He had no prior history of GIB. His physical examination and vital signs were unremarkable. His INR was 2.8, creatinine was 2.3 mg/dl, and hemoglobin was 10.4 from baseline of 12 to 13 g/dl. His last screening colonoscopy was 4 years prior and was reportedly unremarkable. He was admitted for close monitoring, serial laboratory testing, and gastroenterology consultation. He underwent esophagogastroduodenoscopy revealing a gastric ulcer with a clean base with no evidence of active bleeding. A colonoscopy revealed a likely malignant tumor in the cecum, diverticulosis, and nonbleeding colonic angiodysplastic lesions []. The cecal mass was biopsied; it appeared to be actively bleeding and uncontrollable endoscopically. These findings were relayed to the emergency general surgery team.
He was taken emergently to the operating room. A midline laparotomy was undertaken and he was found to have a cecal mass that was perforated into a retroperitoneal abscess. The right colon was mobilized to the hepatic flexure and the abscess cavity was debrided. A right colectomy was performed with a stapled side-to-side ileocolonic anastomosis. A drain was placed in the abscess cavity, fascia was closed, and the skin and subcutaneous tissues were packed with gauze.
Final pathology showed no evidence of malignancy. It revealed a transmural defect of 1.0 cm × 0.5 cm with organizing hematoma and acute on chronic inflammation. Cytomegalovirus testing was negative. There was focal re-epithelialization, thus making bleeding diverticulum a possible diagnosis.
The patient's postoperative course was complicated by prolonged ileus necessitating total parenteral nutrition and pelvic abscess that required percutaneous drain placement. The patient additionally had bacteremia and fungemia. The patient's postoperative complications eventually resolved, and he was discharged to home with home health.


A 38-year-old man was admitted to the ED with stable vital signs and normal level of consciousness after he had been near the site of a high-pressure tank explosion at work. The patient was thought to have miniscule particles of cement and other materials impacted in his skin, especially in the face. Skin damage was observed on the right side of the face and neck, and the center of the chest, where numerous cement particles were presumably impacted. Additionally, the patient presented with a foot fracture, resulting from tripping while stepping backwards at the time of explosion. Facial CT scans revealed the presence of minute FBs in the dermal layers. The ophthalmology department was consulted to eliminate the possibility of ocular FBs. A corneal abrasion was observed, but no FB. Local anesthesia was administered to reduce pain. Immediate treatment consisted of thoroughly brushing out and rinsing the wounds with 2 L of normal saline. Visible FBs in the dermis were also removed using a no. 11 surgical blade. After removal, bleeding persisted with considerable black colored pigmentation in the affected sites, suggesting possible persistent FBs, too small to be visible to the naked eye. For further removal, a slit-lamp microscope (Topcon Slit Lamp SL-3F; Topcon Medical Systems, Oakland, NJ, USA) and a 26-gauge needle were used in order to prevent traumatic tattoos. The patient sat in front of the slit-lamp microscope as we adjusted the focus setting to ×16 magnification. We increased the light intensity, and decreased the slit width. Next, we adjusted the screw of the chin rest bar for proper vertical alignment. For horizontal alignment, the face angle was adjusted to the right or left. We shone the light next to (but not directly on) the impacted area. With direct, localized light, it was too bright to see the FBs, which could be visualized as solid 3-demensional shapes defined by their shadow lines (, ). We used a 26-gauge needle to access the identified areas through a wound in the skin created by the initial penetration (). We confirmed the FBs by feeling them with the needle tip; larger FBs were removed through the formed passage of the wound, while the miniscule powder ones were carefully scratched off the skin surface. Approximately 50 FBs were removed each time, with 150 removed for the three procedures in total (). The removed particles were between 0.5 and 2.0 mm. The total procedure duration was approximately 15 minutes in total. After removal, an antibiotic ointment was applied, and a moistened dressing was given; the wound recovered with no sign of traumatic tattoo or secondary infection at the time of follow-up ().


This was a 40-year-old woman who had been using hard contact lenses for 20 years. Surgical outcome was similar to that predicted by processed preoperative images ().


This was an 80-year-old man with age-related blepharoptosis. Postoperative appearance was different from that predicted by processed preoperative images due to a preoperative narrow eyelid fissure ().


This 92-year-old lady had advanced coronary artery disease and visual loss to finger counting bilaterally from ultra-brunescent cataract () and pseudo-exfoliation. Under pure (no sedation) topical anesthesia, the right eye underwent attempted phacoemulsification. There was excessive wrinkling and mobility of the anterior capsule. Extracapsular cataract extraction was done, and the capsule was spontaneously expressed. An anterior chamber implant was placed. Under topical anesthesia also, the left eye underwent phacoemulsification of the very dense nucleus. The cortex was aspirated from the center as described in the technique. A CTR was not placed as its insertion would traumatize the loose zonules. One day postoperatively the cornea was clear, and uncorrected visual acuity was 20/25. The implant was well centered. At the 1-month follow-up, moderate capsular phimosis () was observed with preservation of the central visual axis and absence of implant-donesis. This persisted at the last follow-up 6 months postoperatively.


A 72-year-old man with no significant past medical was referred to oncology clinic after he was found to have a right upper lobe lung mass. The patient presented to primary care physician with history of dull aching right side chest pain along with noticing specks of blood in his phlegm. A chest X-Ray (CXR) showed an ill-defined 60×45 mm mass in the right upper lobe. Computed tomography (CT) of the chest showed 87×63 mm mass in the right upper lobe with multiple small nodules in both lobes of the lungs (). Histopathology of the sample obtained via a transbronchial biopsy showed NSCLC favoring adenocarcinoma. Mutation analysis of the sample was positive for EGFR mutation (exon-19 deletion) and negative for K-ras and ALK rearrangement. As part of metastatic workup, CT head with contrast was obtained, which showed a 9×8 mm mass in the gray matter of right insular cortex suggestive of metastatic deposit. Magnetic resonance imaging brain showed a bilobed nodular contrast enhancing lesion in the right anterior inferior frontal cerebral cortex measuring 12.2×8.6×4.7 mm, confirming the lesion as metastasis from a distant primary (which was lung adenocarcinoma in this patient). The bone scan showed a blastic lesion in the T8 vertebrae and manubrium sterni. Radiation oncology evaluated the patient and planned for palliative external beam radiation therapy (EBRT) to whole brain (30 Gy in 10 fractions). However, prior to starting the EBRT, patient developed a single episode of significant hemoptysis (around 2 weeks from initial presentation) for which he was admitted to the hospital. Repeat CXR showed stable changes from previous CXR done at the time of admission. A decision was made to administer palliative EBRT to chest targeting the tumor, including the blastic lesions on the spine (T6-T8). Soon after completion of EBRT patient was started on erlotinib 150 nmg PO once daily. Three weeks after starting erlotinib, the patient presented to the emergency room (ER) with weakness, fatigue and diarrhea (3-4 watery stools per day) for 3 days. The patient was also reporting cough associated with occasional white phlegm over last 3-4 days. Vital signs on admission were significant for tachycardia to a rate of 107/min and a temperature of 100.4°C. The laboratory results, at the time of admission, are shown in . A CXR done in the ER () showed improvement in the lung mass and interstitial opacities seen on previous study, however it also reported a lingular infiltrate, which was new from the comparison study. The patient was diagnosed provisionally with health care associated pneumonia and was started on vancomycin and levofloxacin. The stool sample was tested for toxigenic Clostridium difficile using polymerase chain reaction based assay, which returned back negative. Vancomycin was stopped 24 hours after admission due to absence of any growth in the blood culture and resolution of fever. Two days after admission, the patient reported worsening of shortness of breath and was noted to have increased oxygen requirement. His vital signs at this point were significant for the heart rate of 108 beats/min, respiratory rate of 32/min and the oxygen saturation of 87% on 5 L of oxygen via nasal cannula. Patient was shifted to medical intensive care unit (MICU) for this acute onset respiratory distress. A portable CXR, done at this point, showed progression of diffuse bilateral pulmonary opacities since admission (). The patient was started on broad-spectrum antibiotics (azithromycin, piperacillin-tazobactam and vancomycin). His labs at the time of admission to MICU are shown in . The patient was also started on non-invasive positive pressure ventilation but was unable to tolerate it. As part of his advance directives, the patient has signed a Do-not resuscitate and Do-not intubate form. He did not wish to change his CODE status at the time of admission to MICU. In tandem with his code status, he was not intubated and was given oxygen via a nonrebreather mask. Patient and his family opted for comfort care after discussion with palliative care team. The patient expired on 4th day of admission to the hospital.


A 57-year-old female patient came to the hospital with pain in both thighs, especially on the right side. The pain was exacerbated during weight bearing and walking and decreased while resting.
In the physical examination, there was direct tenderness in the right thigh and right groin region. But no edema or external abnormality was observed. The range of motion of the hip joint was normal, and there were no abnormal neurological findings. On the simple radiographic inspection, the cortical bone of the right proximal femur was thinned and showed cystic change. Decreased bone density was also observed and the trabecular bone of the overall femur was thinned (). The magnetic resonance imaging (MRI) was performed on the part showing cystic bone change to determine the bone tumor. Lesions with a low signal in T1WI () and a high signal in T2W1 () were observed in the proximal femur on both sides and in the right pubis. Based on the MRI findings, brown tumor was suspected. An additional blood test was conducted and serum intact parathyroid hormone was 2,720 pg/mL (normal, 15-65 pg/mL), alkaline phosphatase was 2,417 U/L (normal, 104-338 U/L), calcium was 14.5 mg/dL (normal, 8.6-10.4 mg/dL), and phosphate was 2.0 mg/dL (normal, 2.6-4.4 mg/dL). To find out the cause of hyperparathyroidism, we did the ultrasonography of the thyroid. Since a nodule was observed in the left lobe of the parathyroid, fine needle aspiration was performed to obtain pathological results from the parathyroid. Furthermore as malignant change could not be excluded with the presence of a relatively large nodule, a parathyroidectomy was decided.
On the 14th day from admission, the day for parathyroidectomy, the patient felt sudden pain in the right thigh while getting up from a bed to sit down in the morning, and radiographic inspection was performed. In the femur anteroposterior and lateral images, a pathological fracture was confirmed in a site where the brown tumor had formed (). Closed reduction and internal fixation with the intramedullary nailing was performed in orthopaedic surgery department, and a biopsy was conducted using specimen tissue obtained during the medullary reaming. And the additional biopsy was performed along with the parathyroidectomy in the head and neck surgery department. The blood calcium concentration decreased to 10.0 mg/dL after the surgery, and the blood parathyroid hormone concentration became normalized after a month (). In a biopsy on the femoral lesion, brown tumor was diagnosed. The biopsy of the parathyroid confirmed the parathyroid carcinoma. Four months after the surgery, the union of the fracture was confirmed (). The patient became capable of walking without a crutch or walkers by a follow-up ten months after the surgery.


A 61-year-old man was admitted to our regional tropical and infectious diseases unit with vomiting, back pain, and urinary retention on a background of fever and weight loss. He became confused and developed impaired consciousness, and was diagnosed with tuberculosis meningitis on a clinical and radiologic basis. Neurologic impairment included dysphagia, and a PEJ tube was placed for nutritional support and medication administration. Local discussions between the medical staff and pharmacy staff raised concerns that jejunal administration may lead to impaired drug absorption, raising the possibility of treatment failure and the development of drug resistance.
The patient was 8 weeks into the continuation phase of his daily-dosed therapy and thus had reached the fully induced metabolic steady state. Over 8 hours after and 6 hours before any food or enteral feeding solution was given, and 24 hours after the previous dose, 600 mg rifampin solution (100 mg/5 ml; Rifadin; Sanofi, Guildford, UK) and 300 mg isoniazid oral solution were administered via PEJ tube. Serum samples were collected immediately before dose administration and at 1, 2, 4, and 6 hours after dose administration. Rifampin concentrations were assayed by high-pressure liquid chromatography at the Antimicrobial Reference Laboratory (Bristol, UK) (Table ). These values equated to a Cmax of 18 μg/ml and area under the curve from 0–6 hours (AUC0-6) of 50.1 μg/ml.


We report the case of a 3-month-old male infant with bilateral corneal opacity since birth who was transferred from the pediatric unit for further ophthalmic care. Written informed consent was obtained from the patient’s parents to publish this report. Prenatal and natal history were unremarkable apart from the fact that the mother, aged 35 years at the time of childbirth, was HIV positive. There was no family history of similar ocular disorders or other congenital anomalies. Upon initial ophthalmic examination, a positive light pursuit was found. There was a homogeneous bilateral central corneal opacity without neovascularization. Ophthalmologic examination under general anesthesia revealed a deep anterior chamber with iris strands that crossed the anterior chamber from the iris. The lens was transparent on the edges and did not adhere to the cornea. The retina was difficult to evaluate because of central corneal opacity. The intraocular pressure measured with a Schiotz tonometer was respectively 18 mmHg and 20 mmHg in the right and left eye. Other malformed features found in the physical pediatric examination included: broadening of the nose base and microcephaly (), bilateral polydactyly with camptodactyly, clinodactyly of the supernumerary finger (), an umbilical hernia with hypochromic macules of the abdomen () and bilateral supernumerary toe with hypertrophy of the hallux (). There were no genital, vertebral, or cardiac anomalies on pediatric physical examination. Laboratory examination revealed that the child was also HIV positive. The diagnosis of Peters plus anomaly Type 1 was made. Management consisted of the administration of mydriatics, one drop two times per day, 3 days a week. One drop of dorzolamide in the evening was also prescribed. Immediate penetrating keratoplasty (PKP) in both the eyes was advised. After being informed that this intervention was not available in our country, the parents did not bring the child back for further consultation, and were lost to follow-up.


A 10-years-old girl presented with complaints of muscle pain, malaise, coldness in the hands and feet, color changes in her finger in response to cold, and bruising after blanching. Previous medical history revealed no trauma, vigorous exercise, infection, or any medication usage. On physical examination, her height was 124 cm (–2.7 standard deviation [SD]), and her weight was 27 kg (–1.2 SD). She had severe short stature. Her bone age was 8 years. She had normal heart rate (84/min), respiratory rate (30/min), and, blood pressure (95/50 mmHg). Her skin showed diffuse dryness. Coldness in the hands and feet, nonpitting leg edema, and periorbital edema were present. Neurological examination showed weakness of proximal muscles of both upper and lower extremities. She had no sign of joint swelling or arthritis and had normal range of motion of all joints.
A pediatric rheumatologist had performed initial laboratory evaluations and found elevated levels of creatine kinase (CK) (2,039 U/L). A normal electromyogram had been obtained. It had been thought to be systemic sclerosis (SS) among connective tissue disease (CTD). Prolonged gastric emptying time supported this diagnosis. Although, rheumatologic markers, including antinuclear antibody, anti–double-stranded DNA, antineutrophilic cytoplasmic antibody, cytoplasmic, and antiextractable nuclear antigen (anti-Ro, anti-La, anti-Sm, anti-RNP, anti-Scl-70, anti-Jo-1), were all negative, a pediatric rheumatologist started the patient on naproxen and a calcium channel blocker. The patient had no improvement. When it was realized that she had goiter, the patient was sent to a pediatric endocrinologist.
In the thyroid function test, thyroid stimulating hormone (TSH) was elevated (>100 µIU/mL; normal range, 0.35–5 µU/mL), and fT4 was decreased (<0.25 ng/dL; normal range, 0.8–2 ng/dL). Thyroid-peroxidase antibodies (anti-TPO) were present in high titers (201 IU/mL). Thyroid ultrasonography (USG) was consistent with thyroiditis. These findings were also consistent with the diagnosis of autoimmune thyroiditis or HT with associated hypothyroidism. After treatment with L-thyroxine, her muscle strength gradually improved, other clinical symptoms regressed, thyroid function tests, CK levels returned to normal within a few weeks. Thyroid function test were presented in . Her height progressively increased, after 3 years of L-thyroxine treatment she gained 2.9 SD of height and she attained midparental height percentile (). Bone age was appropriate with chronological age.


A 17-year-old female patient was admitted due to cough, chest pain, dyspnea, and swelling in the abdomen. On physical examination, height was 140 cm (–3.5 SD), and weight was 43 kg (–2 SD). She had severe short stature and 2 years retarded bone age. She was pale and somnolent. Her score on the Glasgow Coma Scale was 11 points. She was dyspneic and cyanotic. Oxygen saturation was 65%, respiratory rate was 24/min, and pulse rate was 120/min. She had hypotension (80/60 mmHg) and subfebrile fever (37.4℃). Her mucous membranes were dry. She had dry skin, sparse hair, and goiter. Cardiovascular examination revealed deep heart sounds. A chest X-ray showed a "tents heart" (). On echocardiography, a massive PE was found. She was taken to undergo urgent pericardiocentesis, removing 1,000 mL of fluid. Blood investigations, including complete blood count, erythrocyte sedimentation rate, and serologic markers of viral pathogens and autoimmune diseases, were within normal limits. All work up of the fluid for the etiology of the PE was normal. Although pericardiocentesis was performed, hypotension did not recover. Thyroid function analysis showed raised TSH (>100 µU/mL; normal range, 0.35–5 µU/mL), decreased fT3 (0.9 pg/mL; normal range 2.3–5 pg/mL), and decreased fT4 (<0.25 ng/dL; normal range, 0.8–2 ng/dL) (). Antithyroglobulin antibody (87 IU/mL) and anti-TPO (860 IU/mL) were positive. Thyroid USG showed thyroiditis. After thyroid replacement therapy was started with an oral formulation, because intravenous thyroxine was unavailable in our country, hypotension and other complaints were resolved. We were unable to follow up her, because she did not apply to our outpatient clinic.


A 17-year-old female diagnosed with Down syndrome applied to pediatric cardiology outpatient clinic with swelling around the eyes and hands and dyspnea during sleep. Her height was 143 cm (25th–50th percentile according to growth chart for girls with Down syndrome), and her weight was 50 kg (25th–50th percentile according to growth chart for girls with Down syndrome). Bone age was 16 years. She had normal heart rate (76/min), respiratory rate (20/min), blood pressure (100/65 mmHg), and body temperature (36.8℃). Down syndrome stigmata (nasal eccentricity, simian line) were available on physical examination. Echocardiography revealed a PE exceeding 1 cm (). On laboratory evaluation, TSH was elevated (>100 µU/mL; normal range, 0.35–5 µU/mL), and fT4 was decreased (<0.25 ng/dL; normal range, 0.8–2 ng/dL). Thyroid autoantibodies were positive. After L-thyroxine therapy, facial edema and PE regressed within 15 days. fT4 and TSH levels before and after treatment were shown in . She grew in accordance with growth curves for children with Down syndrome.


A 71-year-old man presented to us with fluctuating motor aphasia of 3 h duration. Magnetic resonance imaging of the brain showed multiple acute infarcts in the left MCA territory and he was started on antiplatelets and statins. By the next day morning, he had developed global aphasia and transient right-sided weakness. His blood pressure (BP) was 150/90 mm Hg and he was taken up for a four-vessel digital subtraction angiography which showed a possible dissection with a thrombus in the distal left MCA []. After obtaining consent, a 4 mm × 15 mm solitaire AB neurovascular modeling device (ev3, Irvine, USA) was placed across the lesion into the superior MCA division with good recanalization. About 5000 U of intravenous heparin was administered during the procedure. Postprocedure, the patient was sedated and ventilated, but had severe hypertension, exceeding 240/140 mm Hg which was difficult to control even with multiple antihypertensives. The next morning, a routine computed tomography (CT) brain (12 h later) showed two discrete intracerebral hematomas (ICH) in the left frontal and temporal areas []. Transcranial Doppler (TCD) showed elevated mean flow velocities of >130 cm/s in the left MCA. Antiplatelets were discontinued and he was started on antiedema measures. Coagulation parameters were normal. On examination, now he had a dense right hemiplegia and global aphasia. His BP was brought down to baseline levels only after 5 days. Two weeks later, a repeat CT showed resolution of the ICH and no fresh infarcts. The patient had a residual Wernicke's aphasia and right hemiplegia at follow-up even 6 months later.


A 34-year-old male patient reported with a history of road traffic accident under the influence of alcohol. The chief complaint was restricted mouth opening, tenderness over temporomandibular joint, fractured upper central incisors, and intraoral swelling in submental region with extraoral laceration. The patient had no history of loss of consciousness, vomiting, seizure, convulsion, and ENT bleeding after trauma. On extraoral examination, laceration was seen on the lower lip and submental region and abrasion was seen on the tip of the nose and lateral border of the left eye and forehead. The extraocular muscle movements were normal and pupils were equally reacting to light which had a positive response. Complete examination of the body was done for any injuries and there were no positive findings.
On intraoral examination, the following were observed: Anterior open bite, restricted mouth opening (20 mm), tenderness while opening mouth over temporomandibular joint on both sides, condylar movement palpable on both sides, fractured maxillary incisor, swelling in the sublingual region, and root stumps in the posteriors. The patient was advised for computed tomography scan, orthopantomogram (OPG), and chest X-ray []. On radiological examination, OPG revealed extracapsular bilateral high condyle fracture with lateral displacement, dentoalveolar fracture in the lower anterior region, and maxillary central incisor. Under the guidance of the General Medicine Department, the chest X-ray revealed no abnormality.
The patient was informed and explained about the findings in the radiological examination and consequences if the fracture was not treated at the earliest. The patient was convinced for the full treatment of open reduction and internal fixation under general anesthesia and consent was taken. Before using the Risdon arch bar wiring, the patient was advised for blood investigation, the result was normal, and HIV and HbsAg were negative.
To treat dentoalveolar fracture and stabilization, Risdon arch bar wiring under local anesthesia is done. Routine preanesthetic evaluation was done and medication was administered. The patient was on nil per oral from 6 h before the surgery.
The right naso-endotracheal intubation was done and general anesthesia was administered. After extra- and intra-oral painting with povidone–iodine solution, preauricular incision was planned and surface marking was done using sterile toluidine blue on the right side. About 2% of xylocaine with adrenaline was infiltrated into the preauricular region, incision and dissection were made layer wise, and as exposing the fracture site, encountered vessels and nerve were identified and ligated. The fracture site was exposed, but there was difficulty in accessibility for reduction and fixation []. Hence, in addition, retromandibular approach was planned and executed []. Unlike the first approach, the fracture site was exposed and reduction was done. Considering the difficulties encountered for the right condyle reduction, retromandibular approach was planned for the left condylar fracture [] and executed by the same procedure. After the reduction of bilateral condyle, the occlusion was checked and using tie wires, intermaxillary fixation was done.
Fixation was done using conventional mini plates and screws made of stainless steel on both sides, respectively:
On the right condyle: 2 mm × 4 hole miniplate with gap and 2 mm × 2 hole miniplate with gap were placed and secured with 2 mm × 6 mm screws [] On the left condyle: 2 mm × 4 hole miniplate with gap was palced and secured with 2 mm × 6 mm screws [].
The occlusion was checked again and intermaxillary fixation wires were released. Meticulous wound closure was done in layers using 3’0’ vicryl and 3’0’ ethilon suture on the right preauricular incision and the right and left retromandibular incision. Beta-iodine was the ointment applied over the incised region and dressing was done with compression bandage on either side.
Extubation was done and recovery was uneventful. Postoperative instruction and medication were given and the patient was under observation for the next 3 days after surgery. Postoperative X-ray was advised after 2 days [] and checked for occlusion.


A 75-year-old pseudophakic female presented with 20/100 vision OD secondary to ME (CST 337 μm) due to exudation from a RAM (fig ). She was treated with IAI 2 mg/0.05 ml at baseline. CST and VA improved to 296 μm and 20/50 respectively at 1 month. Her VA continued to improve to 20/25 at 6 and 12 months without any further interventions. Color photos and IVFA at 1 year showed thrombosis of RAM (fig ) with normal blood flow through the affected artery (fig ) and resolution of ME on SD OCT (fig ).


A 68-year-old female presented with 20/40 vision and 390 μm CST OS due to ME from a RAM in the superotemporal artery (fig –c) and was treated with IAI 2 mg/0.05 ml. At 1 month, her VA improved to 20/20 with a dry macula (CST 250 μm), and was maintained throughout 2 years of follow-up without any further treatment. At 1 year, Color photos and FA showed fibrosis at the site of RAM along with hairpin-like remodeling of the affected artery with a dry macula on OCT (fig ).


A 91-year-old female presented with hand motions vision OS due to a large SMH, 31 mm2 size measured on color photos using OIS WinstationTM, version 11.2.1 (p) for Windows software (Merge Healthcare, Chicago, Ill., USA), and 1,478-μm thickness measured manually on transverse scan through the fovea on SD OCT from a ruptured RAM (fig ). As she was a poor surgical candidate due to her multiple medical problems including chronic congestive heart failure, she was treated with IAI 2 mg. At 1 year, color photos showed a fibrosed RAM but macular scar (fig ). Her VA was counting fingers.


A 78-year-old female presented with recurrent VH from a RAM causing her vision to decrease to 20/200 OS (fig ). She was previously treated with 4 intravitreal 1.25 mg/0.05 ml bevacizumab injections and one laser treatment over the past 3 years, the last treatment being IVB 10 months prior to current episode, for VH from the same RAM. A single IAI led to resolution of VH within 1 month with no recurrence. Color fundus photos at 1 year showed fibrosis of RAM with uninterrupted blood column in the artery (fig ).


A 12-year-old girl was admitted to emergency room with the history of involuntary contractions on her extremities and alteration of consciousness. The diagnosis of epilepsy and status epilepticus was made based on her clinical history at onset. The case was hospitalized to pediatric intensive care unit. Heart rate was 140 pulses/minute, her body temperature was 39.5°C, oxygen saturation was 99% and blood pressure was 120/60 mmHg. Her physical examination showed agitation, hyperthermia, dilated pupils, tremor, increased deep tendon reflexes, positive spontaneous clonus, agitation, flushed skin and diaphoresis, excessive perspiration, and continuous horizontal ocular movements. There were no meningeal irritation signs. We suspect the diagnosis of epilepsy and status epilepticus because of incompatible physical signs and symptoms. Detailed clinical history was retaken and physical examination was repeated. Repeated examination showed that nail biting and clues of self-injury behavior. We learned that she has been living with her stepmother and irregularly receiving risperidone for a week prescribed by psychiatry clinic. She had behavioral problems such as stealing money, lying, and escaping from home and school. She had taken nine pills of 75 mg clomipramine tablets for suicidal attempt, which were belonging to her stepmother, in one day. Her abnormal blood chemistry test results were high creatinine kinase and myoglobin levels (creatinine kinase 2,823 U/L [0–145 U/L]; myoglobin 112 ng/ml [0–7 ng/ml]). Urea, creatinine, Na, K, aspartate transaminase, alanine transaminase, complete blood count, prothrombin time, activated partial thromboplastin time, electroencephalography and brain computed tomography results were normal. The patient has diagnosed as SS. Clomipramine was discontinued, oral diazepam and intravenous hydration was started. Clinical symptoms of the patient disappeared in 24 hours. Two days later, creatinine kinase level regressed to 755 U/L and myoglobin level regressed to 15 ng/ml. The patient was consulted to child and adolescent psychiatry clinic as she had suicidal attempt and thoughts of self-injury. The patient’s physical examination and laboratory test results returned to the normal ranges four days later and she was discharged from the hospital under the supervision of child and adolescent psychiatry clinic.


A 62-year-old African American male with past medical history of chronic kidney disease stage 3, hepatitis C virus, hypertension, and gout. He presented to the Emergency Department with a complaint of skin rash which was limited to the extensor surfaces of the upper and lower extremities, he first noticed the rash 5 days before presentation. Two weeks before presentation the patient was started on allopurinol therapy for gout. He was taking a total dose of 1200 mg instead of 300 mg daily as he misunderstood his doctor's instruction. The patient's medications included aspirin, allopurinol, and metoprolol. Physical examination was remarkable for low grade, skin examination showed diffuse pruritic erythematous maculopapular papular with bullae limited to the extremities extensor surfaces [Figures and ]. Swelling and tenderness of the extremities was also noted. The rest of the physical examination including heart, lungs and abdomen was unremarkable. Labs showed worsening of preexisting renal failure, hemoglobin level of 9.5 g/dL, white blood cell count 11.7 × 103/µL (4.5 × 103 – 1.1 × 104/µL), 13.6% eosinophils (0–7.5%), aspartate aminotransferase 190 IU/L (15–41 IU/L) and alanine aminotransferase 167 IU/L (17–63 IU/L). Rheumatoid factor, antinuclear antibodies, and serum cryoglobulins were within normal limits. Skin biopsy showed nonspecific mild-to-moderate acute inflammation with scattered eosinophils.
Our patient had skin rash, eosinophilia, and renal impairment. Based on the history, laboratory values, and recent use of high doses of allopurinol; allopurinol-induced drug-induced rash with eosinophilia and systemic symptoms (DRESS) syndrome was diagnosed.


A 40-year-old vegetarian Hindu male presented with complaints of hyperpigmented macules predominantly over legs. He also had a history of fatigability, lethargy, and exertional breathlessness for 1 month. He denied muscle aches, abdominal pain, joint pain, fever, trauma, or blood loss from any site in the body. There was no history of chronic illness, drug intake, surgery, or bleeding disorder in his family. The vital parameters were stable. The conjunctiva was pale. There was no organomegaly and lymphadenopathy. Skin examination revealed multiple, diffuse, ecchymosed lesion scattered predominantly on the lower extremities [Figure –]. His hemogram showed hemoglobin of 9.7 g/dL, leukocytes 6120/mm[] (neutrophils 76.2%; lymphocytes 16%; monocytes 7.5%), platelets 169,000/mm[], mean corpuscular volume 87.8 fL, and mean corpuscular hemoglobin was 30.4 pg. The peripheral blood film (PBF) showed few normochromic macrocytoses, hypersegmented neutrophils, and thrombocytopenia. The Vitamin B12 level was 272 pg/mL (normal range 211–911 pg/mL), serum lactate dehydrogenase 1250 IU/L, and serum bilirubin was 2.43 mg/dL. The bone marrow aspiration revealed megaloblastic erythropoiesis []. The antinuclear antibody and Coombs test were negative. The coagulation profile and iron profile were within normal limit. Renal function tests, urinalysis, and electrolytes were within normal limit. Gastroscopy, electrocardiograph, ultrasonography of abdomen, and chest X-ray did not reveal any significant abnormality. He was treated with intramuscular hydroxocobalamin 1000 µg daily for 5 days, after that alternate day for a week, and thereafter weekly for 1 month. At the follow-up of 1 month, his hematological parameters were within normal limits and ecchymosis disappeared.


Female patient, 70 years old, was diagnosed with palmoplantar psoriasis in 2003. She
was treated with topical medications and oral methotrexate, with regression of
lesions. In 2012, she developed cutaneous symptoms with erythema and generalized
pustules, accompanied by systemic symptoms. She searched another dermatology
service, where she was diagnosed with acute generalized exanthematous pustulosis
(AGEP). She underwent corticotherapy by injection, in the pulse therapy scheme, and
then oral prednisone. There was improvement of clinical conditions, but, when she
was in the process of reducing the dose of prednisone, symptoms worsened. At that
moment, the dose of prednisone was increased to 80 mg/day, orally. However, during
the reduction of prednisone dosage, there was worsening of clinical manifestations,
then she decided to abandon treatment and search for another medical service. In
July of 2013, she was attended to in our premises presenting generalized erythema
and edema, followed by pustular lesions with some crusted areas (). Additionally, there was confluence of
pustular lesions, forming lakes of pus, mainly in the lower limbs (). There was also general involvement
with anorexia, nausea, malaise, shivering and burning sensation at the site of
lesions. Due to the seriousness of symptoms, hospitalization was indicated, with
intensive care. As for the laboratory tests, hemogram showed leukocytosis and
elevated erythrocyte sedimentation rate. Histopathological examination revealed
subcorneal spongiform pustule, acanthosis and exocytosis in neutrophils. In the
dermis, there was a mononuclear cell infiltrate and neutrophils (). The patient was treated with acitretin
orally at 30 mg / day and saw significant improvement of lesions, being discharged
21 days after hospitalization. She is still under care, using acitretin, with total
regression of lesions and with no relapses to this day – 16 months after
introduction of the oral retinoid ().


A 23-year-old female presented with dull pain in the left lumbar region and dysuria since 2 months. Ultrasonography revealed a cystic mass in the cortex of the upper part of the left kidney. Contrast-enhanced computed tomography showed a heterogeneously enhancing, well-defined, encapsulated multicystic lesion in the upper part of the left kidney: Left partial nephrectomy was performed. Grossly, the left partial nephrectomy along with cystic mass specimen measured 7.4 cm × 6.2 cm × 5.4 cm and included a small portion of the left kidney. The cut surface of the left kidney showed a well-circumscribed, well-encapsulated cystic growth measuring 6.5 cm × 5.2 cm × 4.8 cm situated in the cortex in the upper pole of the kidney. The cut surface of the growth was having multiloculated cystic spaces. Cystic spaces were of varying sizes with thin septa in between the cysts. The cysts were filled with pale yellow colored thin, gelatinous material []. Microscopic examination of the cystic growth revealed a complex cystic tumor comprising of variably sized noncommunicating cysts separated predominantly by thin septa []. Septa were lined by sheets and nests of tumor cells showing uniform, hyperchromatic nucleus, inconspicuous nucleoli (Fuhrman nuclear Grade 1), and abundant clear cytoplasm with distinct cell borders []. Mitotic figures were scarce. Lumen of the cysts contained eosinophilic secretions. Septa between the cysts contain cords and clusters of similar tumor cells. Adjacent renal parenchyma showed degenerative changes in the form of focal glomerular hyalinization and sclerosis, tubular casts, interstitial fibrosis, and chronic inflammatory cell infiltrate []. The histomorphology was compatible with MCRCC, Fuhrman nuclear Grade 1. Now, the patient is well without any recurrence.


A 50-year-old female complaining of dyspnea and bilateral upper limb numbness progressively worsening for the previous month was referred to the department of neurosurgery for further evaluation. She had been diagnosed with NF-1 about 20 years prior and had been recently diagnosed with left-sided breast cancer detected on Positron Emission Tomography (PET) scan. Histological investigations of the breast mass revealed the cancer to be invasive ductal carcinoma. There was no history of infection, trauma, or spinal surgery. On physical examination, diminished breath sounds were noted on the right. Also, there were widespread café-au-lait macules along with subcutaneous nodules and prominent bilateral freckling in the axillae (). On neurological examination, no focal deficits were appreciated except for the right upper extremity weakness, grade III/V. Chest radiography showed a large mass-like lesion on the right lung associated with significant scoliosis (). Computed tomography and magnetic resonance imaging of the lungs revealed a thin-walled, bilobulated, homogenous cystic mass extending from the second to eighth thoracic segments (). The right neural foramens of the fourth and fifth thoracic vertebrae were dilated, likely due to protrusion of the meninges via these foramens. There was also significant spinal cord compression at the fourth and fifth thoracic levels. A postero-laterally oriented intrathoracic meningocele was thus diagnosed. Scoliotic angle was calculated to be approximately 42 degrees by Cobb's method. Upper extremity weakness could not be explained by the thoracic mass, and so electromyography analysis was performed, revealing left brachial plexus injury. This injury was believed to be due to the left axillary mass, specifically lymph node metastasis from the breast cancer, as shown in a PET scan ().
Due to the large size of the mass and severe dyspnea, surgical removal and deformity correction surgeries were planned. Pedicle screws were first inserted on the left concave side of third to ninth thoracic vertebrae. The scoliosis curve was then corrected with a rod via the derotational technique, and pedicle screws were inserted on the right convex side at the third, seventh, eighth, and ninth thoracic vertebra (). The cystic mass was removed after performing total laminectomies and resection of the right T4 and T5 transverse processes, including removal of the proximal heads of the right fourth and fifth ribs (). As shown in the , two openings of the meningocele into the spinal cord through the intervertebral foramen were found, and cerebrospinal fluid (CSF) was drained from the meningocele. Since the origin of the mass was the ventro-lateral portion of the spinal cord, direct closure of the dura could not be performed easily. Therefore, closure was achieved using a subcutaneous fat graft. The surgery proceeded without any adverse events.
Chemotherapy was started two weeks after surgery, and the patient was followed for about 30 months post-operatively. However, the follow-up X-ray images () 15 months after the initial surgery showed recurrence of the meningocele in the upper lobe of the right lung and satisfactory correction state of kyphoscoliosis. Since there were no respiratory symptoms, conservative management was planned, and the patient was closely followed. After 30 months of close follow-up, the patient expired due to multiple metastases and systemic illness.


A 4-year-old girl who had been complaining of intermittent abdominal pain since 2 years prior presented with a right lower abdominal mass that had been palpable since 6 months prior. At the time of her visit to Seoul National University Children's Hospital, the patient had no abdominal or leg pain. On examination, she had no fever but a 5-cm pulsatile mass-like lesion was palpable on her right lower abdomen. The patient was born, weighing 3.3 kg, by vaginal delivery after 38 weeks and 1 day of gestation. No other abnormalities were found in the screening test. The patient, who had been healthy with no special medical history after birth, had a medical history of hand-foot-and-mouth disease 1 year earlier. She had also been hospitalized to receive pneumonia treatment 12 months after birth and 1 month before visiting our hospital. She had no medical history of abdominal injury. No evidence of inflammation or collagen vascular disease was found in the blood test, and all test results were within their normal ranges.
Abdominal ultrasonography revealed a 4.6 × 5.0-cm well-defined mass in the right lower quadrant, with large internal vascularity (). Abdominal CT revealed a 5.2 cm × 4.5 cm × 5.1 cm, right-sided, partially thrombosed, saccular, iliac artery aneurysm. The aneurysm could be observed at the aortic bifurcation level. The left iliac artery of the patient was normal. However, in the right iliac artery, a communication with the aneurysm, which was located at the level where the common iliac artery bifurcates into the internal and external iliac arteries, was confirmed with contrast enhancement during the CT (). The aneurysm was pushing the internal iliac artery to the medial side, and the external iliac artery could not be traced (). The right common femoral artery was found at the inguinal ligament level by joining of the deep circumflex iliac artery and inferior hypogastric artery, which were more prominent than those of the left side. The size of the right common femoral artery was equal compared to the left side femoral artery, and were located in the same anatomic position. Both iliac veins were normal.
The surgery started with a transverse incision in the right lower abdomen. We reached near the iliac artery by retroperitoneal approach. An encapsulated pulsatile mass measuring 5 cm × 5 cm × 5 cm was found strongly adhered to the right common iliac artery and the surrounding tissues, particularly with the ureter. It was pushing the ureter to the anterolateral side. As it was difficult to separate the mass from the surrounding tissues, we placed vascular clamps on the proximal right common iliac artery and the distal right internal iliac artery. Then, we made an incision in the middle of the mass in the direction of the blood circulation. Large blood clot was found inside of the mass. The inside of the mass was covered with intima. As the mass had a pinpoint fistula with the right internal iliac artery on its medial side, primary closure of the fistula was performed by using a Prolene 6-0 suture (). No leakage was observed when the vascular clamps were removed, and normal distal flow was confirmed by checking the dorsalis pedis pulse. All of the aneurysm, except the parts that were strongly adhered to the surrounding tissues, was removed.
A pathological examination confirmed that it was a true aneurysm, considering that all layers of the vascular wall were stretched with no deficit (). An intimal fibroplasia was confirmed (), and an organizing thrombus was accompanied by chronic inflammation (). Although myxoid degeneration was observed, we found no evidence of vasculitis. In addition, no bacteria were identified from the bacterial culture of the blood clot found from the aneurysm.
The patient was discharged 3 days after the surgery without any complication. Five months passed since the surgery, and the patient is doing well without any abdominal or leg pain.


A 48 year old male patient was referred to a private endodontic practice for evaluation and treatment of a maxillary left lateral incisor. He complained of pain on biting and palpation in the area. Medical history was non-contributory. In his dental history, he reported that the tooth had been treated non-surgically 12 months earlier. Clinical examination revealed moderate percussion sensitivity. Periodontal probing and mobility were within normal limits when compared to contralateral and adjacent teeth. The radiographic examination revealed periapical radiolucency 7 - 8 mm in diameter along the distal surface of the root, indicative of either an accessory canal or a possible apical fracture (). The radiograph also showed a titanium screw that was used for fixation of the membrane during a previous implant placement procedure performed two years before presentation. The tooth had porcelain fused to a metal crown with good margins and esthetics. On the basis of the history and clinical and radiographic examination, a diagnosis of a previous root canal treatment with symptomatic apical periodontitis was established. The patient was offered all treatment options; he opted for microsurgical retreatment. Written consent was obtained.
The micro-surgical technique, as suggested by Kim and Kratchman, was performed in addition to creation of a bony window osteotomy. After rinsing with 0.12% chlorhexidine solution (Peridex, Zila Pharmaceuticals Inc., Phoenix, AZ, USA) for 60 seconds, the patient was administered 2 carpules of 4% articaine with 1:100,000 epinephrine (3M ESPE, Seefeld, Germany) buccal and palatal infiltration. After ensuring profound anesthesia, a full thickness sulcular flap was elevated, with one release incision distal to the left canine. The exposed site was considered a candidate for the bony window osteotomy as the cortical plate was found to be intact. The osteotomy was performed using a piezoelectric device (Piezotome 2, Acteon Satelec, Acteon Germany GmbH, Mettmann, Germany). The BS5 Tip (Acteon Satelec, Acteon Germany GmbH) was used to make an outline on the exposed cortical plate based on the measurement made on the digital radiograph and the topography of the exposed bone. Two vertical and two horizontal grooves were joined to create a bony window of approximately 6 mm by 12 mm, at the recommended setting mode of 3 with 60 mL/minute irrigation of sterile saline (). The average width of the cut was approximately 1 mm. The carved bony window was lifted off with a curved osteotome (). The bone block was stored in Hanks Balanced Salt Solution (Life Technologies, Grand Island, NY, USA) in order to keep it hydrated. The granulation tissue at the surgically exposed site was removed by curettage with bone and curved periodontal curettes until healthy bone margins were encountered and the root tip was clearly visible. A biopsy sample was sent for histologic evaluation. The denuded root was stained with methylene blue and inspected under high magnification (×16) with a surgical operating microscope (Carl Zeiss OPMI Pico, Carl Zeiss, Oberkochen, Germany) for a vertical root fracture or perforation. Upon curettage, the root presented with a fracture line extending from the root tip to about 4 mm along the length on the distal surface. The fractured portion of the root was eliminated during apical resection with a high-speed carbide Lindemann surgical bur (Hu-Friedy, Chicago, IL, USA) at a zero degree bevel. The resected root surface was then stained again for inspection under high magnification (×16). The root-end preparation was achieved using ultrasonic surgical JetTips (B&L Biotech USA Inc., Fairfax, VA, USA), and the root-end cavity was filled with white mineral trioxide aggregate (MTA, ProRoot MTA, Dentsply Tulsa Dental, Tulsa, OK, USA) (). The bony window was repositioned (). Care was taken not to depress it into the osteotomy site but instead place it in alignment with the remaining bone in its original alignment. As the insert used with the piezoelectric to create the bone window was very thin, the bone flap was re-approximated firmly. 6-0 propylene nylon sutures (Supramid, S. Jackson Inc., Alexandria, VA, USA) were used for suturing the soft tissue. A postoperative radiograph was taken (). The patient was prescribed an oral analgesic (ibuprofen 600 mg) and instructed to rinse twice daily with a 0.2% chlorhexidine mouth rinse for 1 week. The sutures were removed 7 days after surgery.
The patient presented for follow-up at 9 () and 18 () months with radiographic signs of complete healing and no clinical signs or symptoms.


A 16 year old male patient with a history of dental trauma 4 years prior was referred for treatment of the maxillary right lateral incisor. Mild percussion and pain on palpation was observed during clinical examination. The radiographic examination revealed a previously treated root canal with an 8 - 9 mm periapical radiolucency, extending apically and along the distal surface of the incisor with signs of a disto-lateral resorptive defect at the mid-root (). On the basis of a history, clinical examination, and radiograph, a diagnosis of a previous root canal treatment with symptomatic apical periodontitis was established. The previous operator had restored the access with radiolucent flowable composite, the coronal portion of which was removed and light cure composite (Filtek Supreme XT, 3M ESPE, St Paul, MN, USA) was placed. In discussion with the patient, apicoectomy was selected as the treatment of choice. Upon flap elevation, as the cortical plate was found to be intact, the surgical procedure as described above was implemented (). The bone window measured about 9 mm horizontally and 18 mm vertically. The lesion in this case was found to have a cyst-like appearance, which was confirmed by histopathological evaluation of the biopsy sample sent to the laboratory. Other than the apical root-end preparation, the lateral perforation was also exposed after curettage. Both areas were carefully prepared with JetTips ultrasonic tips (B&L Biotech USA Inc.) and sealed with white MTA (ProRoot MTA, Dentsply Tulsa Dental) (, ). Upon completion of the microsurgery, the bone flap was replaced and held in position with some CollaCote collagen material (Zimmer Dental, Carlsbad, CA, USA), as there was a break seen along the approximated bone margins (). The flap was sutured with 6-0 propylene nylon sutures (Supramid, S. Jackson Inc.) and the surgical procedure was completed. The patient presented for follow-up at 12 months with radiographic signs of complete healing and no clinical signs or symptoms ().


A 33-year-old pregnant woman, G3P2, at 39 weeks of pregnancy, without a history of hypertension, was admitted to the hospital because of vomiting and dyspnoea. The diagnosis at the referring hospital was threatened premature labour. The patient had a caesarean operation before and had few antenatal tests during this gestation. So, the patient had an emergency caesarean operation.
On the second day, the patient had hyperpyrexia, dyspnoea, convulsion, and muscle weakness. Her temperature increased to 40.2 °C, her heart rate was 160 beats per minute in sinus rhythm, and her respiratory rate was 28 times per minute. The blood pressure of the patient exhibited paroxysmal hypertension and hypotension. She demonstrated grade 2 muscle strength in her limbs. Based on the clinical presentation, we suspected that the patient was suffering from pheochromocytoma crisis and proceeded with an abdominal computed tomography scan, which revealed bilateral adrenal gland tumours.
The tumour on the right was 30.28 × 32.81 mm in size, and the left one was 21.20 × 23.41 mm (Figure
A). Blood analysis showed extremely elevated creatine kinase (CK: 3334 U/L, CK-MB: 24 U/L), cardiac Troponin I (cTnI: 9.94 µg/L), and serum creatinine levels (118 µmol/L). Meanwhile, thyroid function was assessed. The serum thyroxine level was 69.28 nmol/L (reference range: 78.38–157.4 nmol/L). The concentration of thyroid stimulating hormone was 1.59 mIU/L (reference range: 0.34–5.60 mIU/L). The concentration of freeT3 was 2.0 pmol/L (reference range: 3.8–6.0 pmol/L); the concentration of freeT4 was 12.8 pmol/L (reference range: 7.86–14.41 pmol/L). The electrocardiogram showed sinus tachycardia with ST segment depression and T wave inversion in leads V1–V6 (Figure
B). Echocardiography showed global hypokinesis of left ventricular (LV) wall motion (the LV end-diastolic diameter was 53 mm, and the LV ejection fraction was 25%) and mild mitral valve regurgitation.
On the second and third hospital days, the patient's condition was getting worse in spite of continuous infusion of phentolamine and esmolol, ultimately resulting in altered mental status, frequent convulsions, and haemodynamic collapse. Her muscle strength was now grade 0. Creatine kinase levels increased tremendously to over 70 000 U/L, while CK-MB levels increased to 1200 U/L. Her fever was not controlled despite the use of powerful antibiotics. Furthermore, her renal function progressively deteriorated (serum creatinine: 225 µmol/L) and manifested as oliguria. Laboratory tests showed a plasma adrenaline level of 5.8 ng/mL (upper limit of normal is 0.28 ng/mL) and a plasma noradrenaline level of 32.7 ng/mL (upper limit of normal is 1.7 ng/mL).
Continuous renal replacement therapy was started on the fifth hospital day. It was surprising that the temperature of the patient decreased, the heart rate declined, and the haemodynamics stabilized (Figure
A). Blood analysis showed that CK and CK-MB levels rapidly declined to normal (Figure
B). Plasma catecholamine concentration also showed a similar trend (Figure
A). To confirm the effect of dialysis on plasma catecholamines, we examined the catecholamine concentration in the dialysate. Concentrations of adrenaline and noradrenaline in the dialysate were 11.2 and 1.2 ng/mL, respectively, confirming the removal of these catecholamines by dialysis. Following 7 days of CRRT, her muscle strength recovered from grade 0 to grade 5, and her 24-h urine output also returned to normal. On the 12th hospital day, we performed a muscle biopsy of the right bicep muscle, which revealed deranged myofibrils, increased mitochondrial number, and damaged mitochondria (Figure ). Echocardiography showed a recovery in cardiac function with a LV eject fraction of 54.4% (Figure
B).
As a result, the patient was rescued from the pheochromocytoma crisis and underwent bilateral adrenalectomy. Pathological assessment confirmed the presence of pheochromocytoma with haemorrhagic and necrotic cysts. Informed consent was obtained from the patient.


The present case report is about a 33-year-old full-term pregnant woman, a known case of Type I diabetes mellitus who was admitted in obstetrics ward. The patient underwent cesarean section. A female baby was delivered uneventfully. Intraoperatively, surgeons found right-sided ovarian mass. Suspecting it to be an ovarian neoplasm, unilateral oophorectomy was performed. The specimen was submitted for histopathological examination in 10% formalin.
Macroscopic examination showed an enlarged ovary measuring 6 cm × 5 cm × 3.5 cm. Cut surface of the ovary was circumscribed, soft, fleshy, and gray-brown []. Microscopically, sections from right ovarian mass revealed a lesion composed of diffuse masses of cells arranged in sheets, nests, and cords []. The cells were polygonal in shape and had abundant amount of finely granular eosinophilic cytoplasm. Nuclei were small, round, vesicular with prominent nucleoli. Occasional mitotic figures, areas of necrosis, and focal areas of hemorrhage were noted. Based on the clinical and histopathological findings, a diagnosis of pregnancy luteoma was made. Reinke crystals were not found in the sections studied; therefore, Leydig cell tumor and steroid cell tumor were ruled out and final diagnosis of pregnancy luteoma was made.


A-59-year-old male presented with headache after traumatic brain injury (TBI). He had hit his head on the corner of a desk and had lost his consciousness a few seconds an hour before. He did not complain of pain in other parts of his body except for his headache. On neurological examination, Glasgow Coma Scale was 15 and no motor or sensory changes were found. He had had a history of TBI and had undergone bilateral craniotomy and removal of epidural hematoma (EDH) 5 years prior. He had no previous medical problems and took no medication. A brain computed tomography (CT) scan revealed EDH in the right frontal lobe and traumatic SAH in the ambient cistern (). Due to his stable clinical condition, no immediate surgical treatment was planned. Instead, he was admitted for close monitoring of his neurological status.
Two days after TBI, he complained of pain and numbness in the bilateral buttock and posterior thigh. A lumbar spine plain radiograph showed no fracture or dislocation. His pain and numbness progressively worsened. On the next day, he could not sit or stand due to severe pain and numbness. Perianal numbness and voiding difficulty began. A Foley catheter was placed and 500 cc of urine was drained. On neurological examination, motor weakness in the lower extremities was not evident. A follow-up brain CT scan showed a slight decrease in the thickness of EDH, and SAH was much resolved (). Lumbar spine magnetic resonance imaging (MRI) revealed a fusiform lesion within the dorsal part of the spinal canal at the L5 and S1 level. The cauda equina was compressed and displaced laterally. The lesion had low signal intensity in the T2-weighted image (WI) and iso-signal intensity in the T1-WI, suggestive of acute hemorrhage (). Contrast enhancement images showed no abnormally enhanced lesion.
A diagnosis of cauda equina syndrome due to intraspinal hemorrhage was made and emergent operation was performed. After a partial laminectomy of S1, the dural sac was exposed and no EDH was found. The dural sac was tense on palpation. When opening the dura, SDH was not found. On incision of the arachnoid membrane, dark reddish fluid gushed out with high pressure. No blood clot and no definite bleeding point were found. The pain and numbness disappeared immediately after the surgery. He had gradual improvement in his voiding function. At his 1-year-follow-up, he had no subjective discomfort in his voiding function.


A 23-year-old male presented with complaint of cough with purulent expectoration, breathlessness on exertion, history of wheezing sound coming from chest, and low-grade fever of 3 weeks' duration. There was no previous history of such episodes or any other significant illness in the past. On admission, his vital signs were: Pulse rate 62 beats/min, blood pressure 128/72 mmHg, respiratory rate 24 breaths/min, and body temperature 36.5°C. Systemic examination showed bilateral expiratory wheeze on lung field auscultation. Routine laboratory tests revealed eosinophilia (57.5%) with absolute eosinophil count (AEC) of 7180/cu mm. The erythrocyte sedimentation rate was 10 mm fall in the first hour. A sputum smear for acid-fast bacilli (AFB) and protozoa was negative. Sputum culture did not grow any organism. Peripheral blood smear showed no evidence of microfilarial parasite. Viral markers including human immunodeficiency virus (HIV), hepatitis B virus surface antigen (HBsAg), and hepatitis C antibody (anti-HCV) test were negative. Chest X-ray [] and noncontrast computed tomography (CT) of chest were normal. Spirometry was normal. Fiberoptic bronchoscopy and bronchoalveolar lavage (BAL) were done for evaluation of eosinophilia with respiratory symptoms. Bronchoscopy showed congestion of the left lower bronchus with mucoid secretion. Microscopic examination of wet mount of BAL revealed actively motile flagellates with polar tuft of flagella lashing rhythmically [], identified as L. blattarum [Figures and ]. Oral metronidazole 400 mg thrice daily was given for 2 weeks. Steady improvement in the patient's condition was noted, with him becoming asymptomatic and the normalization of peripheral eosinophilia after 2 weeks of treatment.


A 76-year-old man presented to our hospital with a feeling of abdominal fullness and poor appetite for approximately 1 month; he had lost 7 kg, a 10% weight loss relative to his initial weight. Of note, he had a medical history of myocardial infarction. During a regular checkup at the cardiovascular medicine department at our hospital, a computed tomography (CT) scan of the abdominal region revealed a giant, solid mass occupying the epigastrium. He was introduced to our department. An irregular-shaped solid mass with elastic hardness, of the size of an infant's head, was palpated in the epigastrium. No pain or tenderness was noted. Blood test results after admission indicated mild normocytic and normochromic anemia (hemoglobin, 11.3 g/dl) and elevated inflammatory response (C-reactive protein, 10 mg/dl; table ). Contrast-enhanced abdominal CT revealed a giant, solid mass with a diameter of 23 cm occupying the epigastrium, and the gastric corpus was markedly displaced to the left. In the arterial phase, an aneurysm formed within the tumor and the contrast agent was pooling. The left gastric artery had also developed as the feeding vessel. Gallstones were detected; otherwise, no obvious metastatic lesions in other organs were seen. Abdominal contrast magnetic resonance imaging showed an irregularly shaped tumor with hypoechoic signals on T1 images, and mixed areas of high and low intensity were noted on T2 images in the epigastrium. The tumor had dominant borders, with a poorly enhanced area in the center, indicating internal necrosis. Much of the tumor was in contact with the liver, which was being excluded. However, it was clearly demarcated, with regular borders and no apparent invasion (fig. ). Extramural growth from the posterior wall of the middle stomach to the pyloric region was seen during esophagogastroduodenoscopy (EGD). Passage from the stomach to the duodenum was possible.
Based on these findings, the diagnosis of a giant gastric submucosal tumor with extramural growth was established. Despite blood transfusions, anemia progressed.
Surgical findings indicated that a tumor had developed from the lesser curvature side of the stomach. It adhered to the transverse mesocolon, liver, and gallbladder; however, no invasion and metastatic lesions were detected. Therefore, distal gastrectomy and Roux-en-Y reconstruction were performed. Cholecystectomy was also performed for the gallstones. Macroscopic findings of the resected specimen showed a giant tumor of 23 × 20 × 13 cm on the gastric serosal side. Most of the tumor was covered in a capsule, but the capsule had broken in some places and parenchyma was disintegrating. The removed mass was pale pink, solid, and clearly demarcated. Severe bleeding necrosis was observed (fig. ).
Histopathological findings indicated that tumor cells were spindle shaped and oval nuclei exhibited tight, intricate hyperplasia in bundles below muscularis propria of the stomach. Karyokinesis count was 7–8/HPF (400 × 10 field mean value). On immunohistochemistry, the tumor cells were indicated to be CD117 (C-kit)(+), CD34(+), S-100(–), α-SMA (α-smooth muscle actin)(–), and desmin(–) (fig. ). The Ki67 positivity rate was approximately 40%. No metastatic lesions were noted in the greater omentum. Thus, a diagnosis of classical GIST was made, and the tumor was classified into the high-risk group due to the high karyokinesis count and larger diameter.
Imatinib (300 mg/day) was initiated as adjuvant therapy on post-operative day 84.


A 48-year-old male suffered a fourth-degree burn injury by a heated press on the middle phalanx of the left middle and ring fingers. After radical debridement, flap reconstruction was required for defects with tendon and bone exposure. An anterolateral thigh fascial free flap measuring 5 cm×10 cm was elevated and inset as a bridged shape to cover the middle and ring fingers simultaneously. The perforator of the flap was anastomosed end-to-end to the radial proper digital artery of the middle finger and one vena comitans to the subcutaneous vein. After 3 weeks, a split-thickness skin graft was applied, and division was performed 2 months later. Eight years later, his middle finger showed 189% relative thickness, and his ring finger showed a relative thickness of 112%. The final contour was natural and he reported the highest satisfaction score of all patients (84%). A slight extension lag remained but the overall range of motion was satisfactory ().


A 49-year-old female sustained complete amputation of the left index, middle, and ring fingers by a rotary blade. The amputation levels were at the base of the proximal phalanx for the index and middle finger and at the proximal interphalangeal joint for the ring finger. Severe accompanying crushing injuries were observed throughout the amputated digits, thumb, and involved dorsal hand. The largest segment of the sliced digits was replanted to the middle finger to facilitate later pinching motions, and composite grafts were performed. However, tissue necrosis occurred at the tip and dorsum of the middle finger and hand dorsum. Following debridement, a lateral arm fascial free flap measuring 3 cm×8 cm was elevated, including a 1-cm×2-cm skin paddle for the fingertip. The perforator of the flap was anastomosed end-to-end to the radial artery at the snuffbox and one vena comitans to the subcutaneous vein. After 3 weeks, she underwent a split-thickness skin graft. Her postoperative recovery was uneventful, and at follow-up 3 years and 2 months later, the reconstructed tissue showed a relative thickness of 167%. However, her satisfaction score was the lowest of all patients (25%) ().


A 65-year-old female patient presented in January 2013 with unstable angina. Coronary angiography showed a severely calcified long lesion of the proximal and mid segments of the left anterior descending coronary artery [Video S1 (please see enhanced content link on title page)]. In view of the angiographic findings, a decision was taken to do a planned rotational atherectomy (RA), which was performed with the Rotablator™ (Boston Scientific) using 1.5 then 1.75 mm burr sizes, followed by implantation of two overlapping 3.0 × 28 mm bioresorbable scaffolds (BRS) (Absorb™, Abbott). Post-dilatation was done using a 3.0 mm non-compliant balloon at 20 atm. Intravascular ultrasound (IVUS) showed a good result with a minimal overlapping zone (Fig. ). A coronary angiography done 10 months later due to recurrent angina revealed a significant restenosis of the implanted BRS. Optical coherence tomography (OCT) showed a diffuse homogeneous intra-scaffold neointimal tissue with a minimum luminal area of 1.59 mm2 at the distal BRS and 1.98 mm2 at the proximal one (Fig. ). A scoring balloon angioplasty using a 3.0 × 10 mm AngioSculpt™ scoring balloon (AngioScore) was performed followed by 3.5 × 20 and 3.0 × 20 mm Pantera Lux™ (Biotronik) paclitaxel eluting balloons (DEB) in the proximal and distal scaffolds, respectively. OCT clearly showed the neointimal cuts achieved by the scoring elements (white arrowheads, Fig. ), neointimal disruption with some intraluminal material (yellow arrowheads, Fig. ) and lumen expansion. At 2 years after balloon angioplasty (almost 3 years after BRS implantation), the patient remained asymptomatic and a scheduled angiographic control showed a patent vessel with no significant lesions. OCT showed favorable evolution of the neointimal damage caused by the scoring balloon and maintenance of the initial lumen expansion, with partial resorption of the scaffold struts for which footprints were still visible (Fig. ).
Informed consent was obtained from the patient for being included in the study.


A 50-year-old male came to the emergency room of our hospital and stated that a hand-made silicon rod had accidentally passed into his rectum 12 h prior to presentation. He could not remove it on his own. His vital signs were stable, and a physical examination showed that his abdomen was soft and without tenderness. There was a palpable elastic, hard mass in the lower abdomen and no signs of peritonitis. A digital rectal examination by palpation located the end of the foreign body in the deep rectum. An attempt to manually remove it in a transanal manner failed due to its shape, large size, and deep position. Laboratory data were essentially normal, with the exception of slightly elevated C-reactive protein (1.76 mg/dL). Plain abdominal X-ray imaging showed a foreign body in the pelvic area and absence of free air (Fig ), while computed tomography (CT) revealed an 18 × 4 cm foreign body with a cylindrical shape in the rectum (Fig ). No severe complications, such as perforation or obstruction, were seen. We decided to attempt removal in a transanal manner under endoscopic and X-ray fluoroscopic observation.
Following intravenous administration of 15 mg of pentazocine, a scope (PCF-Q260AZI; Olympus, Japan) was inserted transanally with the patient in a left lateral decubitus position to directly visualize the foreign body. The lateral pelvic view obtained by X-ray fluoroscopy showed the foreign body in the rectosigmoid position. We attempted removal with endoscopic instruments, including a snare, biopsy forceps, grasping forceps, and net, though that failed because of the round shape and large diameter. When manually compressed from the abdominal wall under endoscopic and X-ray fluoroscopic observation, we noticed that the axis of the foreign body changed (Fig ). Thus, we were able to guide it using manual abdominal compression with endoscopic and X-ray fluoroscopic assistance. Once the object moved to the lower rectum, it could be removed transanally by manual extraction. After removal, we found that the foreign body was constructed of a silicon material and made by the patient himself, with a size of 18 × 4 cm (Fig ). Sigmoidoscopy following extraction showed mild erosion in the rectal mucosa with no findings of bleeding or perforation. The patient was released without hospitalization or surgery.


A 66-year-old woman was admitted to our hospital for scheduled resection of a right parasagittal brain lesion. She had a history of epileptic seizures and anti-phospholipid syndrome related to a non-Hodgkin lymphoma in remission. The patient underwent brain MRI, 1H-MRS and brain SPECT as part of a protocol which was based on the collaboration of the Departments of Medical Physics, Radiology and Neurosurgery aiming to study the combination of brain SPECT and MRI advanced techniques in the amelioration of brain tumor diagnosis. A 3-Tesla MRI scanner (GE, Healthcare, Signa® HDx) was used. 1H-MRS study was feasible through two different spectroscopy imaging protocols: proton brain exam (PROBE) single voxel (SV) and two-dimensional multivoxel (2D chemical shift imaging (CSI)) spectroscopy. The used sequence was point-resolved spectroscopy (PRESS) pulse with phase encoding gradients towards two directions, automatic and manual shimming and Gaussian water suppression. A single voxel with a volume less than 3.4 mL was cautiously obtained from the tumor area away from the tumor margins by applying measurements of 1,500/35 m/s (TR/TE) and using 128 signal acquisitions (Nacq). 2D CSI technique was applied to the measurements of 1,000/144 m/s (TR/TE) by using 16 × 16 phase encoding steps, with a thickness of 10 mm based on the patient’s intracranial topography. The duration of spectroscopy in both imaging protocols did not exceed the 4 - 5 min. Besides the tumor area, spectroscopic images were obtained also from the healthy brain tissue (). The localization of the desirable voxel area was retrospectively feasible through sagittal, axial and coronal images with T1-weighted FSE, T2-weighted FLAIR and T2-weighted imaging sequences. Contrast agent was used after the completion of the spectroscopy for the optimization of our surgical planning as these images were intergrated to our neuronavigation system.
The brain SPECT was performed 20 - 30 min after intravenous injection of 925MBq (25mCi) tracer activity. The MyoviewTM (General Electric Healthcare Ltd) was used for the preparation of the radiopharmaceutical which reconstituted with Tc-99m pertechnetate (99mTcO4-) sterile solution in the Department of Nuclear Medicine. The processing and fusion of the obtained images was performed through the Xeleris Workstation (GE Healthcare).
According to conventional MRI examination, an enhancing right parasagittal brain lesion with significant edema was recognized. MRS examination raised the suspicion of glioma based on the metabolic profile at the center of the tumor which indicated high ratio of choline to N-acetylaspartate (Chol/NAA) (, ). The SPECT examination indicated intense and homogenous uptake of the radiopharmaceutical, with notably high standardized uptake value (SUV), supporting the diagnosis of meningioma (). The patient underwent a right fronto-parietal craniotomy and her tumor was completely resected. The histopathological analysis of our specimen indicated the diagnosis of a meningioma grade I (, ). The patient had an uneventful postoperative course and at her last follow-up she is tumor free.


A 33-year-old pregnant woman at 37 gestational weeks with a history of major heart surgery was admitted to our institution and scheduled an elective CS. She had been diagnosed with a complex congenital heart defect characterized by dextrocardia, a criss-cross valvular defect (under-over type) with transposition of the great vessel, a hypoplastic right ventricle, an atrial septal defect, and a ventricular septal defect. At 27 years of age, she had undergone Glenn surgery to allow blood to be routed directly from the superior vena cava to the lungs through phasic flow in the pulmonary artery (bidirectional Glenn shunt). Later, it was recommended that she undergo additional surgery to allow deoxygenated blood returning from the lower part of the body to be diverted directly to the pulmonary circulation (Fontan approach); however, she refused any further procedure.
On admission to the obstetric ward, she was 160 cm tall and weighed 85 kg (body mass index = 33.2 kg/m2). A physical examination revealed a good general condition, eupnoea in both the standing and lying positions, a continuous 4/6 heart murmur on both sides of the sternum, no pathological sounds on chest auscultation, digital clubbing, and nail bed cyanosis. Her vital signs were as follows: blood pressure, 135/80 mmHg; heart rate, 65 beats/min; respiratory rate, 15 breaths/min; and oxygen saturation (SaO2), 80% to 85% with a 5% increase after administration of 100% oxygen via face mask at 4 L/min. Oral acetylsalicylic acid (100 mg), subcutaneous enoxaparin (4,000 IU; last dose 16 hours before CS), and antenatal vitamins had been administered since early pregnancy. A preoperative electrocardiogram (ECG) and transthoracic echocardiogram showed sinus rhythm without signs of ischemia, an ejection fraction of 60%, dysplasia and severe stenosis of the pulmonary valve, mild left atrio-ventricular valve regurgitation, and mild aortic regurgitation. Her hemoglobin (Hb) level was 12.0 g/dl (hematocrit = 36%). The patient was classified as New York Heart Association Functional Class II.
The day after admission, she underwent an urgent CS due to pathological cardiotocography (type 2 urgency according to Lucas' classification []). The cardiosurgery team was alerted to perform extracorporeal membrane oxygenation if necessary. Upon completion of monitoring (invasive blood pressure, ECG, and SpO2) in the operating room, 1,000 ml of crystalloid was administered over 10 min, and combined spinal-epidural anesthesia using the needle-through-needle technique was performed with the patient in a sitting position. Hyperbaric bupivacaine (0.5%) 5 mg and sufentanil 10 µg were injected intrathecally at the L3–L4 interspace. An epidural catheter was positioned in the epidural space, and a 3-ml test dose of 2% lidocaine with 5 µg/ml epinephrine (1 : 200,000) was used to exclude an intravascular or subarachnoid injection. The patient was then placed in the supine position with left uterine displacement, and supplemental oxygen was provided via face mask (FIO2 = 1).
The sensory block rapidly reached the T10 level without significant effects on hemodynamics. Epidural 2% lidocaine with 1 : 200,000 epinephrine was administered at a rate of 5 ml every 5 min and titrated up to the T4 level (15 ml in 15 min). The CS was performed uneventfully. A healthy male newborn was delivered with Apgar scores of 9 and 9 at 1 and 5 min, respectively. Hemodynamic parameters remained stable throughout surgery. The extraction maneuver, blood loss (estimated 300 ml), and oxytocin infusion did not reduce the blood pressure to >15% of baseline. The patient was monitored postoperatively in the coronary care unit for the next 24 hours. Postoperative analgesia involving 10 ml of 0.2% ropivacaine and 2.5 mg of morphine via the epidural catheter, and 1 g of acetaminophen four times daily was delivered. The postoperative period was uneventful with no need for transfusion (Hb > 11 g/dl) or vasoactive drugs. Adequate volume was maintained with a crystalloid infusion of 1,500 ml per 24 hours and free early oral feeding. An ECG and echocardiogram performed on postoperative days 1 and 2 showed no difference from the preoperative results.


A 79-year-old man with hypertension and psoriasis was hospitalized for severe sepsis associated with a generalized and painful erythematous rash. He had been diagnosed with psoriasis affecting <1% body surface area (BSA) three months before this presentation and was treated with topical ketoconazole and fluocinolone. Two weeks before hospitalization, he received a five day oral prednisone taper prescribed by a family physician for skin rash. Following this, he developed a confluent, erythematous, scaling rash covering >50% BSA. Methotrexate was started for presumed psoriatic erythroderma; however, his symptoms worsened to include progressive skin involvement, fever, and hypotension which led to hospitalization. Physical exam revealed tender erythematous plaque with scale from head to toe, most prominently involving the head, neck, chest, back, upper arms, abdomen, buttocks, groin, and proximal thighs (). Laboratory evaluation was remarkable for leukocytosis of 23.8×103/µL and pre-renalazotemia. Intravenous fluids, empiric antibiotics, topical steroids, and emollient moisturizer were started. Infectious work-up was negative; yet fevers, leukocytosis, and cutaneous pain symptoms persisted. Dermatology performed a punch biopsy which demonstrated evolving pustular psoriasis (). Apremilast was started for treatment of erythrodermic psoriasis. The patient’s rash and systemic features began to improve by day 10. Though BSA involvement was essentially unchanged, psoriasis plaques demonstrated reduced erythema and scaling with marked improvement in cutaneous pain symptoms (). As a result, Psoriasis Area and Severity Index score improved from 44.0 on admission to 26.4 after initiating apremilast treatment. However, the patient subsequently developed new-onset atrial fibrillation attributed to apremilast which was discontinued and switched to cyclosporine. The patient continued to improve and was discharged on cyclosporine.


A 52-year-old female experienced right knee joint pain when going up and down stairs one month prior to her presentation to a clinic. Examination by a local doctor and magnetic resonance imaging (MRI) resulted in a diagnosis of lateral meniscus injury. She was treated conservatively for 2 months, but the pain was not alleviated, and her left knee joint also became painful so she was referred to our hospital immediately. Examination at our department showed a restriction in knee joint range of motion (ROM), with right knee extension −15° and flexion 125° and left knee extension −10° and flexion 135°. Tenderness was present in the lateral femorotibial joint spaces of both knees, and clicking was palpated during flexion. The McMurray test also revealed lateral pain and clicking in both knees. There were no indirect signs of discoid lateral meniscus such as lateral joint space widening, squaring of the lateral femoral condyle, high fibular head, or hypoplasia of the lateral tibial plateau in plain radiographs (). Full-length frontal plain radiographs of the legs showed hypoplasia of the femoral lateral condyle and varus deformity of the articular surface of the proximal tibia. The femorotibial angle was 176° on the right side and 177° on the left side. The mechanical lateral distal femoral angle was 83° on the right side and 80° on the left side. The medial proximal tibial angle was 80° on the right side and 77° on the left side. Both Mikulicz lines were slightly displaced inwardly (). T2-weighted MRI showed that the medial menisci in both knees were incomplete discoid menisci, and there was high intensity in the posterior section. T2-weighted MRI of the lateral menisci in both knees showed complete discoid menisci and a horizontal high intensity area (). She underwent surgery immediately. Arthroscopy revealed that the lateral menisci of both knees were complete discoid menisci. Based on these findings, the patient underwent partial meniscectomy, leaving margins of about 6 mm. There was a horizontal tear from the anterior to the posterior section. The medial menisci were incomplete discoid menisci, but there were no findings of abnormal mobility or injury; therefore, and the medial menisci were observed without treatment (). At six months postoperatively, her pain and ROM restrictions disappeared. MRI showed no obvious changes in the medial menisci. One year and seven months postoperatively, she experienced no recurrence of pain or hydrarthrosis, and plain X-rays showed lateral femorotibial joint space narrowing ().


A 5 month-old Japanese male was hospitalized because of 5-days' high fever, erythema of the trunk, and conjunctival hyperemia. On admission, he had redness of lip, and swelling of feet and hands. The previously healthy boy was born to healthy parents having unremarkable family history. He received BCG vaccination intradermally at the left upper limb one week before the onset of KD. Complete blood counts showed leukocytes 22.2 × 109 /L, hemoglobin 11.1 g/dL, and platelets 416 × 109 /L. Blood chemistries revealed increased levels of C-reactive protein (CRP) (1.31 mg/dL, reference range [rr]: 0.01–0.14), and normal levels of aspartate transaminase (AST) 31 U/L (rr: 13–33), alanine transaminase (ALT) 15 U/L (rr: 8–42), albumin 4.2 g/dL (rr: 3.7–5.2), and sodium138 mmol/L (rr: 135–148). Under the diagnosis of KD, IVIG (2 g/kg) and aspirin (30 mg/kg, p.o.) were started on the 5th day of illness. The treatment led to the defervescence promptly, and sheet-like desquamation on the 9th day, respectively. On the day 25, small papules in the face and trunks, along with redness and crust formation at the inoculation site of BCG were observed (). Skin biopsy revealed infiltration of inflammatory cells, ulceration, and crust formation without granuloma and leukocytoclastic vasculitis (). Both bacteriological examination from skin lesions and interferon-γ release assay (IGRA) against Mycobacterium tuberculosis were negative. These results suggested that he had papulonecrotic tuberculid associated with BCG inoculation. The skin lesions disappeared without antibiotic therapy over 2 months. His nails became whitish, and were peeled off 45 d after KD onset (). These manifestations completely resoluted 73 d after the onset of KD. He is alive and well without CAL one year after the hospital discharge.


A 5 month-old Japanese male was hospitalized because of fever, redness at the BCG inoculation site, and redness of the lips. The previously healthy boy was born to healthy parents having unremarkable family history. He received BCG vaccination intradermally at the left upper limb before 6 weeks of the KD onset. On admission, he showed neither redness nor ulceration at BCG inoculation site. Complete blood counts showed leukocytes 14.4 × 109 /L, hemoglobin 10.4 g/dL, and platelets 274 × 109 /L. Blood chemistries revealed increased levels of AST 298 U/L (rr: 12–34) and ALT 61 U/L (rr: 5–43), CRP (18.14 mg/dL, rr: 0.01–0.14), and procalcitonin (1.58 ng/mL, rr: 0.00–0.10), low levels of sodium (132 mmol/L, rr: 137–147). On the day 4th of illness, he had conjunctival hyperemia, erythema of the trunk of the body, and swelling of feet and hands. Under the diagnosis of KD, IVIG (2 g/kg) and oral aspirin (30 mg/kg) were started on the 5th day of illness, but not led to the defervescence. Repeated IVIG on the 7th day of illness led to the complete resolution of KD symptoms. On the 10th day of KD, erythema in bilateral cheeks and blood clot and crust formation at the inoculation site of BCG were observed (). Skin biopsy revealed infiltration of inflammatory cells, acanthosis, and epithelioid granuloma without caseous necrosis (). Both bacteriological examination from skin lesions and IGRA were negative. These results suggested that he had lichen scrofulosorum. The skin lesions were gradually disappeared without administration of antibiotics over 2 months. His nails changed during tuberculid (). He is alive and well without CAL one year after the hospital discharge.


A 21-year-old male complained of forwardly placed lower front teeth and difficulty in chewing. There was no associated medical history, and his younger brother (16-year-old) had a similar facial trait, but treatment of the sibling was delayed till completion of growth. Clinical assessment revealed an apparently bilaterally symmetrical face, dolichofacial pattern, concave profile with anterior divergence, prognathic lower jaw, and incompetent lips with protrusive lower lip. Intraoral examination showed a complete anterior crossbite with 2 mm reverse overjet and overbite, Class III molar relation, retained maxillary right deciduous canine, and palatally erupted permanent canine. Orthopantomogram showed all permanent teeth present along with retained deciduous canine and erupting maxillary third molars. Lateral cephalometric evaluation indicated a severe skeletal Class III malocclusion with a sagittal discrepancy of 11 mm which means a single-jaw surgery would be insufficient, average vertical growth pattern, large mandibular corpus length with dentoalveolar compensations showing proclination of maxillary incisors, and retroclination of mandibular incisors []. Temporomandibular joint scintigraphy with Tc-99 showed no hot spots bilaterally, indicating cessation of active growth. After confirmation of candidature for orthognathic surgery, pretreatment “test visual treatment objective (VTO)” was performed. Tracing paper was placed over the original tracing, and dentoalveolar decompensation was traced which created a reverse overjet of 7 mm; then VTO of maxillary advancement was traced followed by that of mandibular setback. The VTO after surgery had normal inclination of incisors, normal basal jaw relationship, and Class II molar relation [].
The objectives of treatment were:
Correction of crossbite and palatally displaced canine Surgical correction of skeletal jaw malrelationship Correct profile and lip incompetence Achieve an optimum functional occlusion with acceptable esthetics.
Extraction of the retained deciduous canine, maxillary first premolars, and mandibular third molars was performed, and a preadjusted edgewise appliance with Roth prescription was bonded, and super elastic 0.014” NiTi archwires were ligated for alignment and leveling. Second molars were also banded to augment posterior anchorage, and en masse retraction of maxillary anteriors was done with a K-SIR archwire[] made from 0.019 × 0.025 titanium molybdenum alloy. After completion of decompensation, 0.021 × 0.025” steel wires with surgical hooks were ligated in both arches. After presurgical orthodontics of 14 months period, a reverse overjet of 7 mm was created, and worsening of profile was evident. Thereafter, a new set of records was taken, and a “Presurgical VTO” was performed to confirm the initial treatment planning. A facebow record of the patient using Hanau spring bow was transferred to a “Hanau Wide-Vue” semi-adjustable arcon articulator []. Mock surgery was performed on the articulated casts, first maxillary base was advanced to 4 mm, and an intermediate splint was fabricated, and later 7 mm of mandibular base setback was done for fabrication of “final splint.” Maxillary advancement surgery was performed with the help of LeFort I osteotomy and mandibular setback with bilateral split sagittal osteotomy with rigid internal fixation (RIF) followed by the placement of intermaxillary elastics intraoperatively. A month after surgery, finishing and detailing was started, and occlusal settling was carried out. Retention plan involved the use of fixed lingual retainers for both arches.
Total treatment duration was 21 months, and 7 months postsurgically, there was minor relapse with increased prominence of chin, yet the patient had a harmonious skeletal relationship, pleasing profile, competent lips with a good Class II buccal occlusion, positive overjet, and overbite [ and ].