The patient A, a 32 year old male with a 12 years history of Bipolar I Disorder presented with manic and depressive symptoms, including dysphoric and depressive affect, anhedonia, suicidal thoughts and behaviours, thoughts of fear about future, overtalkativeness and graphomania, increased energy, irregular sleep, loss of appetite, increased immersion in projects, irritability, agressive behavior, impulsivity in May 2013. He was complaining about decreased functionality, distractibility, sadness, thoughts of suiside, aggresivity, loss of interest to his environment, forgetfulness.
He had a history of three manic and a depressive episodes which he was diagnosed as Bipolar I Disorder. No alcohol and subtance abuse was reported.
The first episode of the disorder had come into existence with the delusions of grandiosity and reference, increased self esteem, hyperactivity, flight of ideas, impulsivity, irritability, decreased need for sleep when he admitted to an outpatient psychiatry clinic 12 years ago. At that time, he was diagnosed as 'psychotic disorder' and given antipsychotics (risperidone) and anticholinergic durg (biperiden). He went on a remission period, but incompliance occured. He undergone two other manic episodes especially including impulsivity, agressive behaviors, graphomania, overtalkativeness, distractibility and irritability. He was diagnosed as 'Bipolar I Disorder' and given mood stabilizators (Lithium carbonate, sodium valproat), antipsychotics (olanzapine, risperidone), anticholinergic drug (biperiden) and he stayed in hospital three times during that manic period.
On follow up visits he showed depressive and cognitive symptoms like depressive affect, decreased energy levels, psychomotor retardation, hypersomnia, unwillingness, attention and working memory deficits, anhedonia, hopelessness, thoughts of guilt and fear about future life. And then olanzapine and biperiden were stopped. When using citalopram some hypomanic symptoms like excessive talking, decreased need for sleep, euphoric affect and sexual disfunction occured. Then aripiprazole 10 mg/day, bupropione 150 mg/day were added to the treatment and citalopram was stopped day by day. In the following days he was hospitalized, because his symptoms didn't show a decline. When he was discharged from hospital, his treatment was aripiprazole 5 mg/day, duloxetine 60 mg/day, sodium valproate 1250 mg/day. Cognitive and depressive symptoms repeated 3 months after discharging from hospital. His treatment was changed to lithium 1200 mg/day, venlafaxine 225 mg/day, quetiapine 600 mg/day at outpatient clinic. On follow up he expressed depressive and hypomanic symptoms including dysphoric and depressive affect, anhedonia, suicidal thoughts and behaviours, thoughts of fear about future, overtalkativeness and graphomania, increased energy, irregular sleep, decreased appetide, increased immersion in projects, irritability, agressive behavior, impulsivity. Venlafaxine treatment was stopped for the reason of manic symptoms. He didn't show response to lithium carbonate therapy. So lithium carbonate treatment changed with sodium valproate.
Finally, he had been followed-up the inpatient clinic for two months in 2013 May to June. After 5 weeks treatment of sodium valproate 1250 mg/day, quetiapine 500 mg/day his depressive and manic symptoms improved well. On the other hand his cognitive symptoms like working memory, attention and learning deficit remained unchanged.
Neurological examination and electroensephalography were normal. Cranial Magnetic Resonance Imaging was compatible to the morphological features of Dandy Walker Variant. Bender Gestalt Visual Motor Sensation Scale (BGVMSS), Benton Visual Motor Memory Scale (BVMMS), Weschler Memory Scale (WMS) were applied to examine the organisity. Attention, working memory deficit and difficulty in learning were observed in WMS. BVMMS showed signs of cerebral organic pathology like significant turning mistakes and perseverations. All of them were compatible with a cerebral organic pathology. Young Mania Rating Scale (YMRS) performed before and after the treatment. During the treatment YMRS scores showed decrease from 26 to 13. Minnesota Multiphasic Personality Inventory (MMPI) was also administered to the patient. MMPI results were valid and showed an increase in hypocondriac and histrionic scales (,,).


A 16-year-old male patient presented with a history of left shoulder pain after an acute single episode of trauma 5 months prior to his clinic visit. This occurred during his gym training session while doing ‘pectoral-fly's’ — a chest exercise done when lying supine, with the shoulders in 90 degrees of forward flexion, and using dumbbell weights gradually abducting the shoulder, and thus eccentrically working the pectoralis muscle. During one of the repetitions, he lost control of the weight in the left arm which underwent a forceful abduction injury. He heard a ‘snapping’ sound followed immediately by pain in the anterior shoulder. He reported an abrupt onset swelling and bruising. He visited the emergency department of his local hospital, was assessed, and then discharged home with a diagnosis of a soft tissue injury. No treatment was recommended. The pain subsided gradually but not completely over the next few months and the injury was not a hindrance to him carrying out his daily activities; however, due to the persistent nature of the pain he sought treatment in our clinic.
His past medical history and general examination were unremarkable. Examination of his left shoulder revealed a hard bony non tender mass in the anteromedial aspect of the limb over the pectoralis major muscle insertion. The rest of the shoulder examination was otherwise normal.
Initial X-ray and MR images were taken 3.5 months after the injury at an outside institution. The X-ray demonstrated an ossifying mass in the upper third of the arm within the pectoralis major muscle that coalesced with the underlying humerus []. The MRI showed some zoning phenomenon especially on the coronal T1 scan [] and the water sensitive sequences also showed some swelling and high signal around the mass. A second series of imaging X-ray [Figure and ] and CT scan [] at 5 months showed further maturation especially of the outer compact bone of the mass with resolution of the surrounding soft tissue swelling at the insertion of the pectoralis major muscle.
A diagnosis of myositis ossificans was made. A decision was made to manage the patient conservatively.


A 48-year-old male visited our hospital, complaining of recurrent abundant hemoptysis for 2 months. He was a smoker with a 40 pack-year smoking history and had been taking medications for diabetes for 5 years. He did not have a family history of malignancy or immunosuppressive disease. He had a history of pulmonary tuberculosis 3 years ago and had taken an anti-tuberculosis medication for 6 months. On admission, he presented with a blood pressure of 110/70 mm Hg, a heart rate of 80 beats per minute, a respiratory rate of 20 breaths per minute, and a body temperature of 36.8℃. Physical examination of the chest revealed crackles in both lungs. Lymph nodes in the neck could not be palpated. The complete blood count showed a white blood cell count of 14,200/mm3 (neutrophils, 78.4%; lymphocytes, 16.2%; monocytes, 5.1%; and eosinophils, 0.2%), hemoglobin level of 7.0 g/dL and platelet count of 665,000/mm3. Routine blood chemistry and tumor markers were within normal limits except for C-reactive protein, which was 15.5 mg/dL. Chest X-ray and computed tomography (CT) scans of the chest revealed a consolidative lesion, which had high internal attenuation with bubble lucency, and a solid mass of the left upper lung (). Also there was a round mass with soft-tissue opacity within a lung cavity of the right upper lung. In the left upper lung, the mass was separated from the wall of the cavity by an airspace of variable shape and size indicative of an "air crescent" sign, and there was no contrast-enhancement (). There was no evidence of mediastinal or hilar lymphadenopathy elsewhere radiologically. The clinical diagnosis was a fungal ball with hematoma. The patient underwent bronchial artery embolization twice for persistent hemoptysis. After this, fiberoptic bronchoscopy for pre-operation evaluation of the exact site of bleeding was planned. Fiberoptic bronchoscopy showed that some blood clots with active bleeding were present in the left upper lobe apicoposterior segment (especially in the posterior subsegment). Because of the uncontrolled hemoptysis, the patient underwent left upper lobectomy and decortication. Video-assisted thoracoscopic surgery showed that there was a 20×12×8-cm-sized mass () and a 8×7-cm-sized cavitary lesion in the left upper lobe ().
Pathologic examination of the biopsy revealed extensive central necrosis and a solid area without any evidence of fungal involvement. On immunohistochemical staining, the tumor cells showed a negative reaction for cytokeratin, vimentin, actin, desmin, S-100, CD34, CD68, D2-40, calretinin, and p63, except for a focally positive reaction to epithelial membrane antigen. The tumor cells had a large nucleus with atypism and focally eccentric eosinophilic cytoplasm (). The tumor was diagnosed as an undifferentiated malignant tumor of the rhabdoid phenotype because of the poor differentiation. A brain magnetic resonance imaging and positron emission tomography-computed tomography scan demonstrated no metastatic lesion and we made a plan to follow up the patient with CT scanning in the outpatient department.


A 41-year-old woman with a medical history of allergic conjunctivitis presented to the Kansai Medical University Takii Hospital with a chief complaint of abnormal tearing from the left eye accompanied by left cheek pain. On computed tomography, a mass with unclear borders was found in the left cheek; it invaded the extraocular muscle and subcutaneous fatty tissues, involving the lacrimal gland and the lateral rectus muscle (fig. ). In addition, the tumor nearly invaded the left ocular sclera. BCC was suspected based on positive cytological examination of fine-needle aspiration (FNA) samples from the orbital cavity. BCC with neuroendocrine differentiation was confirmed by biopsy, which was performed after cytology. Taken together, HBCC with neuroendocrine differentiation was diagnosed. No other lesions were detected by a systemic search, and no specific findings were identified on blood examination. Due to the invasiveness of the tumor, the patient received radiotherapy, and her course has been uneventful as of 10 months after the first diagnosis.
After FNA, the aspiration needle was washed using CytoLyt Solution® (Hologic, Mariborough, Mass., USA). Then, the washed sample was centrifuged at 3,000 rpm for 5 min and processed using a ThinPrep2000® processor (Hologic) according to the manufacturer's instructions. Cytological examination revealed several cellular clusters, which exhibited poor anisonucleosis, loss of polarity, and unclear cell borders in a clear background. Cytologically, isolated bare cells were frequent; the cells were observed to be small in size with scant, insufficient cytoplasm and round to oval nuclei containing fine granular chromatin. Mitosis and single cell necrosis were occasionally seen (fig. ). However, peripheral palisading was not noticeable in the cell clusters. Immunocytochemically, the tumor cells were positive for cytokeratin (CK) 7 (fig. ) and negative for CK20, CD56, synaptophysin, and chromogranin. Thus, HBCC was suspected both cytologically and clinically. The biopsy sample from the orbit was fixed with 20% neutral buffered formalin and embedded in paraffin; the sample was sectioned at 3 µm and stained with hematoxylin and eosin (HE). Serially cut sections were used for immunocytochemistry. In brief, immunohistochemical examination was performed employing the amino acid polymer method using a Nichrei Histostainer (Nichirei, Tokyo, Japan). After histopathological diagnosis, the tissue block was deparaffinized and used for electron microscopic study. Histologically, tumor cell nests with peripheral palisading were scattered in the dermis. The tumor cells had round to oval nuclei with increased chromatin and scant cytoplasm. Mitotic figures were seen (fig. ). Immunohistochemically, the tumor cells were diffusely positive for CK7 (fig. ) and focally positive for CD56 (fig. ); they were negative for CK20, synaptophysin, and chromogranin A, and the Ki-67 labeling index was approximately 70%. As some of the tumor cells from the biopsy specimen selectively stained positive for CD56, the sample was further studied ultrastructurally. Electron microscopically, 200–300 nm-sized membrane-bound dense-core granules were detected in the tumor cell cytoplasm (fig. ).


A 38-year-old male patient resident of Sidi Bouzid (Tunisia) was admitted to hospital with cough, left thoracic pain and increasing dyspnoea of two months duration. He was a tobacco smoker (3 pack-years). Physical examination revealed the dullness to the percussion and diminished breath sounds over the left lower lung field. A CXR [] showed a large left-sided hydropneumothorax with significant shift of midline structures. Electrocardiographic data were normal. Laboratory studies revealed hemoglobin of 13.8 g/dL, total leucocytes count of 16400 cells/mm3, erythrocyte sedimentation rate (ESR): 47 mm/hr. Arterial blood gas values, on room air, revealed hypoxemia (arterial oxygen pressure PaO2: 76 mmHg). Thoracic computed tomographic (CT) scan revealed large left-sided hydropneumothorax due to ruptured hydatid cysts []. Surgical intervention was indicated. The patient underwent resection of the pulmonary cyst without postoperative chemotherapy instituted. There were no complications in the postoperative period and no recurrence of the disease during a follow-up of 6 months.


A 68-year-old male patient was admitted with a 5-month history of cough and chest pain. In the past story of the patient, there was a concept of contact with carnivores and a sheep. Physical examination revealed decreased breath sounds over the all the right lung and scattered rhonchi were heard in his lungs bilaterally. The admission chest radiograph was initially interpreted as showing right plentiful pleural effusion, a right lower lobe consolidation and a left oval cystic lesion. At the abdominal ultrasound, the appearance of the liver, spleen, gall bladder and pelvic organs was normal. Investigations revealed a normal complete blood count, an elevated ESR, and a negative indirect hemagglutination test. Arterial blood gas values, on room air, revealed very hypoxemia (PaO2:61 mmHg). A right posterolateral thoracotomy was performed for the patient. Surgical treatment consisted on removing the pleural fluid, the cystic membrane and total pericystectomy. There was a septic shock in the postoperative period which had evolved with antibiotic and inotropic support. The antihelmintic agent albendazole (10 mg/kg) was administered daily for three months postoperatively. There was no recurrence of the disease during a follow-up of six months.


A 68-year-old female patient presented with a history of cough, right chest pain and low abundance hemoptysis since 40 days. Physical examination revealed tachypnoea with respiratory rate of 24/min, tachycardia with heart rate of 110/min, and the blood pressure was 130/70 mm Hg. There was no cyanosis and temperature was 37°C. Chest examination revealed diminished movements over right hemithorax with decreased breath sounds in the right infra scapular, infra axillary and mammary area. Cardiovascular examination was unremarkable except for tachycardia. Per abdominal examination revealed no organomegaly. Investigations revealed hemoglobin of 12.1 g/dL, total leucocytes count of 8400 cells/mm3. ESR: 110 mm/hr. Electrocardiogram showed sinus tachycardia. Emergency chest radiograph showed a left oval cystic lesion and a right-sided hydropneumothorax with significant shift of midline structures. Ultrasound abdomen was normal. CT thorax showed cavitary lesion measuring 8.5 × 8 cm, involving the right lower lobe. Folded membrane like structure was seen with in the cavity. All lesions were associated with pleural effusion. CT features suggested ruptured hydatid cyst on the pleura with significant shift of midline structures. The rest of lung fields showed left oval cystic lesion. Patient was referred to surgeon for consideration of surgical intervention. The decortication procedure was performed with cystotomy. Patient was discharged on seventh day after the surgery. Albendazole was started at the dose of 10 mg/kg as a postoperative prophylactic measure to prevent recurrence.


A 53-year-old male patient presented to the medical emergency with a 9-day history of cough and right pleuritic chest pain which increased with inspiration and cough. Physical examination revealed tachypnoea with respiratory rate of 23/min. Blood pressure was 130/70 mm Hg. Temperature was 39°C. The chest examination revealed diminished movements over the right hemithorax with decreased breath sounds and persistent crackles. The CXR showed uniform opacity in the lower part of the right hemithorax with a concave upwards upper border []. CT of the chest showed cavitary lesion measuring 7.5 × 7 cm, involving the right lower lobe surrounded by parenchymal condensation and right pleural effusion. Folded membrane like structure was seen within the cavity []. CT of the abdomen showed a residual calcified lesion in the right liver lobe. Investigations revealed hemoglobin of 12.3 g/dL, total leucocytes count of 12,300 cells/mm3. The hydatid antibody level was raised at 1/2560 (indirect hemagglutination test). Electrocardiogram was normal. The patient was posted for decortication and right posterolateral thoracotomy was done. Parietal pleura was thickened >1 cm and visceral pleura was approximately 4 mm. We removed the pleural fluid and performed visceral and parietal pleural decortication. A ruptured hydatid endocyst was found adhered to the thickened pleura overlying the right lower lobe and was removed. A bronchopleural fistula was seen originating from floor of probable site of ruptured cyst cavity in the right upper lobe of lung which was repaired. On long-term follow-up, the patient remained healthy and there was no recurrence.


A 48-year-old Caucasian female presented with a three-month history of blurred vision in the right eye (OD). There was past history of smoking over ten years ago and biopsy-proven primary NSCLC diagnosed one month previously. The patient had stage IV disease with brain and bone metastases.
On examination, visual acuity was 20/100 OD and 20/25 left eye (OS). Anterior segment examination was normal in both eyes (OU). Fundus evaluation revealed a 10 × 8 × 4.8 mm solitary juxtapapillary yellow-white choroidal metastasis superior to the optic disc OD [Figures and ]. Extensive subretinal fluid was found extending beneath the foveola and inferiorly [Figure ]. The left fundus showed no evidence of tumor. Owing to systemic and choroidal metastasis, the patient was started on 100 mg oral erlotinib daily under the supervision of a medical oncologist.
Subsequent ocular examination two weeks later showed complete regression of choroidal metastasis to a flat scar. The subretinal fluid was resolved OD [Figures –]. No new tumor was detected OS. Visual acuity improved to 20/25 OD and 20/20 OS. The tumor remained regressed with preservation of visual acuity OU at five months follow-up [Figures –]. Trichiasis and trichomegaly of two eyelashes OS were noted and were epilated. The patient is under continuous monitoring for systemic metastasis.


A 15-year-old girl presented with a yellowish plaque on the left medial canthus and a group of closed comedo-like papules on the right side of the cheek. She has not had any developmental problems or a history of seizures. No other family members had similar lesions. The 2 different EN lesions on the patient's face were noticed during a dermatological examination. The yellowish, asymptomatic, bean-sized plaque with a verrucous surface was noted on the left medial canthus (). It was present at birth. In addition, an aggregation of closed comedo-like papules and depressed pinpoint craters were found on the right side of the cheek (). It developed at the age of 10 years. She has also had numerous, scattered, pea-sized, hyperpigmented macules on her face for several years (). Her physical examination was normal except for the dermatological findings. Her neurological examination and laboratory examinations, including complete blood cell count, blood chemistry, and urine analysis, were within normal limits. Histopathological examination of the plaque on the left medial canthus showed acanthotic and papillomatous epidermal hyperplasia and large sebaceous glands located close to the epidermis (). Histopathological examination of the papule on the right side of the cheek revealed a dilated follicular infundibulum filled with keratin and incomplete hair follicles, consistent with the clinical diagnosis of NC (). She received laser treatment for NS and comedo extraction for NC in a private clinic before visiting our hospital. However, the NS of the left medial canthus recurred, and depressed craters were left with comedones on the right side of the cheek. The NS was surgically removed from the left medial canthus. The patient declined treatment of the NC and hyperpigmented macules.


The patient, a 54-year-old female, was found to have a mass in the right lower lung (RLL) on chest radiography during a routine health examination in 2010. Thoracoscopic lobectomy of the RLL and lymphadenectomy was performed. The histopathology was reported to be cribriform type ACC. On positron emission tomography-computed tomography (PET-CT) which was performed to evaluate for metastatic disease, no suspicious other primary lesions were identified. Laryngoscopy was performed from nasopharynx to glottis level. There was no suspicious primary lesion. The patient was diagnosed with primary ACC at the peripheral lung.
When the patient was hospitalized after the thoracoscopic lobectomy, cystoscopy was implemented due to hematuria. The patient was diagnosed with bladder cancer and received partial transurethral resection of the bladder. Histopathology demonstrated a non-invasive papillary bladder cancer. During the follow-up period, two years after the primary lung ACC diagnosis, fluorodeoxyglucose uptake on bilateral upper neck lymph nodes were found on PET-CT and the patient was referred to the Department of Otorhinolaryngology-Head and Neck Surgery.
The patient did not report any specific symptoms at the time. Additionally, there were no palpable neck lymph nodes in the bilateral upper neck on physical examination. On laryngoscopy, a small round mass of 1.0 cm was identified in the center of the base of the tongue (). It was firm and fixed on palpation. On CT scan and PET-CT, a lesion was not clearly identified, although enlarged lymph nodes (left, 2.0 cm; right, 1.3 cm) were found at bilateral neck level II areas without contrast enhancement (). Magnetic resonance imaging (MRI) demonstrated a 1.5×1.7 cm mass with T2 contrast enhancement and irregular margins in the center of base of the tongue as well as abnormally enlarged lymph nodes at bilateral neck level II areas (). Biopsy of the lesion was performed and histopathology showed cribriform type ACC. Ultrasound guided fine needle aspiration and cytology was performed on both neck nodes, but only polymorphous lymphoid cells were found.
The patient planned to have surgical treatment at the primary site and bilateral necks based upon an American Joint Committee on Cancer (AJCC) cancer stage IVA (T1N2cM0). The primary mass was suspected to extend to the left lingual nerve, and a frozen section was performed to confirm invasion. Cribriform type ACC was identified in histopathologic examination (). Ligation and excision were performed at the proximal lingual nerve due to invasion (). The resection margins had sufficient distance for all areas. Perineural invasion (), lymphatic invasion (), and single lymph node metastasis less than 1 cm at the level II area without extracapsular spread were also reported. Both enlarged lymph nodes were identified as chronic granulomatous lymphadenopathy, which was considered to be caused by mycobacterium bovis bacillus Calmette-Guérin (BCG) lymphadenitis or other mycobacterial infection. The cancer was stage III (T1N1M0) following surgery. Adjuvant radiation therapy with 5,880 cGy was performed. The patient has continued with follow-up without any recurrence.
TTF-1 immunohistochemical staining was performed in the previously excised lung specimen to identify whether it was a metastatic or primary lesion. Focal positive (brownish color) staining was identified in TTF-1 staining of the peripheral lung specimen (). It represented a primary cancer in the lung.


This was a case of a 15-year-old boy who was admitted with 6 months history of recurrent painless mass (8 cm × 4 cm) on the upper 1/3 anteromedial aspect of left leg [] Arrow]. Patient had undergone prior surgical resection of mass from the same site, one year prior to the current presentation. Clinical examination and laboratory test were otherwise non-contributory except for the soft-tissue tumor. Repeated fine-needle aspirations were hemorrhagic and hypo cellular. Microscopy showed occasional small cluster and dispersed spindle cells with evenly distributed chromatin. A diagnosis of spindle cell lesion was suggested. Patient's previous tumor from the same site was classified as SFT based on histomorphology and immunohistochemical (IHC) studies. Patient underwent surgical removal of the mass. Surgery and post-operative period were uneventful.
Grossly, a well-delineated (7.5 cm × 3 cm × 1.5 cm) white mass was received for histopathological examination []. Histomorphology of routine hematoxylin and eosin stained slides was similar to previous resected tumor and showed haphazardly arranged spindle cells (pattern less growth), dense collagen and areas of marked hyalinization. Spindle cells have oval to elongate bland vesicular nuclei with a moderate amount of cytoplasm. No significant nuclear pleomorphism or mitotic activity was noted [Figure and ]. Many thin walled blood vessels were seen []. Microscopic foci of mature adipose tissue were seen []. Surgical margins were free of tumor tissue []. Tumor cells were negative for actin, desmin, epithelial membrane antigen (EMA), S100 and strongly positive for CD34 immunostains [Figure –]. A diagnosis of SFT was made.


A 9-year-old girl was admitted to our academic hospital with trauma to the left-side eyeball. The pre-clinical diagnosis was corneal laceration with a sharp wire. Clinically, the patient presented with the following: A bruised eye and traumatic conjunctivitis, and intact vision, but third cranial nerve (CNIII) palsy with ptosis and a dilated pupil. Workup computed tomography (CT) scans and magnetic resonance imaging (MRI) revealed probable related trauma with unreliable history, namely left periorbital soft tissue swelling with retrobulbar stranding in keeping with a small amount of hemorrhage and inflammatory change [], and also, incidental left cerebellar focal hemorrhage []. Pre-operative angiography with the transfemoral approach was performed. Access to the right common femoral artery was gained with a 22 G Jelco and a micro-puncture guide wire was advanced into the right common femoral artery. A 4 F pediatric sheath was advanced over the micro-puncture guide wire into the right common femoral artery. A Headhunter catheter was used and 50 ml of Jopamiron 300 was administered intra-arterially without any side effects. A six-vessel study, i.e. ECA, ICA, and vertebral artery (VA) on both sides, was selected to exclude an underlying cause for the hemorrhage observed. Injections appeared normal and no pseudo-aneurysms, arterio-venous fistulae, extravasation of contrast, or abnormal blush were demonstrated. No embolization was required and the sharp wire was successfully removed. Although cranial palsies can be a complication of embolization, the CNIII palsy was not procedure related. The patient was treated for eye infection and pain before being discharged from hospital with a remaining CNIII palsy.
Conventional angiograms revealed normal right-side vascular anatomy, but on the left-side dual OAs were observed. An OA with normal origin from the ICA that coursed through the optic foramen presented with the CRA []. An OA variant with M-OA origin via the maxillary artery (MA) from the ECA coursed through the superior orbital fissure []. A lateral view angiogram illustrated both OAs, caused by overflow of the injected ECA []. The M-OA consisted of an MMA (course: Through the foramen spinosum) with normal branches (i.e. anterior and posterior branches) and an OA variant (course: Through superior orbital fissure) with a distinct branching pattern, namely supraorbital, lacrimal, and ethmoidal branches [Figures and ]. A smaller OA (origin: ICA; course: Through optic foramen) with a distinct branching pattern, namely terminal branches (i.e. supratrochlear and nasal branches) and ocular branches (i.e. ciliary and muscular branches), as well as the CRA (as witnessed by choroidal blush) were observed []. The left-side vertebral artery followed normal anatomy. Right-side angiograms showed normal anatomy of all the vessels.


A 3-year old boy presented to our Outpatient Department (OPD) with progressive proptosis of left eye for the last 3 months and left facial palsy for last 20 days. On examination, he was found to be moderately anemic without petechial patches and had loss of appetite and weight. There were no symptoms of raised intracranial tension. His systemic neurological examination showed left facial nerve palsy. There was no palpable abdominal organomegaly and no lymphadenopathy. Ophthalmological examination revealed non reducible axial proptosis of left eye without subconjuctival hemorrhage. Ocular movements were not restricted in all directions. Pupillary reflexes were positive in both eyes. His hemoglobin was 7.0gm% and the total leukocyte count was 8000/mm3, differentiated leukocyte count showed 28% neutrophils, 48% lymphocytes, 12% blast and platelet count was 20,000/mm3. The contrast CT scan/MRI of orbits showed polypoidal soft tissue mass in the left maxillary antrum showing pressure erosions of smooth thinning of the medial, posterolateral walls and boxy orbital floor at places extending into the inferior extraconal space of the left orbit with mild proptosis. The bone marrow aspiration showed hypercellular marrow smears; 15% blast, 45% promyelocytes with increased myeloid erythroid (M: E) ratio conforming to the diagnosis of acute promyelocytic leukemia (AML, M3). Incisional biopsy of the orbital swelling was avoided in view of the low platelet count and imaging report correlating with leukaemic proptosis. The brain MRI and CSF analysis were normal. Thus, the patient was diagnosed as AML, M3 with extra- medullary disease involving left orbit and left facial nerve palsy. After second cycle of chemotherapy induction cycle comprising of injection Daunorubicin 45g/m2 and injection Cytarabine 200mg/m2 there was partial remission of proptosis and improvement of the facial palsy. Patient is doing well up to last follow up.


A 23-year-old unmarried male patient presented at our OPD with a one-year history of multiple, raised, painful skin lesions on the glans penis. There was no history of remissions or exacerbations, nor any history of sexual exposure. The patient did not have a history of cough, hemoptysis, chest pain, dyspnea, hematuria, pain in abdomen, hematochezia, headache, weight loss, fever, or loss of appetite. There was no history of ulcers over the genitalia, burning micturition, or purulent discharge per urethra. He had undergone circumcision in his childhood as a part of religious practice. On examination, he was moderately built and nourished and afebrile. Four ill-defined, discrete, erythematous, firm, tender, papules were present on the glans penis, two on the dorsum of the glans and the other two on either side of the frenulum []. There were no ulcers, fissures, erythema, or edema over the glans penis and no discharge per urethra. Inguinal lymph nodes and other lymph nodes were not palpable. There were no other skin lesions elsewhere. BCG vaccination scar was visible. Mucosal examination was normal. Other systemic examination was normal. Histopathological examination of intact papule showed epithelioid granulomas consisting of Langhan's giant cells, epithelioid cells, and lymphocytes []. Mantoux test was strongly positive, maximum diameter measuring 35 mm []. Other investigations done to search for any foci of tuberculosis elsewhere in the body like chest radiograph and abdominal and pelvic sonography were normal. Other routine investigations were normal. Enzyme-linked immunosorbent assay (ELISA) for HIV 1 and 2 and venereal disease research laboratory (VDRL) were nonreactive. At this stage, a diagnosis of cutaneous tuberculosis was made, and the patient was started on category 1 antitubercular therapy (ATT) with isoniazid 600 mg, rifampicin 450 mg, pyrazinamide 1500 mg, and ethambutol 1200 mg. The patient was reviewed again after six weeks of starting ATT, and all the lesions had subsided with the treatment; no ulcers or scars were present except for the biopsy scar []. The diagnosis of lupus vulgaris was confirmed and the treatment was continued.


A 68-year-old woman was referred on January 2014 to the Department of Cranio-Maxillo-Facial Surgery of our hospital with difficulty on mouth opening, trismus, fever, headache, and general malaise. The patient’s past medical history was relevant for RA, treated from 1993 with gold salts, methotrexate, leflunomide, daily oral calcium and vitamin D3, and prednisone. From 2005, after multiple vertebral fractures caused by severe osteoporosis, the patient started a treatment with ibandronic acid, 150 mg, one tablet once a month. In March 2013, following an abscess in 46 zone, her dentist extracted the tooth element.
The patient showed a noticeable right-sided mandibular abscess and a right-sided soft temporal swelling and redness (), with severe pain on mouth opening.
The oral examination revealed the presence of an abscess in the posterior mandible, in the area of the recent extraction (), with pus leaking from the empty alveolus. Infection and swelling was extending distally to the back molar 47.
Radiologic exams (orthopantomography and CT [computed tomography] scan) () showed a widespread zone of radiolucency, rarefaction of trabecular bone with a large osteo-necrotic lesion around the extraction site, which extended posteriorly to include the adjacent second molar, persistent extraction socket, and bone sequestra. All these data allowed us to diagnose advanced BRONJ in the right mandibular zone. Magnetic resonance imaging () showed a temporal abscess located lateral to the alveolar crista of the upper jaw and upwards deep into the temporal fascia.
Before admission to hospital, the patient was treated with amoxicillin and clavulanic acid (875 mg and 125 mg respectively) injection.
After 2 days, a surgical toilette of necrotic bone in mandibular angle was performed with extraction of the second molar. The temporal fascia abscess was drained through a temporal incision. Microbiological samples showed an Actinomyces infection, with susceptibility to ampicillin, meropenem, and metronidazole, and with resistance to amoxicillin and clavulanic acid. Surgical incision was not saturated, and daily medication with irrigation on sodium hypochlorite and positioning of gauze of ialuronic acid was made twice a week. After microbiological analyses, which showed a resistance to antibiotic therapy, amoxicillin and clavulanic acid was substituted with meropenem 2 g and metronidazole 500 mg day.
After 3 weeks of therapy, the patient was discharged and was followed up monthly in our clinic. Three months after the hospitalization, the patient had complete resolution of infection.


A 25 year old woman was referred with a history of chronic headache for a period of three months. The headache was severe and refractory to NSAIDs or other pain relievers. There was no history of chills and fever, gait disturbance, hearing loss and memory problems. No history of using illicit drugs such as cocaine, alcohol, cannabis was also found. Drug history was negative for oral contraceptive pills, nalidoxic acid, tetracycline, corticosteroids, vitamin A and other drugs. She was student, lived in an urban area with history of travels to rural areas. No history of using unpasteurized milk and contact with animals were found.
In physical examination, vital signs were normal. Generally, she was cooperative with intact orientation. Cranial nerve examinations were normal and meningeal signs were not detected. There was a significant papilledema in ophthalmologic examination. Deep tendon reflexes (DTRs) in upper and lower limbs were normal. Muscle forces in proximal and distal regions of lower and upper limbs were also normal. No impairment in the sensation of extremities was detected. Gait was intact with no ataxia and tremor. Psychological examination was also done. There was not any abnormality in mood and affect evaluation and no cognitive impairment was also observed.
Laboratory studies including complete blood count with differentiation (CBC/ diff), prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), blood urea nitrogen, creatinine (BUN,Cr) and liver function tests (LFT) were normal. An elevated ESR was detected (68mm/hour). HBS Ag, HCV Ab, VDRL and HIV Ab were also negative. Anti-nuclear antibody (ANA), Anti-neutrophil cytoplasmic antibodies (ANCA), C3 and C4 were in normal range. Brain CT scan in addition to T1 and T2 weighted brain MRI plains after gadolinium injections were also performed that revealed no pathologic findings. The patient underwent lumbar puncture. Cerebrospinal fluid appeared xanthochromic and presented with a high opening pressure (280 mmH2O), low glucose (43mg/dl) and elevated protein levels (338mg/dl). Spinal fluid analysis showed leukocytes. Brucella (capt test) tube agglutinin was positive at 1/2560 titers in blood and positive at spot and 1/2560 titers in CSF. Tuberculosis PCR test was negative for the CSF sample.
In summary, we had a case with a history of chronic headache characterized by increased intra-cranial pressure (ICP). Papilledema was the only positive finding in the initial physical examination. SAT (serum antibody test) was the only positive finding for brucella within the laboratory test. Other investigations including imaging studies were normal. The patient received intravenous cefteriaxone 1gr BID and oral doxycycline 100mg BID and rifampin 600 mg once daily for 1 month; and then rifampin continued for 14 months. Headache began to improve during treatment and disappeared after 3 months.


A 63-year-old man suffering from PD with implanted DBS electrode [] was scheduled for radical nephrectomy for renal cell carcinoma. He had been suffering from PD for the past 18 years and his disease progressed to severe immobility in spite of being on medical treatment. He underwent bilateral DBS implantation surgery 2 years ago after which he had marked improvement in his symptoms. The patient was on a combination of carbidopa (10 mg) and levodopa (100 mg) 4 times a day and trihexyphenidyl 1 mg thrice a day, orally.
At the preoperative visit, patient was able to walk, with mild tremors and mild muscle rigidity, which was tolerable. On examination of the cardiovascular system and respiratory system, no abnormality was detected. On the morning of surgery, his usual medication for PD (carbidopa, and levodopa and trihexyphenidyl) was given. Inside the operating room IV line was secured and then neurostimulator was switched off in the presence of the treating neurologist. This resulted in exacerbation of muscle rigidity and tremors. Anaesthesia was induced with thiopentone sodium 250 mg, pethidine 30 mg, while intubation of the trachea was facilitated with vecuronium bromide 8 mg. Maintenance was with isoflurane, 70% nitrous oxide in oxygen, and intermittent top ups with vecuronium bromide with IPPV. Monitoring consisted of electrocardiography, noninvasive blood pressure, pulse oximeter and end tidal C02. The duration of surgery was 3 h and the blood loss was 300 ml. Patient was haemodynamically stable throughout the surgery. Bipolar cautery was used, with cautery plate placed under the buttock. At the completion of the surgery after the abdominal closure was over, the neurostimulator was switched on. At the end of the procedure, neuromuscular block was antagonized with neostigmine 2.5 mg and glycopyrrolate 0.5 mg. The patient emerged from anaesthesia smoothly. His vital signs were normal; blood pressure - 120/70 mm Hg, heart rate - 98 bpm, respiratory rate - 20/min and SaO2 98%. No respiratory difficulty was noted.


A 78 year old man referred to our Unit due to a solitary, palpable, erythematous,
dome-shaped, 8mm papule on his left leg. Lesion was asymptomatic and was said to have
been present since a few months.
No personal or family history of psoriasis was declared. Dermatoscopy showed unequivocal
patterns of CCA, i.e., dotted vessels organized as "strings of pearls" and keratinized
collarette ( and ). Clinically and dermoscopically
well-defined borders in combination with lesion and patient history reasonably excluded
psoriasis.
Since the patient refused all proposed destructive treatments, after informed consent
was obtained, an alternative, off-label therapy was performed.
Calcipotriol 0.005% cream was applied twice a day and
followed by a two-week dermoscopic digital monitoring period. Therapy was administered
for 2 months during which time the patient did not report any local or systemic side
effects.
Dermatoscopic images were obtained by means of both an immersion non-polarized
contact device (Delta 20, Heine) and a polarized light device (DermLite Pro II,
3Gen).
-After 15 days of therapy no macroscopic changes were visible. Only
a yellowish, irregular, star-shaped area was appreciated in the center of the lesion
().
-After 30 days of therapy a scaly collarette appeared, with
persistence of a few dotted vessels. The central yellowish structure became larger
and more evident ().
-After 45 days of therapy the lesion was no longer palpable. A pink
to light brown background area, lacking vascular structures and covered with fine
white scales was appreciated. A few small, brown-red structures, compatible with
crusts/microerosion, were detectable ().
-After 60 days of therapy only a light brown pigmentation was
visible on a slightly pinkish background, with no evident vessels (). Treatment was interrupted.
-Twelve months after stopping therapy no recurrence appeared, and a
slightly hypochromic area was dermoscopically and clinically visible ( and ).


A 15-year-old female patient was referred to Seoul National University Hospital with palpitation and chest pain. Three years previously, she had been diagnosed with Graves disease and her transthoracic echocardiogram (TTE) and electrocardiogram had revealed mild mitral regurgitation (MR), mild tricuspid regurgitation (TR), and atrial fibrillation (AF); however, the patient was lost at follow-up. She had not been compliant with medication and had had no medication for at least the 3 previous months. One week before she was referred, she had visited a hospital complaining of general weakness, palpitation, chest discomfort, cold sweat, and loss of 6 kg of body weight in 3 weeks; she was then diagnosed with thyroid storm. After 1 week of medical treatment for thyroid storm and improvement of symptoms, she was referred to Seoul National University Hospital for further management.
At the point of time that she was referred, the initial laboratory test showed high serum-free T4 (2.12 ng/dL; normal range, 0.70 to 1.80 ng/dL), low serum thyroid stimulating hormone (TSH) (<0.05 μIU/mL; normal range, 0.4 to 4.1 μIU/mL), and high titer of autoantibodies (thyroglobulin antibody, 110 IU/mL; normal range, 0 to 100 IU/mL; TSH receptor antibody, 13.8 IU/L; normal range, 0 to 1 IU/L) implying autoimmune hyperthyroidism such as Graves disease. Grade IV systolic murmur with irregular heart beat was auscultated, and the electrocardiogram revealed AF (). Further, the chest radiograph showed severe cardiomegaly (). The TTE revealed 58.5% of left ventricular ejection fraction (LVEF), moderate to severe MR with anterior leaflet prolapse, moderate TR with mild leaflet prolapse, and 68.8 mm of left ventricular end diastolic diameter, which implied left ventricular dysfunction and enlargement ().
After 11 days of medical treatment, the thyroid function test was normalized (free T4, 1.24 ng/dL; TSH, 0.01 μIU/mL), but the heart failure and valvular dysfunction did not improve. We concluded that the heart including the valves and chordae had already been changed structurally and therefore, performed surgery. As intraoperative findings, the mitral valve showed diffuse chordae thinning and elongation with diffuse leaflet prolapse, and the tricuspid valve showed diffuse chordae thinning and elongation with severe anterior leaflet prolapse. Therefore, we performed mitral valvuloplasty making two artificial chordae at A2 and A3, respectively, mitral annuloplasty with a 32-mm Cosgrove ring, tricuspid valvuloplasty making 4 artificial chordae at the anterior leaflet, De Vega-type tricuspid annuloplasty, and Cox maze procedure. After the surgery, the TTE revealed improved cardiac function with 66.1% of LVEF, mild MR, and trivial TR, and decreased the left ventricular end diastolic diameter to 49.5 mm (). The chest radiograph also showed an improvement of the cardiomegaly (). The patient’s cardiac rhythm was AF when she was discharged on postoperative day 16 but was converted to normal sinus rhythm from the first out-patient follow-up (postoperative day) to the last follow-up (2 years after operation) (). Her thyroid function has also been controlled well (free T4, 1.09 ng/dL; TSH, 1.26 μIU/mL at last follow-up) with medication including oral methimazole and levothyroxine.


A 37-year-old woman was referred to our institution for further management of a mass lesion located in the thoracic cavity, which was revealed on a chest computed tomography (CT) scan taken at another hospital. She complained of left-sided flank pain that was aggravated with deep inspiration for twelve months and began to experience dyspnea for one month. She had a history of pulmonary tuberculosis with a six-month course of anti-tuberculosis medication 20 years earlier. She did not have a history of smoking or environmental or occupational exposures to toxins. The laboratory tests including tumor markers on admission were normal. The result of acid fast staining of her sputum was also normal. Findings of physical examinations were unremarkable. The initial chest radiograph taken at the other hospital 8 months previously demonstrated an ambiguous consolidation in the left lower lung without a definite mass lesion (). The patient did not receive treatment for the lesion but has been followed-up for eight months. A chest radiograph taken eight months after the initial visit revealed an irregularly shaped large mass occupying the left lower lung field and compressing the left lower lobe and diaphragm (). Compared with the initial chest radiograph, the mass had grown markedly. Consequently, chest CT was carried out immediately. Chest CT showed two irregularly shaped soft tissue masses adjacent to the parietal pleura in the left hemithorax, which contained dense calcifications without the invasion of the ribs ().
For correct diagnosis and proper treatment, surgical excision of the masses was performed through left thoracotomy via the 7th intercostal space. The intraoperative findings showed two hard and irregularly shaped masses with a hard osteoid surface. These masses were clearly separated. One was 8 cm in size and was located at the costophrenic angle, and the other was 4 cm in size, located adjacent to the inner surface of the shaft of the 6th rib. They had invaded the adjacent structures including the left lower lobe, chest wall, and the diaphragm, but had not invaded the adjacent ribs. These masses were radically excised involving the invaded organs to obtain adequate resection margins (), and the defect of the diaphragm was reconstructed with a 2-mm-thick polytetrafluoroethylene (Gore-Tex WL Gore and Associates Inc., Flagstaff, AZ, USA) patch. Histologically, the tumors consisted of osteosarcoma, pleomorphic sarcoma, and leiomyosarcoma. The microscopic findings (H&E stain) showed the histologic appearance of the mass (), which consisted of smooth muscle differentiation and osteoid production cells. Differences in nuclei size and shape were also observed in the H&E stain. In the immunohistochemistry stain, smooth muscle actin was detected. The microscopic findings of the two masses were the same, and therefore, these were considered seeding. The patient underwent four cycles of adjuvant chemotherapy with the regimen of high-dose methotrexate, cisplatin, and doxorubicin. Currently, she is doing well without any evidence of recurrence for 14 months after surgery.


A 47-year-old man, with no significant medical history, was admitted for the evaluation of abnormal electrocardiography (ECG). ECG showed sinus rhythm with pathologic Q waves in leads II, III, and aVF. He denied having recent chest pain but complained of general weakness and mild dyspnea on exertion since a motor vehicle collision 5 months ago.
Initially, he had been transported to the emergency room (ER) of Dongtan Sacred Heart Hospital and had been diagnosed with multiple facial bone fractures, cardiac contusion, and chest wall contusion without definite evidence of any bony thorax injury. Then, he was transferred to a local hospital near his residence. On review of his previous ER chart, the initial ECG at the ER () showed ST elevation in leads II, III, and aVF and increased cardiac enzyme levels (serum creatinine kinase myocardial band fraction of 14.2 ng/mL and troponin-I of 2.64 ng/mL).
Transthoracic echocardiography on readmission revealed a dilated left ventricle (LV), akinesia of mid-to-basal inferior wall, and hypokinesia of the LV apex with an LV ejection fraction of 40%. The valvular functions were normal, and an abnormal flow via the fistula was identified between the right atrial (RA)-right ventricle groove and RA (Qp/Qs=1.3) by color flow Doppler.
Coronary angiography revealed an RCA–RA fistula and totally occluded distal RCA just beyond the fistula (), while the other coronaries were normal (). There was no abnormal collateral vessel around the fistula or along the RCA. Coronary computed tomography (CT) angiography showed similar findings to coronary angiography except a calcified plaque on the proximal left anterior descending (LAD) artery, and the size of the proximal RCA (4.5 mm) was not dilated compared with the left main coronary artery (4.9 mm) ().
We concluded that the RCA injury by blunt chest trauma sustained 5 months previously induced RCA–RA fistula, distal RCA occlusion, and myocardial infarction (MI) consecutively or simultaneously. Their cause-and-effect relationship and time sequence were extrapolated retrospectively.
Surgery was planned for revascularization of the RCA and coronary artery fistula closure. Surgery was performed through standard median sternotomy with normothermic cardiopulmonary bypass. Before infusing a cardioplegic solution (Custodiol; Kohler Chemie GmbH, Alsbach-Hahnlein, Germany) via the aortic root, RCA around the fistula was dissected and clamped without any difficulty. After infusion of the cardioplegia, long arteriotomy was done from the distal RCA to bifurcation and a fistula opening (7×3 mm) to the RA was revealed. The distal RCA was occluded beyond the fistula opening up to the proximal posterolateral branch and filled mainly with fibrous tissue with loose myxoid stroma macroscopically and microscopically.
The fistula opening was closed with two horizontal mattress sutures of 5-0 prolene and excluded from the RCA, and a left radial artery graft was interposed between the distal RCA and the posterolateral branch. The posterior descending artery was sacrificed because the lumen of the proximal portion was very small (diameter<1.0 mm) and filled with fibrous tissue. Postoperative coronary angiography showed complete obliteration of the coronary artery fistula and good patency of the RCA and the interposed radial artery graft (). The postoperative course was uneventful, and the patient was discharged on postoperative day 7.


A 62-year-old lady, a known case of hypothyroidism, presented with weakness of the left upper limb. Magnetic resonance imaging (MRI) of the brain showed an intracranial space-occupying lesion. She was put on empirical anti-tuberculosis treatment, suspecting a tuberculoma; however, her condition worsened. As a part of the workup, USG of her abdomen and neck was performed, which showed a well-defined, hypoechoic lesion, measuring 3 × 5 mm, in the right lobe of the thyroid, without calcification. We obtained a USG-guided FNA from the same. The USG of the abdomen was normal. The FNAC showed cells arranged in papillary and micro-follicular clusters. There were singly scattered plasmacytoid cells as well as binucleated cells. The cells showed minimal nuclear pleomorphism with fine chromatin. Some cells showed fine cytoplasmic granularity. Benign-looking follicular epithelial cells were seen admixed with neoplastic cells. There were no nuclear features of papillary carcinoma of the thyroid []. A possibility of medullary carcinoma of the thyroid was considered. However, in view of atypical morphological features like numerous papillary clusters and a vague acinar pattern, the possibility of an intrathyroidal metastatic tumor could not be excluded. A subsequent CT scan showed well-defined, randomly distributed nodules in both the lungs, suggestive of metastasis. A CT-guided biopsy and immunohistochemistry was performed of the lung nodules. The tumor cells were positive for CK7 and TTF-1; and negative for thyroglobulin and calcitonin, confirming primary adenocarcinoma of the lung.
A retrospective audit using the hospital information system of all FNAs of thyroid performed in our institute over a period of three years, from March 2010 to February 2013, revealed a total of 11 cases of carcinomas, of extrathyroidal origin, diagnosed by FNAC. There were a total of 3703 thyroid FNAs in three years, out of which an extrathyroidal type of malignancy was diagnosed in 11 cases, which constituted 0.3%. The cases are summarized in . The most common malignancy was metastatic adenocarcinoma (six patients), followed by squamous cell carcinoma in three patients, and metastatic invasive ductal carcinoma and small cell carcinoma in one patient each. The most common primary site was the lung. The duration between the detection of primary and secondary tumors ranged from two weeks to 56 months. A delayed metastasis after 56 months was seen in a case of adenocarcinoma of the colon. Another case of rectal adenocarcinoma presented with intrathyroidal metastasis after 29 months. Follow-up is available only in four patients. One patient with carcinoma tongue expired within a month of diagnosis of metastasis. The other three patients were alive at the time of the last follow-up and had survived for a period of nine months (carcinoma colon), 12 months (carcinoma breast), and 28 months (carcinoma prostate) after the diagnosis of intrathyroidal metastasis.


A 32 year old woman, G8 P2 A5, 39 weeks of gestation was referred to obstetric clinic of Adnan Menderes University, School of Medicine with complaint of vaginal bleeding. Total placenta previa was diagnosed by ultrasonography and magnetic resonance imaging (MRI). She underwent an emergency caesarian section. A 2450-gr baby was born with 1 and 5 min. APGAR score of 8/9. Placenta could not be removed completely as it invaded in right-posterior wall of lower segment of uterus. Postpartum hysterectomy was performed to stop bleeding. The vaginal vault was closed with polyglactin 910 (Vicryl-1/Ethicon) continuous interlocking suture. The estimated blood loss was over 2 L. She was administered 4 U of packed cells, fresh frozen plasma, and she was observed on the intensive care unit in the postoperative period for two days. Postoperative recovery was uneventful, and she was discharged 5 days after the operation. On day 21, she applied to emergency clinic by heavy vaginal bleeding and watery discharge. An intra-abdominal hematoma of approximately 16 × 10 × 9 cm in diameter was observed in ultrasonography and MRI. In pelvic examination, vaginal cuff dehiscence was observed (Fig. ). The patient was hemodynamically stable. Intravenous broad spectrum antibiotic had been started. On day 2 of the admission, exploratory laparotomy was performed. Dense adhesions between bowel and bladder were observed. Intra-abdominal hematoma was located between these dense adhesions of bowel, on vaginal vault which could be hardly evaluated. Hematoma was drained abdominally. It was impossible to explore vaginal vault by abdominal surgery because of the dense adhesions. Operation continued in lithotomy and Trendelenburg position. Examination of the vaginal vault in lithotomy position showed the entire dehiscence. Necrotic tissue was debrided, and irrigation, aspiration was performed. Vaginal cuff was closed with synthetic absorbable suture using interrupted sutures. Her postoperative recovery was uneventful and she was discharged on day 29.


A 61-year-old man who had been diagnosed with hypertension and diabetes 15 years previously was referred to our outpatient clinic for an incidental finding on ultrasonography of a right renal mass. He had the nonspecific symptom of fatigue since 12 weeks previously. No palpable mass was detected on the physical examination. The results of routine laboratory examinations and urinalysis were within normal limits. A computed tomography (CT) scan revealed a 10-cm right renal mass with areas of necrosis and suspicious perirenal fat infiltration and invasion to the right adrenal gland. Some lymph nodes were enlarged in the aortocaval area. The tumor also infiltrated the right renal vein and the IVC as a typical advanced RCC (). A diagnosis of RCC with IVC thrombus (cT3bN1M0) was made and a radical nephrectomy with vena caval thrombectomy was planned.
Under general anesthesia, the patient was placed in the supine position with the right side elevated by 15 degrees. A midline abdominal incision was made and a Kocher maneuver was done to expose the right kidney. The liver was retracted to expose the right renal vein and IVC. The right kidney was mobilized and a venous cannulation was performed above and below the IVC mass, and arterial cannulation was performed on the left femoral artery. The incision on the IVC was made where the renal vein was ligated after cardiopulmonary bypass. Vena caval thrombectomy was done and reconstruction was accomplished by use of nonabsorbable sutures. En bloc resection of the right renal mass and regional lymphadenectomy were performed successfully. The pathological diagnosis was invasive urothelial carcinoma, of a high grade, with sarcomatoid differentiation, which invaded the renal cortex but was limited to the capsule (, ). The IVC thrombus was composed of urothelial carcinoma of a high grade; the lymph nodes were free of carcinoma (pT4N0M0). The patient was discharged on the fourth postoperative day, and adjuvant chemotherapy with the methotrexate, vinblastine, doxorubicin, and cisplatinum regimen is scheduled.


A 43-year-old male without any underlying illness, suffered a neurologic deficit and neurogenic intermittent claudication (NIC) of his lower legs, which were precipitated by ambulating a distance longer than 100 meters. His symptoms were aggravated despite the conservative treatment. This patient had no history of administering any exogenous corticosteroid. He was fatty and of a short stature without cushingoid appearance. His body weight was 57 kg and his height was 148 cm.
Lumbar MRI on T2-weighted image (T2WI) implicated that the fatty lesion extended from the posterior aspect of L1 body to the body of S1 (). The axial image revealed the typical "Y-sign" or "Stellate-sign" of the thecal sac (). Multi-level small laminotomy was performed on the left side of L1, L2, L3, L4, and L5, while bilateral decompression was carried out with a one-side approach (). The patient showed an immediate improvement after surgery. Postoperative MRI revealed a much reduced epidural fat and decreased compression of the sacral sac (). Six months after follow-up, he was free from the symptoms.


A 58-year-old male had a sustained lower back pain, leg fatigue and weakness, showing neurogenic intermittent claudication (NIC). He had diabetes mellitus and hypertension. The NIC symptoms were precipitated by walking longer than 50 meters. He had no history of administering any exogenous corticosteroid. He had no definitive cushingoid appearance. His body weight was 76 kg while his height was 164 cm.
The sagittal and axial T2WI MR images showed an extensive epidural fat deposition with a thecal compression from L1 to L5-like thread beads on the string (). Concomitant L4-5 spinal stenosis, due to a protruded disc and ligamentum flavum hypertrophy, was also seen. Right L3 hemipartial laminectomy and L4 total laminectomy with the interbody fusion on L4-5 were performed for the treatment of underlying spinal stenosis (). The fat above and below the laminectomy level was scraped out with a hook. Postoperative MRI revealed much reduced epidural fat with decompression of the thecal sac (). After the operation, the patient improved immediately and one year after follow-up.


A 69-year-old male with diabetes mellitus, hypertension, and chronic renal disease, had a longstanding radiating pain, and showed symptoms of NIC predominantly in the anterior aspect of the right knee. These symptoms were precipitated upon a mere initiation of ambulation. He had no definite cushingoid appearance. His body weight was 62 kg while his height was 155 cm. This patient had numbness in the sensory dermatomal distribution of L4 in the right leg.
The Lumbar MRI revealed moderately bulged intervertebral discs at L4-5 and abnormal hypertrophy of the adipose tissue on the posterior aspect of the spinal canal extending from L3 to L5. It was especially shown in the anterior aspect of the body of right L4, which revealed compression on the dural sac and right L4 nerve root (). Right L4 hemi-laminectomy, L4-5 discectomy and debulking of the epidural fat, especially on the right anterior aspect of the L4 body (), were performed. The postoperative MRI revealed a greatly reduced epidural fat, distinctive visualization of the decompressed sacral sac, and L4 root (). He also showed satisfactory improvement during the follow-up observations.


A 77-year-old man (height, 168 cm; weight, 70 kg) presented at our hospital with black tarry stool. An esophagogastroduodenoscopy was performed and a gastric intestinal stromal tumor 4 cm in size was detected. Thereafter, endoscopic full-thickness gastric resection (EFTGR) was planned. EFTGR can be regarded as a hybrid form of NOTES or as an intermediate form step since a full-thickness incision in the gastric wall is made endoscopically and closure is achieved laparoscopically. We planned the surgery in such a way that endoscopic resection of the tumor would be performed by an endoscopic operator experienced in internal medicine and the laparoscopic dissection and closure of the stomach would be performed by a general surgeon.
The patient had a history of diabetes mellitus and hypertension, and he been taking medicines for these disorders. His preoperative routine laboratory values were within the normal range and a preoperative electrocardiogram (ECG) showed sinus bradycardia of 58 beats/min. The patient was premedicated with 1 mg of butorphanol and 0.2 mg of glycopyrrolate intramuscularly before surgery. His vital signs were stable upon arrival at the operating room and were monitored thereafter using ECG (lead II), pulse oximetry, end-tidal carbon dioxide concentration (ETCO2), and noninvasive blood pressure (BP) determination Because the endoscopes were placed in his mouth, the patient's temperature was measured using a skin temperature probe.
Anesthesia was induced using 120 mg of propofol, 50 mg of rocuronium, and 100 µg of fentanyl and nasotracheal intubation was performed using a nasal RAETM tracheal tube with a 7.5 mm inner diameter (ID), because nasotracheal intubation is convenient for endoscopic procedures. General anesthesia was maintained using O2 at 2 L/min, N2O at 2 L/min, and 1.5-2.5 vol% of sevoflurane, and the concentration of sevoflurane was controlled using the bispectral index. Mechanical ventilation with a tidal volume of 600 ml and a respiratory rate of 10 breaths/min was maintained. After induction, the peak inspiratory pressure (PIP) and ETCO2 were 16-17 cmH2O and 35-37 mmHg, respectively.
The patient was placed in the supine position while the laparoscopic operator remained on the right side of the patient to insert the port and perform the stomach dissection. A pneumoperitoneum was created using carbon dioxide (CO2) gas at a pressure of 14 mmHg throughout the surgery. After CO2 injection, the ETCO2 increased up to 40 mmHg, and hence, the respiratory rate was controlled; however, no change was made to the tidal volume as the PIP was maintained at 23-25 mmHg. After laparoscopic dissection, the endoscopic operator moved into position near the patient's head to perform an endoscopic full-thickness resection of the tumor with sufficient surgical margins (). During endoscopic resection, visibility was ensured through air insufflations, and the PIP pressure was approximately 5-7 mmHg lower than that measured during the laparoscopic procedure using CO2. After confirming no active bleeding, the endoscope was removed, and the laparoscopic operator performed closure of the stomach and sutured the skin wound.
During the entire procedure, hemodynamic stability was maintained and ETCO2 was maintained at 32-37 mmHg. The time required for the laparoscopy was 70 min and that for the endoscopy was 60 min; the anesthesia time was 160 min. Upon completion of the surgery, the patient was transferred to the general ward. No specific complications were observed during the postoperative period, and the patient was discharged on postoperative day 4.


A 50-year-old man (height, 167 cm; weight, 65 kg) was diagnosed with esophageal achalasia due to swallowing difficulty for several years. He was scheduled for peroral endoscopic myotomy (POEM), which is a technique that was developed in the context of transesophageal NOTES as an endoscopic alternative to laparoscopic esophageal myotomy. The patient had no relevant medical history, and preoperative examination did not reveal any specific conditions. He was premedicated using 1 mg of butorphanol and 0.2 mg of glycopyrrolate intramuscularly before surgery.
In the operating room, routine monitoring was conducted using ECG (lead II), pulse oximetry, ETCO2 measurements and noninvasive BP monitoring. The patient's vital signs were as follows: BP, 110/69 mmHg; heart rate (HR), 65 beats/min; and peripheral oxygen saturation (SpO2), 100%. General anesthesia was induced using 120 mg of propofol, 50 mg of rocuronium, and 100 µg of fentanyl, and nasotracheal intubation was performed using a nasal RAETM tracheal tube with a 7.5 mm ID. For the same reason as in case 1, tracheal intubation was performed through the nose. Anesthesia was maintained using O2 at 2 L/min, N2O at 2 L/min, and 1.5-2.5 vol% of sevoflurane. Volume controlled ventilation was performed using a tidal volume of 600 ml and at a rate of 10 breaths/min.
The patient was placed in the left lateral decubitus position, and the endoscopic operator stood on the left side of the patient. CO2 gas was provided for insufflation during the procedure, using a CO2 insufflator and a standard insufflating tube. Endoscopic CO2 insufflation was controlled with a gas feed of 1.2 L/min. The operation comprised the following steps: (1) creation of the mucosal entry and submucosal tunnel, (2) endoscopic myotomy, and (3) closure of the mucosal entry. First, the endoscopic operator administrated a submucosal injection (0.9% normal saline with indigo carmine dye) at the level of the midesophagus in order to ensure a safe mucosal incision. The mucosal incision was then made on the mucosal surface using an electric knife, and the endoscope was inserted into the submucosal space. The submucosal tunnel was then extended 2 cm below the gastroesophageal junction via the endoscopic submucosal dissection technique. Next, the endoscope was withdrawn to the mucosal incision and a circular muscle myotomy was performed. After completion of the myotomy, the mucosal entry site was closed using several hemostatic clips.
For this patient in particular, the surgical duration was relatively long as the achalasia lesion was large.
During surgery, ETCO2 was maintained at 30-34 mmHg and PIP at 13-15 mmHg. The patient's abdomen was not covered using surgical drapes to ensure visibility so that severe pneumoperitoneum could be recognized immediately (). The patient was hemodynamically stable throughout the entire surgery. The time required for the operation and anesthesia were 120 min and 160 min, respectively. The patient was transferred to the general ward after surgery, and a postoperative chest radiograph showed no pneumomediastinum.


In May, 2010, a 49-year-old woman presented with 4 year history of both buttock pain. The onset of the pain had been insidious with no significant history of trauma. The pain was localized to both buttock and lower back. She was referred to our hospital for further evaluation from other clinics. Laboratory findings revealed that serum alkaline phosphatase (ALP) level was 57 IU/L (reference range, 30 to 115 IU/L). A bone scan, which undergone at outside hospital 4 year ago, confirmed pagetic changes in the left ilium (). And, pelvis anterior-posterior radiograph obtained at our hospital revealed a typical mosaic pattern of PD in her pubic and left ilium ().
She had no family history of PD. Physical examination revealed the tenderness at the left iliac crest and posterior iliosacral joint. Her weight was 61.4 kg, height was 162 cm, and body mass index was 23.4 kg/m2. Range of motion at left hip was decreased due to pain, and she walked with a mild limp.
Although the level of ALP was within reference range, pamidronate treatment was started orally for 3 months, because she had a severe pain. However, her pain intensity level increased. The ALP was 44 IU/L, and bone scan show still hot uptake in her both ilium and lumbar vertebrae ().
Subsequently, she received intravenous zoledronate (5 mg) in a single dose at August, 2010. After this treatment, we evaluated clinical and biochemical remission and improvement in bone scan. Three months after administration zoledronate, ALP decreased 26 IU/L, and a severe pain and limping gait disappeared. Six months after intravenous zoledronate, ALP decreased 21 U/L, and bone scan showed the improvement, which means a response of zoledronate (). After then, she was lost to follow-up.
In March, 2012, she visited our hospital again, because of left hip pain. Although ALP was 34 IU/L, and bone scan showed hot uptake in both ilium and lumbar vertebrae ().
One year after second zoledronate, ALP was 37 IU/L, and the bone scan also improved (). She had no pain, and refused the third injection of zoledronate. There was no adverse drug reaction during the treatments.


A 35-year-old man presented with a history of small painful nodule over his right knee for past 2.5 years. Family history and past medical history were insignificant. The lesion began as a small papule, which slowly increased in size over time. The lesion was tender on firm pressure, adherent to superficial dermis, and clinically well demarcated. Routine haematological and biochemical investigations were normal. Mantoux test was negative. The lesion was excised and dispatched for histological examination. Gross examination of the resected specimen showed a 5 × 4-cm, pink-blue nodular lesion with adherent normal looking skin [Figures and ]. The specimen was fixed in 10% neutral buffered formaldehyde solution, tissue was processed and stained with hematoxylin and eosin stain. Microscopic examination revealed several sharply delineated, basophilic nodules in the dermis without any connection with the epidermis []. At higher magnifications, the tumor mass was observed to be composed of two distinct cell population the first type being small, dark basaloid cells located at the periphery of the lesion and the second type being large, pale cells having large vesicular nuclei with pale cytoplasm at the center of the lesion. Parts of the tumor also showed some cytological atypia []. Patient was on follow-up, and, until the time of writing this article, no recurrence has been observed.


A 14-year-old female patient presented with four year history of progressively increasing swelling of the scalp. At first presentation the swelling was small and appeared as lytic lesion on CT scan []. The patient underwent surgery three times, as swelling recurred frequently. Curettage was done at first time, partial craniectomy second time, and total excision the third time. The duration between first and the second surgery was six months, and between second and third surgery was one year. Histopathology examination showed tumor cells with clear cytoplasm. The cells were arranged in nodules infiltrating the superficial dermis with comedonecrosis. There were frequent mitotic figures []. The findings were suggestive of MNH. The tumor cells were positive for CD99 (membrane positivity) and negative for cytokeratin, desmin, leucocyte common antigen, chromogranin and synaptophysin. The surgical margin was found free from tumor third time. Following the third surgery the patient underwent external beam radiotherapy, 45 Gy in 25 fractions. The patient again developed recurrence within a year. At this time the patient had a massive scalp swelling, which was hard and non tender. CT scan showed a large scalp lesion with streaks of calcification, and brain parenchymal invasion. A surface shaded display reconstruction of CT scan showed sunburst appearance from parietal bone. At this time parents of the patient refused for further treatment.


A 45-year-old female patient had swelling in the left parietal region for three months for which she underwent local excision elsewhere. Within one and a half month the swelling reappeared, and progressed rapidly in next two months. At arrival to our institute she had a large swelling in the left parietal region. CT and MRI scan of the head showed a large scalp swelling causing the bone destruction with intracranial extension []. She underwent left parietal craniotomy and total excision of tumor. Histopathology revealed MNH. She was referred for adjuvant therapy to cancer hospital. She succumbed to her illness while receiving radiotherapy within three months of the surgery.


A female patient aged 47 years came to neurosurgical department with complaints of severe headache for 1 week. She was diagnosed to have right frontal lobe abscess based on CT and MRI scan findings. She is a known case of Ebstein's anomaly of heart diagnosed 12 years back. She was apparently normal before, she then developed chest pain, palpitations, dyspnoea, on exertion (NYHA grade III) and poor effort tolerance. She was on regular treatment for recurrent episodes of CHF with diuretics and digoxin. Her physical examination revealed peripheral cyanosis, grade III clubbing of all digits, irregular heart rate and peripheral oxygen saturation (SpO2) of 84%. On auscultation grade II pansystolic murmur was heard in tricuspid area. Electrocardiogram (ECG) showed irregular rhythm with intermittent atrial and ventricular ectopics, large P waves, and T wave inversion in inferior leads. Chest x-ray revealed cardiomegaly and right atrial enlargement. Two-dimensional echo showed right atrial enlargement, atrialization of right ventricle, moderate TR and pulmonary hypertension, intact atrial septum, and moderate left ventricular dysfunction with ejection fraction of 50%. Her laboratory investigations revealed polycythemia with haematocrit of 59.3%, hemoglobin 18.9 grams%, total white blood cell count of 14 600/mm3, and creatinine of 1.1 mg%, normal blood sugar, and serum electrolytes. Arterial blood gas analysis revealed severe hypoxemia with PaO2 of 52 mm Hg and SaO2 of 87%.
Preoperatively she was advised to stop tablet digoxin and diuretics one day prior to surgery. She was put on tablet amiodarone 150 mg twice daily for two days prior to surgery. Prophylaxis for infective endocarditis was given on the day of surgery. In the operating room her baseline vitals were recorded and standard ASA monitoring was established. A 16G intravenous cannula and right radial artery catheter to monitor invasive blood pressure (IBP) secured. Her baseline vitals were heart rate (HR) 84/min, IBP of 147/89 mm Hg and SpO2 of 84%.
A loading dose of intravenous dexmedetomidine 1 mcg/kg was given over 15 min followed by a continuous infusion of 0.5 mcg/kg/h. Induction of anesthesia was with intravenous midazolam 1 mg, fentanyl 50 mcg, and ketamine 50 mg given slowly and titrated to effect. Intubation was facilitated by intravenous vecuronium 0.1 mg/kg. Anesthesia was maintained with 50% nitrous oxide in oxygen and sevoflurane 0.5–2% intermittently in circle system with controlled ventilation. A 16G peripherally inserted central venous catheter was secured in left arm with the tip of catheter at superior venacaval – right atrial junction confirmed radiologically. Surgery was performed with the patient in supine position with 30° head up and turned to left.
Twenty minutes post intubation patient developed hypotension, so dexmedetomidine infusion was tapered to 0.25 mcg/kg/h and dobutamine infusion was started at 5mcg/kg/min. Oxygen saturation was maintained between 80–94% and 100% oxygen was given when saturation dropped below 80%. Stable hemodynamics was achieved intraoperatively with mean arterial pressure between 70–100 mm Hg and HR between 60–80/min. Raised ICP in the intraoperative period was managed by hyperventilation to maintain end tidal CO2 at 30–35 mm Hg, head up position and intravenous mannitol 200 mL. Ventricular ectopics were noticed after 2h of surgery. A loading dose of intravenous amiodarone 300 mg was given followed by continuous infusion of 1 mg/min for 6 h. Serum potassium levels were low at 3.0 meq/L and hence potassium supplementation was done at 10 meq/h for 6h. Surgery lasted for a period of 4 h. Dexmedetomidine 0.25 mcg/kg/h was continued till extubation. Extubation was smooth after surgery with patient hemodynamically stable with HR of 92/min, IBP of 116/77 mm of Hg and O2 saturation of 84%. Patient was shifted to neurosurgical ICU with maintenance infusion of amiodarone and dobutamine. Oxygen support was given for 48 h, tapered and withdrawn. Tablet amiodarone 150 mg was started on second postoperative day. Sinus rhythm was restored on second postoperative day. Her further course in the hospital was uneventful and she was discharged home on fourteenth postoperative day.


A 45-year-old male patient Asian origin (—Kerala, India) was admitted with pain in abdomen, nausea, and vomiting with fever since 2 days. Clinical symptoms, signs, and investigations were suggestive of acute appendicitis. Patient was scheduled for an emergency appendicectomy. His weight and height were 70 kg and 173.5 cm, respectively with BMI 23.25. On medical history he had chest pain and for the same was admitted to Hamad general Hospital 1 year back. There was no history of chest pain after that episode, syncope, palpitations in the past. He was investigated with normal blood investigations during that time. But on ECG there was RBBB with ST elevation (coved) in lead V1–V3. Holtermonitorings were done suggestive of atrial premature contractions. On the stress test, as per Bruce protocol, it was negative with the target rate, no ECG abnormality. So cardiologist suggested that baseline ECG suggestive of Brugada syndrome. He was having past history of productive cough, which was diagnosed as asthmatic bronchitis 3 weeks back. He received antibiotics and salbutamol inhaler (as and when required- last used 3 weeks back). There was family history of father's sudden death, but details are not available. No past surgical or allergic history. On general and airway examination was normal except fever. Systemic examination was normal except abdominal tenderness. Chest X-ray was normal. ECG findings same as before RBBB with ST elevation (coved) in lead V1–V3 with QTc 420 msec.
Looking at clinical examination, investigations and as per surgical indication, general anesthesia with avoidance of sodium channel blocker medications was planned. Detail explanation given to patient and consent was taken. Routine monitorings were used. Defibrillator was kept ready. Atropine as per routine was kept ready for abolish any vagal effect. As any vagal stimulation in this type of cases, this leads to dysrrthymias.
General anesthesia was induced with propofol 2.5 mg/ kg and neuromuscular blockade provided through atracurium 0.5 mg/kg. Analgesia was supplemented with fentanyl 2 mcg/kg and patient maintained on sevoflurane with air for controlled ventilation. Paracetamol 1 gm intravenous was given. Spontaneous extubation was carried out with smooth emergence and breathing spontaneously, obeying commands, and satisfactory muscle power. Neostigmine was avoided due to its ability to produce dysrthymia in these cases. Postoperative analgesia provided with morphine in titrated doses. Postoperative care was given in the postanaesthesia care unit. No untoward events (no bradycardia or ventricular fibrillation) occurred during the anesthesia. Total surgery and anaesthesia times were 45 and 65 min, respectively. Invasive monitorings were avoided due to short surgical procedure without much haemodynamic instability. Patient was discharged following an uneventful hospital stay.


A 30-year-old male is known to have bronchial asthma, on Salbutamol as needed, contact dermatitis on both hands and gout. Patient underwent a low anterior resection with diverting loop ileostomy for a midrectal adenocarcinoma 4 months back and received three cycles of adjuvant chemotherapy. Complaining of bleeding per rectum was presented to the clinic. Clinical examination revealed a very tight anastomotic stricture. A trial of balloon dilatation using the flexible sigmoidscope failed even with the usage of the guide wire. Biopsy revealed ulceration with granulation tissue, but no malignancy was seen. Patient was admitted for dilatation under anesthesia. Under spinal anesthesia, strictured anastomosis was rigid and fibrotic; aggressive finger and instrumental dilatation (Higar dilators) was performed. There was a minor bleeding postdilatation. Flexible sigmoidoscopy was performed intraoperatively at the end of the procedure. Ninety min after dilatation, patient complained of sudden onset shortness of breath followed by tachyarrhythmia with oxygen desaturation reaching 78% that was followed by bradycardia. Patient was immediately intubated. In a second, tachyarrhythmia change to Bradycardia, then systole yellowish discoloration, bluish discoloration. CPR was initiated.
The patient was intubated ventilated with 100% oxygenation, atropine-given adrenaline colloid started cardiac pulmonary resuscitation initiated immediately, external cardiac massage with chest compression 100/min, location of endotracheal tube was confirmed immediately by chest auscultation there was equal air entry in both sides, 1 mg epinephrine every 5 min but not responding to CPR.
During CPR, authors searched and treat possible reversible causes of cardiac arrest-like Hypovolemia, acidosis, tension pneumothoraxsocolloid was given, chest X-rays requested ABG-showed acidosis corrected by sodium bicarbonate, no hypokalemia or hyperkalaemic, not responding to external pace maker and after aggressive resuscitation for 45 min and the patient declared dead after 45 min.
Differential diagnosis was pulmonary embolism, tumor embolism, air embolism sever intra-abdominal bleeding.
On site CXR was immediately taken after announcement of death and showed a large lucent area projecting over cardiac shadow. Most of the cardiac silhouette has been replaced by lucent shadow that is peripherally outlined by the cardiac muscle indicating the presence of significant pneumocardium.
There was no air dissecting around the major vascular structure in the neck and thymus gland is not separated from the cardiac shadow thar ruled out pneumomediastenum [].


A 43-year-old female came to the emergency room with complaints of pain abdomen, was diagnosed to have acute appendicitis and was scheduled for an emergency appendectomy. She was a known case of DCM since 1½ years. She gave a history of hospital admission 5 months ago with features suggestive of congestive heart failure. Her symptoms were well-controlled on treatment with oral frusemide, spironolactone, digoxin, ramipril and carvedilol.
On examination, her heart rate was 88/min and blood pressure of 106/66 mmHg. There were no features suggestive of congestive cardiac failure. A 12 lead electrocardiography (ECG) showed normal sinus rhythm and T-wave inversion in leads III and aVF. Chest X-ray revealed cardiomegaly. The ECG showed LVEF of 20%. Routine laboratory investigations were normal with hemoglobin level of 10.7 g%.
High-risk consent was taken from the patient and regional anesthesia technique explained.
Combined spinal-epidural anesthesia was planned. After taking patient in the operating room, pulse oximetry, ECG and non-invasive blood pressure monitors were applied. After securing intravenous line, left radial artery and right internal jugular vein cannulation was also carried out under local anesthesia.
Under all aseptic precautions, a combined spinal epidural block was given. Sub arachnoid block with 7.5 mg of 0.5% bupivacaine heavy along with 25 μg fentanyl and 0.3 mg of morphine attained a sensory level of T5. It was associated with hypotension with blood pressure of 76/40 mmHg, which was managed with intermittent intravenous boluses of 3 mg ephedrine. Surgery lasted 45 min. Central Venous Pressure (CVP) ranged from 7 to 9 cm H2O.
Her post-operative course in high dependency unit for 1 day and further in ward till discharge was uneventful.


The present case report is about a 28-year-old male patient who was brought into our ICU after a road traffic accident, with an ETT secured in the casualty. He had a head trauma, with a Glasgow Coma Score 8, stable vitals but shallow respiration. The patient required mechanical ventilation and was connected to a ventilator on Synchronized Intermittent Mandatory Ventilation mode. We noticed that the ETT was fixed at 24 cm using tie and plasters and breath sounds were lesser on the left side on auscultation. Hence, the plan was to re-fix the tube after slight withdrawal once bilateral equal breath sounds were heard on auscultation. After thorough oral suctioning, while the ETT tie was being cut, it leads to cutting of the ETT cuff tubing as well. Following this, we noticed a leak and inadequate ventilation. The patient was mask ventilated with 100% oxygen, using Artificial Manual Breathing Unit bag and then re-intubated with an 8.0 mm ID cuffed Portex ETT. We secured the ETT carefully this time at depth of 21 cm with plasters.


The case we present here is about a 40-year-old man who was referred to our pain clinic with severe ischemic pain of right lower limb. The pain started gradually 10 months back and became very severe for the last 1 month. The intensity of pain was increasing in both the sitting and lying down positions and decreasing in a standing position. Many non-steroidal anti-inflammatory drugs were tried earlier without much benefit. Over the last 1 month, the severity of the pain was so bad that the patient had to stand all the time and sitting or decubitus position was not tolerable even for 1 min. His sleep was so miserable that he had been taking small naps in that standing position leaning onto some support. He had carcinoma rectum for which he underwent abdominoperineal resection 8 years ago. There was history of smoking prior to that. After the surgery, he had been leading a near normal life driving auto rickshaw for a living until he developed the present problem. There were many gangrenous ulcers over his right thigh and leg. A computed tomography-angiogram was done previously that showed a thrombus in the right common iliac artery measuring about 9.5 cm extending up to the right superficial femoral artery with a near total occlusion of the lumen and poorly developed collaterals. He was scheduled for a conventional peripheral angiogram for deciding on the further plan. However, he could not lie down in the catheterization laboratory due to severe pain and was referred to our Department of Pain Management. We initially tried a conservative approach with a combination of oral pregabalin, diclofenac, paracetamol, and tramadol as per the standard dosage protocol for 2 days. When there was no satisfactory pain relief, we planned epidural analgesia. However, the problem here was the positioning. Patient was not able to tolerate either sitting or lateral decubitus position even for 1 min. He was somewhat comfortable only in the standing position. Considering the special situation, though not conventional, we decided to place the epidural catheter in that standing position. An intravenous line was started using an 18G venous cannula. Electrocardiogram, pulse oximeter, and non-invasive blood pressure monitors were connected. Patient was made to stand besides the operating table holding on to it for support. He was also supported by a technician from the front []. After painting and draping the back, L 4-5 inter-space was identified and local anesthesia was given with 2% lidocaine. Epidural space was engaged with 18G Tuohy needle using loss of resistance to air technique. The epidural catheter was carefully threaded and placed such that the length of the catheter was 5 cm in the epidural space. Catheter was gently aspirated to check for blood and cerebro-spinal fluid and was fixed after subcutaneous tunneling for about 5 cm []. Patient was reassured and gently placed on the operating table in the supine position. A quick test dose was given with 3 ml of 2% lidocaine with 15 mcg adrenaline confirming the epidural placement followed by a bolus of 10 ml of 1% lidocaine along with 1 ml of 7.5% sodium bicarbonate. The pain was relieved within 1 min and the vital signs were stable. Epidural infusion was maintained thereafter with a solution of 0.125% bupivacaine and dexmedetomidine 2 mcg/ml at the rate of 5 ml/h. Patient was very comfortable and slept peacefully. Next day peripheral angiogram was performed, which confirmed the findings of CT-angiogram. Balloon angioplasty was attempted after 2 days, but was not successful and an above knee amputation was performed subsequently. Epidural catheter was removed after 2 days and further pain control was achieved satisfactorily with oral medications.


A 65-year-old obese woman (gravida 3 and para 2) presented to a private clinic with a complaint of vaginal bleeding for 3 months, having been menopausal since age 55. The result of Pap smear was atypical glandular cells, favor neoplastic with negative HPV (human papillomavirus) DNA test. The patient had history of hypertension and hyperlipidemia. Her medications included estrogen replacement therapy and aspirin for 4 years.
She was referred to the Yonsei University Wonju Severance Christian Hospital for definitive diagnosis and therapy. Abdominal computed tomography revealed uterus didelphys with complete duplication of uterine horn and cervices and suspicious 2.0×1.7-cm-sized, oval-shaped relatively soft tissue mass in right cervix. Abdominal ultrasonography result showed mild fatty liver change with two hepatic cysts in S6 (0.7 cm) and S7 (2.2 cm). PET-CT (positron emission tomography-computed tomography) revealed focal FDG (fludeoxyglucose) uptakes in the left uterine cavity.
Uterine endometrial and cervical biopsies were performed. The endometrial biopsy revealed malignant tumor, suggestive of undifferentiated carcinoma while cervical and endocervical biopsies showed inflammatory change.
Total abdominal hysterectomy, bilateral salpingo-oophorectomy, and staging workup (bilateral pelvic lymph node dissection and pelvic washings) were performed. At the time of surgery, it was determined that the patient had a bicornuate uterus. Gross examination revealed a bicornuate uterus () (left horn 6.5×4×3.5 cm, right horn 7×4×3 cm) with a single cervix (4×3.5×3 cm). On opening, the entire endometrium of left horn showed an ill-defined white-gray granular mass, measuring about 6×4×0.5 cm (). The endometrium of right horn was grossly unremarkable with focal granular irregularity in the lower uterine segment. The myometrium revealed two small leiomyomas in the right horn, measuring 2 cm in diameter in the larger one. The attached bilateral ovaries and tubes showed no gross abnormality.
Microscopic examination revealed a mixed endometrioid adenocarcinoma (80% component) () and undifferentiated carcinoma (20% component) () in the left endometrium. The endometrioid adenocarcinoma had less than 50% solid areas, hence designated as International Federation of Gynecology and Obstetrics (FIGO) grade II. Immunohistochemical stains showed positivity for EMA, CAM 5.2, estrogen and progesterone receptors in endometrioid adenocarcinoma component while undifferentiated carcinoma component showed no positivity (). The Immunohistochemical stain for cytokeratin showed diffuse positivity in endometrioid adenocarcinoma component and focal positivity in undifferentiated carcinoma component (). The tumor showed superficial invasion (0.4 cm in maximum depth) into the myometrium (2.5 cm in thickness). The endometrium of right horn showed a tiny focus of endometrioid adenocarcinoma, measuring less than 1 mm in diameter. The bilateral adnexae, parametria and pelvic lymph nodes were all free from tumor. The disease was consistent with FIGO stage IA (T1aN0Mx). Other histological findings were adenomyosis and leiomyomas in myometrium. The patient recovered from surgery and is receiving chemoand radiotherapy.


A 24-year-old-female patient reported to surgical outdoor with history of constipation, mild vague abdominal pain for 1 week. Menstrual cycle was regular. On examination, the vitals were stable. Central nervous system and cardiorespiratory system examination was normal. Abdomen was soft and non tender on palpation and revealed normal bowel sound on auscultation. Complete blood count and urine examination was normal. The patient had normal report of abdominal ultrasound study which was carried out two days back in private diagnostic center. Contrast-enhanced CT scan of abdomen was performed in our hospital after oral and intravenous contrast administration to the patient for further evaluation. Liver showed three hepatic veins such as right hepatic vein, middle hepatic vein and left hepatic vein draining to inferior venacava (). The hepatic veins are of normal caliber. MPV revealed single IHPV without bifurcation () entering the right lobe of liver, coursing anteriorly in an arch like pattern with decreasing caliber to reach the left lobe of liver and giving rise to segmental branches to both lobes of liver. The MPV caliber was normal and measures about 9 mm in diameter. Thick maximum intensity projection axial and oblique images showed MPV behind pancreatic neck, absence of MPV bifurcation at porta hepatis, single IHPV entering right lobe of liver, giving rise to segmental braches to both lobes of liver (). Both lobes of liver were of normal size. No intrahepatic biliary channel dilation was seen. Abdominal organs, bowel loops, and retroperitoneum were unremarkable in the abdominal CT study. The normal anatomical pattern of portal vein and hepatic veins in CT study of abdomen in another patient was shown in for comparison.