A 3-year-old girl was admitted to the West China Hospital of Sichuan University with a complaint of a painless abdominal mass in the right upper side of the body. Perinatal and family histories were noncontributory to the diagnosis. Upon physical examination, a well-defined, firm, round, non-tender mass was found in the upper right abdomen. Her serum β-human chorionic gonadotropin (β-HCG), α-fetoprotein (AFP), carcinoembryonic antigen (CEA), and neuron-specific enolase (NSE) levels were normal. Laboratory tests, including serum electrolyte levels, urinalysis, and complete blood counts, showed normal results. Transabdominal ultrasonography revealed a cystic-solid mass with a clear boundary in the right abdomen. The mass had multifocal solid components with variable echogenicity (Fig. ). Contrast-enhanced computed tomography of the abdomen showed a cystic-solid mass in the upper right abdomen, with some calcification, that was 10 × 12 × 15 cm (Fig. A and B). Hypodense areas of fat density were seen within the mass. Other symptoms such as lymph node enlargement, ascites, vascular invasion, or obstruction of the collecting system were not found.
Under general anesthesia, the patient underwent an exploratory laparotomy through a transverse abdominal incision. The operative finding was a large and well-defined retroperitoneal mass with a clear boundary and no invasion of the surrounding organs and vital vessels. The resected specimen was a well-encapsulated multinodular soft mass, which was 10 × 13 × 14 cm with mostly solid areas and some focal cystic areas. The outer surface was covered by a thin fibrous capsule. On a cut section, the mass was composed of yellow adipose tissue, bone, cartilage, and abundant mucoid contents. The remainder consisted of several nodules of a solid, fleshy tumor that were yellow-gray in color and that occasionally exhibited a variegated appearance with hemorrhage and necrosis.
Microscopic examination of the lobulated adipose tissue portion of the mass revealed a mature teratoma composed of fibrovascular septa, adipose tissue, skeletal and smooth muscles, bone, cartilage, and cystic structures. The solid area revealed a diffuse proliferation of immature tumor cells, which resembled renal blastemal components; these were separated by mature fibrous, fatty, and glial tissues (Fig. A–C). Anaplasia was not present.
The solid area of this tumor was strongly positive for Wilms tumor antigen 1 (WT1), transducing-like enhancer of split 1 (TLE-1), and Antigen Ki-67 (Fig. A–C) but was diffusely negative for Sal-like protein 4 (SALL4), chromogranin A (CgA), Syn, EMA, S-100, glial fibrillary acidic protein (GFAP), desmin, Lens culinaris agglutinin (LCA), oligo-2. These findings are consistent with the diagnosis of TWN (stage I).
The patient was discharged home on the 8th day after surgery because of her high therapeutic compliance. The girl had no complaints during the 2 years follow-up period, and her serum β-HCG, AFP, CEA, and NSE values were all within the normal ranges.
A literature search was conducted using PubMed/NCBI. The selected keywords were “teratoid Wilms tumor,” “teratoma with nephroblastic tissue,” or “teratoma with nephroblastoma.” We were able to identify 53 previously reported cases in addition to our case.[ The cases involved 31 boys and 23 girls, with a male-to-female ratio of 1.35:1. Almost all patients were young children, except for a 62-year-old woman and 6 adult men. The mean age at diagnosis was 80 months (range, 0–744 months).
The locations of these 54 tumors were the kidney (31), retroperitoneum (7), sacrococcyx (4), testis (3), mediastinum (2), abdomen (the specific location is unknown, 2), thoracic cavity (1), stomach (1), neck region (1), uterus (1), and vagina (1). At presentation, 12 patients had stage I disease, 6 had stage II disease, 5 had stage III disease, 2 had stage IV disease, and 5 had stage V disease; the stages of the other 24 cases were unknown. Three patients presented with pulmonary metastasis at diagnosis, 2 had lymph node metastasis, and 1 had brain metastasis. Abdominal pain and distension were the most common presenting symptoms. In all cases, microscopic studies showed that the tumors were largely composed of heterogeneous tissues, including adipose tissue, skeletal and smooth muscles, fibrovascular septa, cartilage, immature glomeruloid elements, and tubular structures. The masses in the majority of cases were composed mainly of adipose tissue, and the next most common component was epithelial tissue.
The chemotherapy protocols that were utilized were not uniform. Chemotherapy was administered in 38 cases. However, only 1 patient (2.6%) demonstrated sensitivity to chemotherapy. In 19 cases, chemotherapy was administered preoperatively, and the sole responder was in this group. Thirty patients were administered postoperative chemotherapy, and 11 patients received both preoperative and postoperative chemotherapy. Six patients received both preoperative whole-body external-beam radiotherapy and chemotherapy, but none of those patients responded to treatment. Twelve patients were administered postoperative radiotherapy.
The mean length of the follow-up period for all cases was 23 months (range, 0–7 years). Moreover, 49 of the 54 cases (90.7%) were alive and healthy at the last follow-up time point, although 1 patient developed chronic renal insufficiency. Five deaths (9.3%) occurred as follows: 1 from primary tumor, 2 from tumor recurrence, 1 from postoperative sepsis, and 1 from pulmonary relapse at 6 months.


A 73-year-old man presented to our emergency department with lower right abdominal pain 3 days after a routine screening colonoscopy. His past medical history was significant for hypertension and gout. No significant abnormalities were found through the colonoscopy and no biopsy was performed. The procedure itself was uneventful, and intubation into the terminal ileum was easily performed. The bowel preparation was excellent and good visualization of the caecum, appendiceal orifice, and ileocaecal valve was obtained (Fig. ). There were no signs of inflammation in the caecum or around the appendiceal orifice. The patient initially felt mild lower right abdominal pain shortly after the procedure, but he did not pay enough attention to it at that time and left the hospital.
Three days later his lower right abdominal pain gradually intensified and spread to the whole abdomen, accompanied by nausea, vomiting, and fever. The vomitus was stomach contents. On examination he was found to have a temperature of 38.3 °C, a pulse of 109 bpm, and a blood pressure of 158/84 mmHg. On physical examination the patient had signs of generalized peritonitis. His abdomen was diffusely tender, especially in the lower right quadrant, with rebound tenderness and guarding. The laboratory results revealed a white blood cell count of 13.1 × 109 cells/L, a neutrophil count of 11.8 × 109 cells/L (90.4%) and a C-reactive protein level of 188.9 mg/L. Abdominal and pelvic computed tomography (CT) (Fig. ) revealed the presence of multiple free gas in the right subphrenic space and abdominal cavity with exudate effusions in both sides of the paracolic sulci and the pelvic cavity, especially around the ascending colon and caecum. The CT scan also showed a dilated and inflamed appendix with fecaliths, and cholecystolithiasis.
The patient was arranged for exploratory laparotomy after initial diagnosis. A right middle-lower vertical rectus abdominis incision was made. Intraoperative findings were of a large amount of yellow purulent fluid in the abdomen, the greater omentum abnormal gathering in the right lower abdomen, and an inflamed gangrenous appendix with focal perforation in the midportion. The appendix was about 8.5 cm long and 1.5 cm wide with impacted fecaliths in the lumen of the appendix root. The colon showed no evidence of perforation or other areas of concern. An appendectomy was performed and the abdominal cavity was rinsed and drained thoroughly. Histopathological examination (Fig. ) subsequently confirmed the clinical diagnosis of acute gangrenous appendicitis with periappendicitis, perforation, and appendiceal fecaliths. The postoperative course was uneventful.


A 21-year-old female patient was referred to the department of Conservative Dentistry & Endodontics due to pink discoloration seen in her maxillary right lateral incisor (tooth #12) []. The medical history was noncontributory. The patient had history of orthodontic treatment about a year prior. On clinical examination, pink discoloration on the labial surface of the crown in the cervical region was seen and a “catch” was detected [] with subsequent bleeding. The tooth was nontender to percussion and gave a positive response to electric and thermal pulp testing. Radiographic examination showed an irregular radiolucency having a mottled appearance involving the coronal dentine and extending to the coronal third of the root []. Axial CBCT (Planmeca ProMax 3D, Planmeca Oy, Helsinki, Finland) slices revealed the extent and encircling nature of the lesion []. Though the lesion appeared to be in close approximation to the pulp space, some amount of intervening dentine was present. Coronal CBCT slices and 3D CBCT reconstruction images revealed compartmentalization of the lesion, with presence of bone like tissue in the lower compartment [Figure –]. The diagnosis was Heithersay's Class 3 ICR lesion. The patient was presented with two treatment options: (a) Surgical approach combined with nonsurgical internal approach which would warrant an intentional root canal therapy or (b) surgical approach only and root canal therapy in case of pulp exposure during the surgical approach or if the tooth becomes symptomatic at a later date. The patient opted for the second approach.
A full thickness labial mucoperiosteal flap was reflected following local infiltration anesthesia. Granulomatous tissue was seen involving the labial surface and part of the distoproximal surface []. A small cotton pellet dipped in 90% trichloroacetic acid (TCA) was applied on the tissue with gentle pressure for 1 min []. Care was taken to squeeze the excess TCA from the cotton pellet with a gauze before application to avoid contact with adjacent bone. The necrotic tissue was scooped out with the help of a discoid excavator (Acharya Instruments, Manipal, Karnataka, India) []. This procedure of application of TCA and removal of necrotic tissue was carried out till a sound dentinal base was seen []. The area of osseous ingrowth was left untouched and the defect was refreshed with a round bur (Maillefer, Dentsply, Switzerland). No exposure of the pulp was evident at this stage. The resorptive defect extended from the cervical one third of the crown to the cervical one third of the root, involving the distoproximal line angle, with the defect becoming shallow toward the root. A combination of resin modified glass ionomer cement (RMGIC) (Fuji II LC; GC Corporation, Tokyo, Japan), composite resin (Tetric-N-Ceram, Ivoclar Vivadent, Liechtenstein), and MTA (Angelus, Londrina, Brazil) was used to restore the defect. After obtaining moisture control with absorbable gelatin sponge (Gelfoam, Pfizer, USA), a “framework” with RMGIC was created by building the distal proximal surface and the cervical portion of the tooth, resulting in two cavities: Coronal and radicular []. The axial wall of the coronal cavity was also lined with RMGIC. MTA was mixed and packed in the radicular cavity and the coronal cavity was restored with composite resin []. The flap was sutured back [] and the patient was called for follow up after 1 week for suture removal. The postoperative radiograph revealed the nonrestored osseous compartment and an infiltrative channel present mesially alongside the canal in the coronal one third of the root []. At a 1 month recall, the patient was asymptomatic and the probing depth was normal with no gingival recession. However, after 2 months, the patient presented with pain in relation to tooth #12. The tooth was sensitive to percussion and did not respond to electric and thermal pulp testing. The diagnosis was pulp necrosis with symptomatic apical periodontitis. Hence, it was decided to initiate a root canal therapy for tooth #12.
Access cavity preparation was done and the canal was negotiated. A small communication with the external root surface was probed with an endodontic explorer (DG-16, Hu-Friedy, Chicago, USA) in the cervical region with no evidence of bleeding. A long shanked endodontic excavator (31W Endo excavator, Hu-Friedy, Chicago, USA) was used to check for the presence of any granulomatous tissue. Long shank burs (Munce Discovery Burs, CJM Engineering, Inc., Santa Barbara, CA, USA) were used at slow speed in the cervical region through the access cavity, under magnification and illumination (STAC loupes ×3.5, Analytical Medical Technologies, India), for thorough debridement and removal of osseous tissue. Cleaning and shaping of the canal was carried out and calcium hydroxide (Ca-Excel, Ammdent, India) intracanal medicament was placed in the canal. Calcium hydroxide powder (Deepti Dental, India) mixed with saline, to a thick consistency was carried with an amalgam carrier (GDC, India) and packed in the cervical defect, to limit its solubility. After 1 week, calcium hydroxide was removed and root canal obturation was carried out. MTA was mixed as per the manufacturer's instructions and condensed into the resorptive defect. A moist cotton pellet was placed in the pulp chamber and the access cavity was temporized (Cavit, ESPE, Seefeld, Germany). After 48 hours, the MTA was checked for set and the access cavity was restored with composite resin (Tetric-N-Ceram, Ivoclar Vivadent, Liechtenstein). Some amount of unintentional extrusion of MTA, beyond the confines of the defect was observed []. At a 1 year follow-up, clinically, the periodontal status of tooth #12 was good and probing depths were within normal limits. The follow-up radiograph [] showed complete periapical healing and adequate sealing of the resorptive defect with no changes in the surrounding osseous tissue. There was no progression in the extent of the infiltrative line on the mesial aspect.


A 6-year-old boy born to non-consanguineous marriage presented with thickened keratotic plaques over both hands and feet. The lesions started at 3 years of age and gradually progressed leading to fissures and flexion deformity of digits. The patient was initially diagnosed as ectodermal dysplasia and Olmsted syndrome at two different centres and referred to us for opinion. On examination, the patient had diffuse alopecia with follicular prominences, thin and sparse eyebrows, and pits over the malar eminence [Figure and ]. All 20 nails were dystrophic and subungual hyperkeratosis was present. None of his siblings (3 sisters and 2 brothers) had similar lesions. Histopathological examination of the lesional skin of the palm revealed hyperkeratosis, acanthosis, and perivascular inflammatory dermal infiltrate, whereas the papular lesions revealed a histology suggestive of keratosis pilaris. Based on these findings, a diagnosis of XLO syndrome was made. Tests before initiation of retinoids were done including a baseline complete blood count and chemistry panel which included liver function tests, fasting triglyceride, and cholesterol levels, as well as baseline radiographs of lateral cervical, lumbar, and thoracic spine. Following this, saline compresses and topical salicylic acid 6% with oral isotretinoin (0.5 mg/kg) was initiated and there was marked improvement in PPK at 1-month follow up [Figure –]; the dose was subsequently reduced by 5 mg every alternate day for a month.


A 53-year-old male patient presented with a tetraparesis after the accident. He first woke up in a hospital after the accident. After 1 day, he was brought to a hospital in Germany for diagnosis and treatment.
The patient had a reduced muscle strength on examination. It is shown in . The muscles of the right side of his body were weaker than the left side. Furthermore, the right hip flexors were not affected as much as the muscles in the other segments below C5. The anal sphincter was floppy but could be activated to a minor degree from the right side. Clinical testing on the muscle strength showed that the patient had spared muscle movement below the level of the injury and could not move against gravity on one half of his body. The other half was not effected in this way. In conclusion, the right part of his body has to be classified as American Spinal Injury Association (ASIA) C, while the left part of his body can be classified as ASIA D.
The patient has to be checked for injuries of the vertebrae, the spinal cord and the soft tissue of his dorsum. Fractures can be assessed using X-ray or computed tomography (CT) of the spine. The CT imaging should be preferred if available because it is not possible to display the complete spine using X-ray. Especially the cervicothoracic junction is often superimposed by the shoulders. The biggest advantage of the CT is the possibility to create multiplanar reconstructions of different planes of the spine. Magnetic resonance imaging (MRI) is necessary to evaluate whether the patient has a direct or indirect (swelling/edema/bleeding) injury of the spinal cord or soft tissue injury. There are also patients who have a neurological deficit but no radiographic evidence for a trauma. This is called SCIWORA (Spinal Cord Injury Without Radiographic Abnormalities).
The patient initially received a CT, which showed an avulsion of the anterior inferior margin of the 6th cervical vertebra. Additionally there were fractures of the transverse processes of the 6th and 7th cervical vertebra, the 1st thoracic vertebra and rib fractures from the 4th to the 8th rib on the left side. To evaluate the soft tissue damage and the injury of the spinal cord, he also underwent an MRI. A discoligamentous lesion between C5 and C6, as well as a swelling of the spinal cord was detected and is shown in .
The patient received no methylprednisolone because he arrived more than 8 hours after the injury happened. The intervertebral disc between the cervical vertebras 5 and 6 was removed and the vertebras were joined. During this surgery, a suprapubic fistula of the bladder was applied to allow the urination.
To reduce the influence of the secondary injury the patient received an experimental therapy with an initial intrathecal application of erythropoietin (EPO). From the first postsurgery day until the 58th postsurgery he was treated with subcutaneous injections of EPO, granulocyte colony-stimulating factor (G-CSF) and vitamin C every 3–5 days and regular control of his laboratory values.


A 63-year-old Afro-Caribbean female patient was electively admitted to The London Clinic in London, UK for a liver biopsy prior to starting anti-viral treatment for recently diagnosed HCV infection. Liver assessment with non-invasive means had previously failed, as transient elastography produced inconsistent results. Her past medical history was remarkable for B cell lymphoma and cholecystectomy. She was a non-smoker and denied any alcohol consumption. She was not taking regular medications. She was incidentally diagnosed with HCV infection while managed for the lymphoma and subsequently she was referred for further management. Viral load at that point in time was 1.5 × 106 IU/ml.
A single pass 18-gauge ultrasound guided percutaneous liver biopsy was carried out and tissue was taken from the right lobe; the procedure was well-tolerated. Later during the day, she reported severe right upper quadrant abdominal pain radiating to the right shoulder, with associated nausea and vomiting. An abdominal ultrasound was carried out and a large right perihepatic haematoma and a moderate-sized haematoma within the right liver extending centrally were shown. There was a gradual fall in haemoglobin from 129 g/dl on admission to 111 g/dl after the biopsy and 106, 87 and 67 on Days 2, 3 and 4 after the biopsy respectively. She remained haemodynamically stable and packed red cells were transfused. A repeat ultrasound showed stable appearance of the haematoma and a trace of free fluid in her abdomen. CT angiography two days after the biopsy demonstrated innumerable tiny (1–2 mm) predominantly peripheral and subcapsular microneurysms (Fig. A). Subsequently, the coeliac axis and hepatic artery were catheterized and digital subtraction angiography confirmed the presence of the microaneurysms (Fig. B). Co-axial microcatheter technique was used to interrogate the right hepatic artery branches; the branch that was clearly bleeding was embolized with coils (Fig. C). The appearance of the microaneurysms was resembling that seen in PAN [–].
Following rheumatology assessment, serum autoantibodies, including perinuclear and cytoplasmic anti-neutrophil cytoplasmic antibodies, were tested and only weakly positive anti-nuclear antibodies were demonstrated (titre 1:160); cryoglobulins, rheumatoid factor and anti-citrullinated protein antibody were also negative; immunoglobulins were within normal range. No skin lesions were detectable on clinical examination. With the presumption of hepatic vasculitis, she was empirically commenced on Prednisolone 30 mg daily as per the rheumatologist’s recommendation. Recovery was uneventful and the patient was discharged a week later. Follow-up at 3 months showed a predictable change in the ultrasound appearance of the communicating intrahepatic and subcapsular haematoma, typical of an organizing haematoma (Fig. D). Prednisolone was gradually reduced and eventually discontinued. She continued with her management overseas, where she was scheduled to receive anti-viral treatment with direct-acting antivirals (DAAs). She also had follow-up cross-sectional imaging at 6 and 12 months after the haemorrhage, and reportedly no microaneurysms were seen.


The presenting symptoms of this 62-year-old woman included 2 years of symmetrical polyarthritis in hands, xerostomia and conjunctiva sicca. After the diagnosis of RA with Sjögren’s syndrome was made, she took MTX 5 mg three times a week regularly for several weeks but developed insidiously intermittent fevers up to 39°C, oral ulcers and productive cough with copious mucopurulent sputum within 2 weeks after start of the medications. There was no chest tightness, abdominal pain, diarrhoea or dysuria. On presentation to the hospital, body temperature was 37.9°C, heart rate 103/min, respiratory rate 20/min and blood pressure 115/67 mm Hg. Physical examination revealed neck and axillary lymphadenopathies (LAP) as well as fine crackles in bilateral lower lungs. After initial exclusion of neoplasm (such as alveolar cell carcinoma or metastatic lung cancers), empirical antibiotics was given for 1 week but could not alleviate fever.


A 53-year-old Hispanic female with a past medical history significant for hypertension and diabetes mellitus presented with six episodes of bright red blood per rectum mixed with bowel movements for 1 day. She denied nausea, vomiting, or abdominal pain. There was no history of non-steroidal anti-inflammatory drug (NSAID), anti-platelet or anti-coagulant drugs use. She has no history of gastrointestinal system bleeding, never had a colonoscopy with no family history of gastrointestinal cancer. On physical examination, she was pale, but not in severe distress. Her blood pressure was 106/50 mm Hg, heart rate was 104 beats per minute, temperature was 35.8°C, and body mass index (BMI) was 36.6. She was alert, oriented, and her abdomen was soft, non-tender, and not distended with normal bowel sounds. Bright fresh blood was seen in the rectal examination. Laboratory tests on admission revealed hemoglobin of 8.3 g/dL, platelets of 204 × 103/µL, blood urea nitrogen (BUN) of 36.9 mg/dL, and creatinine of 1.4 mg/dL. Her liver function test and coagulation panel were unremarkable. Intravenous normal saline fluid was given in the emergency room, and patient was transferred to the intensive care unit for close monitoring. Although she had bright red bleeding per rectum, but due to her high BUN/creatinine ratio, we elected to place her on pantoprazole and octreotide drips to cover any possible upper gastrointestinal source of bleeding. There were no further episodes of rectal bleeding. However, her hemoglobin had dropped to 6.8 g/dL on repeated measurement 6 h later. Two units of packed red blood cells were transfused, which raised her hemoglobin level to 8.5 g/dL. Gastroenterology team was consulted and subsequently performed esophagogastroduodenoscopy (EGD). The EGD showed non-erosive gastritis located in the body of stomach with no signs of active bleeding. Therefore, the pantoprazole and octreotide drips were stopped, and the patient was bowel prepared for colonoscopy, which was done next day. The colonoscopy revealed the presence of an actively bleeding DL in the rectum (). An endoclip was placed on the lesion and excellent hemostasis was obtained. The patient did not have any more bleeding per rectum after the clipping, and no more blood transfusions were needed. She was discharged home with a prescription of iron supplement. At 1-month follow-up visit, she did not have any recurrence of bleeding with improving hemoglobin level.


A 75-year-old woman (virgo, gravida 0, para 0, body mass index (BMI) = 21) presented with diffuse abdominal pain and enterorrhagia. She entered menopause at the age of 55 and she had regular menstrual cycles with no dysmenorrhea. Her medical history includes hypertension treatment with angiotensin II receptor blocker. She had undergone knee arthroplasty bilaterally and had never complained of bowel or reproductive system symptoms before, while there is no family history of colorectal or endometrial neoplasms.
The patient underwent colonoscopy, which was not completed due to bowel intussusception, 28 cm from the anus. It was assumed that intussusception was the result of external pressure. Blind biopsies were performed and the relevant histopathological examination revealed intestinal mucosa with tubular adenoma of low-grade dysplasia. Computed tomography (CT) of the upper and lower abdomen demonstrated a midline pelvic lesion with a transverse diameter of 6.1 cm ( and ). Additionally, two more nodal lesions with a transverse diameter of 2.8 cm each were found in a cephalad and caudal direction (). The caudal lesion was found to be in contact with the anterior surface of the fundus of the uterus. Thus, local expansion of the intestinal tumor to the uterus was hypothesized. Small (diameter <5 mm) local lymph nodes were also revealed. Small cystic lesions were found in both ovaries. The rest of the organs appeared normal (). The lower abdomen ultrasound revealed an atrophic uterus (51 mm × 22 mm × 35 mm) with a thin endometrium (3 mm). The ovaries could not be visualized. No pathological findings were observed in the pouch of Douglas. A thorax CT scan was negative for pericardial or pleural effusion and for any other parenchymal diseases. The preoperative blood test results were normal.
The patient underwent sigmoidectomy, with excision of the intestinal mass found preoperatively in CT and colonoscopy, and end-to-end anastomosis with the use of a stapler. Intraoperatively, uterus and adnexa were normal, thus no hysterectomy and/or oophorectomy was carried out. The histological examination revealed a moderately differentiated adenocarcinoma of the colon. According to the morphological characteristics and the immunophenotypic analysis (CK7+ CK20–, Vimentin focally), an endometrioid adenocarcinoma arose from endometriosis while a lesion secondary to endometrioid adenocarcinoma of the endometrium or the ovaries is highly unlike. The carcinoma caused the expansion of the whole intestinal wall and the serosa. The postoperative period was uneventful and the patient was discharged on the ninth postoperative day in a really good condition.


A 71-year-old Caucasian female had a past medical history of arthritis, central serous retinopathy, remote deep vein thrombosis (not on anticoagulation), hyperlipidemia and osteoporosis. She presented with a 3-month history of fatigue, abdominal pain and loss of appetite. She was referred to the emergency room after an outpatient work-up for gradual progression of fatigue and anemia. She had a hemoglobin of 10.7 g/dL (reference value [RV]: 13.7-17.5 g/dL), mild thrombocytopenia and abnormal liver function tests. During her hospital admission, she was afebrile with the following vital signs: pulse 110 beats/minute, blood pressure 115/80 mmHg, and O2 saturation of 95% on room air. Her notable lab values were Na+ 128 mmol/L (RV: 134-146 mmol/L), AST 110 U/L (RV: 15-56 U/L), ALT 73 U/L (RV: 11-50 U/L), GGTP 94 U/L (RV: 3.0-28.7 IU/L) and albumin 2.6 gm/dL (RV: 3.5-5.0 gm/dL). The abdominal computed tomography suggested hepatic and portal vein thrombosis, with suspicion of hepatitis, pancreatitis, and colitis. On magnetic resonance imaging, right hepatic vein thrombosis and a 1.9 × 1.8 cm lesion in the pancreatic tail was noted; based on the imaging studies, a pancreatic carcinoma or a pancreatic neuro-endocrine tumor was suspected. A CT-guided needle core biopsy on the pancreatic tail mass showed multiple foci of large frankly neoplastic cells infiltrating normal-appearing pancreatic lobules featuring scant cytoplasm, nuclei with regular contour and prominent nucleoli; mitotic figures and numerous apoptotic bodies were noted. Extensive immunohistochemical work-up was unrevealing and proliferation index by Ki-67 was high (>95%). Ultimately, the patient was given a diagnosis of diffuse large B-cell lymphoma (DLBCL) on the concomitant cytology specimen, which was the actual diagnostic material. The cell block showed highly atypical large cells intermixed with pancreatic acini. Those cells were positive for CD20, CD79a, and CD45, and focally PAX-5 (). Stain for MUM-1 was non-contributory, and a further sub-classification could not be performed. Subsequent bone marrow aspirate and biopsy showed no involvement.
Her hospital course was complicated by Weisella confusa and Enterococcus faecalis bacteremia and she was treated with piperacillin-tazobactam (ZosynR). She was noted to have up-trending creatinine (0.7 mg/dL to 1.4 mg/dL to 1.7 mg/dL to 2.1 mg/dL; (RV: 0.6-1.0 mg/dL) and elevated lactate dehydrogenase (LDH) (9.1 U/L to 3487 U/L to 8097 U/L to 5686 U/L to 4328 U/L to 4636 U/L; (RV:140-280 U/L) of unclear etiology reminiscent of tumor lysis albeit disproportionate to lymphomatous involvement that at the time was thought to be restricted to the pancreas. Her diastolic blood pressure was intermittently fluctuating from 50 to 90 mmHg and she had up-trending liver function tests (AST/ALT: 50/47 U/L to 108/69 U/L to 410/155 U/L to 172/101 U/L), all of which were refractory to intravenous fluid. Her antibiotic regimen was broadened to vancomycin and meropenem and later she was transferred to the intensive care unit (ICU). With septic shock in mind, she was started on metronidazole (FlagylR) and oral vancomycin for Clostridium difficile colitis, empirically. Fluids and a norepinephrine drip did not improve her lactic acidosis. She was intubated due to worsening respiratory status; antibiotics were again broadened to vancomycin, meropenem, amikacin, micafungin, oral vancomycin, and metronidazole. Stress dose steroids were also given. She subsequently developed disseminated intravascular coagulopathy, pulmonary emboli and rapidly evolved into irreversible multi-organ failure ultimately resulting in the patient’s demise at day 13 after admission. There was an informed consent for the autopsy, which was performed in accordance with the institution’s ethics guidelines.


A 13-year-old boy presented to us with several asymptomatic masses at different parts of his body. A large mass was situated over his left shoulder for the last 3.5 months. Initially, it was small which enlarged at a rapid pace. There was a central crater filled with whitish, semi-fluid material. Besides, there were several subcutaneous masses of varying sizes, some clubbed together around the umbilicus and in the right lower quadrant and two large masses with whitish keratinous centers, in the upper part of his right thigh which slowly increased in size over the last 1.5 years. There were also two large masses at the upper part of his buttocks, with similar history of growth, the right mass having a central keratinous crater. Family history was unremarkable and the patient failed to recall any episode of trauma or injection over the affected area, excessive milk or antacid intake, or any local or systemic illness prior to the development of the lesions.
Physical examination revealed multiple skin-colored, well-circumscribed, firm, dome-shaped nodules ranging from 2 cm × 2 cm to the larger ones measuring 9 cm × 10 cm. The lower abdominal masses were surmounted by pedunculated, firm, nontender dome-shaped nodules sized about 2 cm × 2 cm, with a central crater filled with keratinous material. There were variably sized swellings around the umbilicus and in the right lower quadrant of the abdomen, better felt than seen. Some nodules were clubbed together at places. These masses sized about 3 cm × 1.5 cm in diameter and felt hard on palpation. Examination also revealed two conspicuous dome-shaped nodules measuring about 6.5 cm × 4 cm, over the right groin, which were firm, nontender, irregular, and the overlying skin being normal except for the presence of a central crater filled with keratinous material []. Two large nontender, firm, subcutaneous masses were present in the lower trunk (posterior aspect) sized about 6.5 cm × 5 cm. The left-sided mass showed an ulceration suggestive of extrusion of whitish chalky material from the same []. There was no associated lymphadenopathy. Systemic examination revealed a malnourished child, weight being 41 kg.
Routine hematological investigations revealed anemia (hemoglobin: 7.5% g); serum calcium, phosphate, uric acid, alkaline phosphatase, creatinine, and blood urea nitrogen levels were within normal limits. Skiagram of the lower abdomen showed irregularly round-to-oval, radiodense-calcified areas []. Fine-needle aspiration cytology showed amorphous granular material with occasional histiocytes. One of the small pedunculated masses over the lower abdomen was excised and sent for histopathological examination (HPE) which revealed irregular, epidermal proliferation with hyperkeratosis extending into the mid-dermis, with a central keratin-filled crater. The epidermis extended like a buttress over sides of the crater, suggestive of KA. Basophilic granular material, suggestive of secondary calcification within KA, was observed []. One of the small firm peri-umbilical subcutaneous masses was also excised for histological examination. Milky fluid came out during sectioning. Basophilic amorphous granular material of varying sizes consistent with calcium deposits was found in a scattered distribution []. An inflammatory infiltrate was also seen in the dermis. Histiocytes were seen occasionally. Thus, HPE revealed the features of both KA and TC in the same lesion.


A 62-year-old otherwise healthy Taiwanese woman presented with a 7-year history of
nonpruritic, multiple black-colored hyperpigmented patches without scaling, atrophy
or telangiectasias on her trunk and right leg. Similar hyperpigmented patches
developed and progressed on her chest and flank over half a year (). Some of the pigmented patches had
become surrounded with erythema two weeks prior to presentation (). She denied use of special medications
and she had no known history of dermatological diseases. There was no fever, body
weight loss, or night sweating, neither was palpable lymphadenopathy nor
hepatosplenomegaly present upon physical examination. Because of intractable
eruptions, she underwent a skin biopsy. The histology of lesional skin from a
hyperpigmented patch and surrounding erythema both showed prominent epidermotropism
and atypical lymphocytes (small to medium-sized hyperchromatic indented nuclei)
aligning along the basal layer and perivascular space with dermal melanophages
(). Immunochemistry showed atypical
lymphocytes positive for CD3 and CD8 but negative for CD4, CD7, CD20 and S100. Her
blood count, blood biochemistry panel including lactate dehydrogenase level, tumor
markers, coagulation profiles, T-cell subset analysis, serum protein
electrophoresis, chest X-ray, abdominal ultrasonography, bone marrow aspiration and
biopsy were all unremarkable. Fluorodeoxyglucose positron emission tomography showed
no active signs of visceral involvement. Based on the pathology, she was diagnosed
as stage I CD8+ hyperpigmented mycosis fungoides. She then received psoralen plus
ultraviolet A therapy with oral 8-methoxypsoralen three times a week along with a
potent topical corticosteroid agent (clobetasol propionate). After 8 weeks of
treatment, the erythematous lesions regressed with no development of new lesions,
and the involved pigmented area had reduced from 10% to 6% of the total body surface
area ().


A 55-year-old female patient reported a 2-year history of itchy persistent lesions on
the eyebrows. She had a permanent makeup cosmetic tattoo 16 years before the onset
of lesions (). Histopathological
examination of one of the lesions showed thick dermis with lymphocytic infiltrates
around epithelioid granulomas involving the entire dermis, with presence of black
pigment in the central portion (). She
was diagnosed with sarcoidal granulomatous reaction secondary to tattoo.
Complementary studies included blood count, liver function tests, chest radiography
and tuberculin skin test, all were within normal limits. Patient received two
intralesional therapies with triamcinolone acetonide (0.4ml in each eyebrow -
50mg/ml), showing improvement of lesions.
The second case was a 20-year-old man, tattoo artist, who reported the onset of
painful lesions on 3 tattoos made one year and a half earlier (). Histopathology revealed a sarcoidal granulomatous
reaction (). Systemic treatment with
hydroxychloroquine 200mg/day was prescribed along with intralesional therapy with
triamcinolone acetonide; however, patient was lost to follow-up.


A 9-year-old village boy fell off the roof 2 h ago and was brought to our orthopedic emergency with complaints of pain, swelling, and difficulty to move his left elbow with other associated injuries. On examination, his forearm was in semi-prone position while the elbow was in 20° of flexion. He had swelling more over the lateral side of elbow which was bony hard in consistency. There was diffuse tenderness over the elbow. There was no associated neurovascular deficit in the left upper limb.


A 78-year-old nomad man presented in the Department of Ophthalmology, Second Hospital of JiLin University, with a giant tumor in his right eyelid, which had developed over 3 years.
Clinical examination at admission revealed a huge pigmented, nonhealing ulcerated lesion in the right eyelid. Necrotic tissue was present, along with crusts and scabs in the granulation tissue. The lesion extended superoinferiorly, from the eyebrow to the horizontal level of the nasal alar and mediolaterally, from the nasal dorsum to the lateral canthus (Fig. A). On examination, visual acuity was light perception in the right eye and 0.4 in the left eye. Slit lamp examination of the right eye showed tumor invasion into the conjunctiva and sclera accompanied by conjunctival congestion and chromatosis, corneal opacity, and neovascularization. There were no abnormalities observed in the left eye other than lenticular opacity. A computed tomographic (CT) scan of the orbit showed a large skin tumor, approximately 52 × 44 × 40 mm3 in size, located in the anterior part of the right orbit, engulfing the eyeball, and invading the medial lacrimal system (Fig. B). The following differential diagnoses were considered based on these clinical manifestations: basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and conjunctival melanoma (CoM). BCC is the most common type of cancer, constituting 90% of malignant eyelid tumors. Most BCC in Chinese patients is pigmented, however, this subtype is uncommon in white people.[ BCC is characterized by pearly skin nodules and sometimes presents with ulceration and bleeding. SCC is the second-most common type of skin cancer. The clinical appearance of SCC is highly variable, however, it normally presents as an ulcerated lesion with hard, raised edges, or as a reddish skin plaque that is slow growing and bleeds intermittently. CoM is another common malignant tumor of eye and local tumor seeding can occur spontaneously to the adjacent lid or skin.[
The aim of exenteration is to achieve local control of the disease. Therefore, in the current study, a safe incision margin was made 5 mm outward, along the tumor. The wide surgical excision required removal of all anterior orbital tissue, including the eyeball, lacrimal system, and periorbita along with the eyelids; however, the posterior orbital tissues were preserved. Rapid frozen section margin control was used to guide skin excision.
To reconstruct skin defects after exenteration, double forehead pedicle myocutaneous flaps were transposed to cover the exposed orbital cavity and a free abdominal skin flap was transplanted to cover the exposed area of the forehead. The 1-month postsurgery follow-up showed that the pedicle flaps, along with the surrounding tissue and skin, had healed perfectly and that the free abdominal flap also healed quickly and satisfactorily (Fig. C). The patient was subsequently advised to undergo adjunctive radiotherapy and to undergo follow-up examinations, including orbital CT scans, every 3 months.
Pathological examination revealed that the tumor was BCC. Characteristic epithelial lobules of cells with oval nuclei and scanty cytoplasm with prominent peripheral palisading of the nuclei and elongated strands of basaloid cells embedded in a dense fibrous stroma were observed. The tumor cells had aggressively and deeply infiltrated the adjacent dermis, conjunctiva, sclera and orbital structures (Fig. ).


A 52-year-old rural male farmer reported to the Department of Orbital Surgery complaining of a huge tumor in the right eyelid. Patient medical history revealed that the mass was initially the size of a soybean and gradually grew over 3 years to the size of a fist. Vision in the right eye diminished as the tumor became bigger and was completely gone approximately 1 year prior to examination. The patient had delayed proper medical treatment due to financial difficulties.
Upon physical examination, the basal part of the tumor was found to be derived from right lower eyelid and was growing eccentrically. The tumor invaded the right inner canthus and lacrimal system medially, reached the right side of maxillary buttress laterally and extended from supraorbital ridge to the horizontal level of nasal alar superoinferiorly. The tumor surface was approximately 7 × 7 × 8 cm3, ulcerative, nodular, exophytic, and had purulent blood exudate. The skin of the upper eyelid appeared to be intact. The vision in the left eye was normal, ocular movements in all directions were intact and all other parameters were within normal range. The axial and coronal sections of the orbital CT showed that the eyeball was squeezed superiorly and laterally, that the lesion occupied most of the orbital cavity space and that the orbital cavity was extruded and increased; however, no obvious erosive damage was observed in the bony structures (Fig. ). Based on the clinical history, examination, and radiological findings, a provisional diagnosis of carcinoma of right lower eyelid was suggested and sebaceous gland carcinoma (SGC) was highly suspected considering it was a solitary nodule with an eccentric growth pattern.
A safe surgical excision (5 mm skin around the tumor base including the lacrimal system and lateral canthus) was performed and skin margin control was inspected with rapid frozen sections. The orbital contents were completely enucleated and a canal connecting the orbital cavity to the ethmoid sinus was made in order to drain the cavity exudatives. The normal skin and subcutaneous muscle layer of the upper eyelid was preserved (Fig. A). Finally, a pedicle myocutaneous flap from the upper eyelid was transposed inferiorly to cover the orbital cavity and sutured with a skin incision margin. Histopathological examination revealed SGC with necrosis in the center of the tumor. The tumor contained large anaplastic cells that exhibited sebaceous differentiation, hyperchromatic nuclei, and characteristic features of vacuolated foamy-frothy cytoplasm (Fig. ).
At the 3-week follow up, the flap had healed satisfactorily and the patient had good compliance (Fig. B–D). The patient was advised to undergo further adjunctive radiotherapy and to undergo follow-up orbital examinations and general physical checkups every 3 months to reduce the risk of recurrence.


A 17-year-old post-menarche girl referred to our center with palpable mass of right breast. The result of core needle biopsy performed at local clinic was intraductal carcinoma. In imaging study, a 3.1 cm irregular heterogeneous enhancing mass at right upper inner quadrants without lymph node enlargement in both axilla was identified (Fig. A). Laboratory test was normal and no clinical evidence of distant metastasis at positron emission tomography-computed tomography (PET-CT) and systemic examination.
The patient underwent right nipple sparing mastectomy (NSM) and breast reconstruction with implant. The sentinel lymph node biopsy performed during surgery was negative for malignancy. Histopathologic finding of resected mass was an alveolar rhabdomyosarcoma with lympho-vascular invasion and medial resection margin was involved by tumor. When immunohistochemical stained, the specimen was myogenin, desmin, and vimentin positive, indicating that the tumor originated from muscle tissue (Fig. A–D). She was referred to oncology part and adjuvant chemotherapy was recommended. However, she did not visit the clinic anymore.
Five months later, she appeared with right chest mass and symptoms caused by SVC syndrome. The tumor extended beyond the sternum to the left side and both axilla lymph nodes (Fig. B). Chemotherapy of vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide (VAC/IE) regimen began in January and the mass remained stable until June when the 51-week schedule was completed. Since the end of chemotherapy, she has remained stable until now.
The patient provided written informed consent and ethics approval was not required for this paper as it is a case report.


A 50-year-old Korean woman who had never smoked visited our lung cancer clinic in February 2015. She complained of upper airway infection symptoms of mild back pain followed by cough with sputum and rhinorrhea. Computed tomography (CT) from an outside hospital showed a right upper lobar mass with enlargement of adjacent interlobar lymph node, and miliary distribution of multiple tiny nodules in both lungs (). She was diagnosed with stage IV lung adenocarcinoma with metastases to both lungs, T12 spine, left femur and brain that was proven by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), positron emission tomography and brain magnetic resonance imaging (MRI). Her initial tumor biopsy from primary mass and lymph nodes was negative for EGFR mutation and ALK translocation.
She received four cycles of pemetrexed and cisplatin, and her tumor burden was retained as stable disease (). She stopped the chemotherapy due to poor performance status without maintenance therapy. Upon progression of right upper lobar mass, multiple lung nodules and metastatic lymphadenopathies after 2 months without subsequent treatment (), she received gefitinib for the next 2 months. Subjectively-rated symptoms of nausea and myalgia seemed to ease, but gefitinib was finally stopped due to aggravation of gastrointestinal toxicity and lung-to-lung metastases (). Thereafter, progression in brain metastasis was also demonstrated in follow-up MRI. She suffered from general weakness, nausea and back pain, and so was reluctant to receive further cytotoxic chemotherapy.
In September 2015, she agreed to be tested for another activating mutation using previously achieved specimen by EBUS-TBNA. Pathologic examination revealed a poorly differentiated atypical cell nest with focal glandular differentiation (). Immunohistochemical stain for c-erbB2 showed weak membranous staining (). After direct sequencing as screening test, the following next generation sequencing (NGS) of the tissue revealed a HER2 exon 20 mutation with A-to-G base change at nucleotide 2437 (c.2437A>G), which led to substitution of aspartate for asparagine at position 813 (p.N813D) (). This mutation has never been reported. In October 2015, she started afatinib 40 mg daily. An initial clinical and radiologic response was achieved within a month. She professed a sense of well-being and relief of back pain, and simple chest X-ray showed more decreased lung nodules grossly. During week 6 of treatment, a CT assessment revealed a partial response in extracranial lesions with prominent regression of primary lung tumors in the right upper lobe and lung-to-lung metastases (). Brain metastases had maintained the stable state, and she did not complain of any neurologic symptom or sign. After stepwise dose reduction to 20 mg due to stomatitis and nausea, she has continued the medication until February 2016 without deterioration of subjective symptom and tumor burden. Last CT scan on January 2016 still showed a partial response in extracranial lesion, but brain MRI revealed mild increase of metastases. At last visit on February 2016, the patient complained of general weakness and anorexia with stomatitis, and thereafter she was lost to follow-up.


A female patient aged 29 years, who was single, accompanied by her parents, was referred by a psychiatrist for dental implantation and prosthetic rehabilitation for her edentulous state. A detailed history was elicited from her parents, and it was gathered that the patient, a graduate, developed psychiatric symptoms following family issues. A psychiatric consultation was sought earlier and she was under treatment for the past 6 years.
At the time of admission to the present mental health clinic, she presented with cardinal symptoms of schizophrenia such as auditory hallucination, delusion of reference, delusion of persecution, obsessive-compulsive features of frequent bathing, and repeatedly doing same jobs. She had disorganized behaviors such as stripping off her clothes in the public, wandering behavior, restlessness, excessive talk, and abusive and assaultive tendencies with no insight. She had also attempted suicide more than once. All these odd behaviors forced the parents to bring her to the present psychiatrist.
There is no family history of any other psychiatric illness. During the course of treatment, her mood and ideas fluctuated on and off. One such instance being she insisted on tooth extraction and threatened to commit suicide if not obliged. The patient claimed that she has been commanded by some voice to go for removal of teeth and was also deluded that her mouth was infested with worms. Meanwhile, she visited many dentists, more than ten dental surgeons, and had 7–8 healthy upper teeth extracted first, by forcing the dentist in spite of assurance by the dentist that her teeth were normal. And finally, she had all her teeth extracted over a period of 6 months [Figures -].
She still had another somatic delusion that her nose was being drawn inside and sinking. Later in the course of illness, she said that she got all her teeth removed in response to the voice of the person. Hence, it was clear that she had communicating and commanding auditory hallucinations to which she responded.
She has been treated with antipsychotic drugs and was not administered electroconvulsive therapy as her parents were not willing for the treatment.
After total extraction of the upper teeth, she tried having dentures but she refused to wear and threw it away. At present, the patient is getting better and symptoms are under control by treatment but still she is under counseling for denture or dental implantation.
A review of various literature reveals documentation of patients with a known psychiatric disorders who were hospitalized and the effects of psychotropic medication on oral health, for example, temporomandibular joint disorders. Mental health problems may be manifested as the only symptom or the first one relating to oral mucosa such as facial pain, preoccupation with dentures, increased erosion, and self-inflicted injury.[]
Self-inflicted lesions that cause mutilation are observed in schizophrenic patients. An interdisciplinary approach to self-mutilation due to psychiatric disorders was emphasized. An interaction between the two teams, dentistry and psychiatry, is very important for the improvement of the patient's condition.[]
In addition, many patients complain of halitosis and get recurrent cleaning and scaling done, thinking their teeth are full of dirt. This sort of false belief of having a bad odor which none can perceive, neither the clinician nor the other person, is called delusional halitosis. A study was done by Akpata et al. which shows significant correlation of patients associated with oral factors and delusional halitosis.[] Screening can be done in dental patients with comorbid mental disorders and simultaneously both can be treated.[]
Among patients presenting for cosmetic treatments, up to 15% suffer from body dysmorphic disorder, a psychiatric condition characterized by an imagined defect in appearance with references to nose and teeth. Definitely, this proves that the preformed ideas associated with one's physical appearance is a motivating factor for undergoing certain types of cosmetic dental procedures.[]
A proper history taking and physical examination is a must for any patient and obviously includes even noninstitutionalized psychiatric patients. Drug history is also a must. The knowledge of various side effects of the drugs should be known which commonly include dryness of mouth.[]


A 44-year-old male patient reported to the Department Of Prosthodontics with a complaint of severe sensitivity pertaining to his posterior teeth and generalized discoloration of his teeth. The patient's history did not reveal any habits pertaining to his complaints, but his spouse reported about night grinding habits. Extraorally no loss of vertical dimension was noted [ and ]. On intraoral examination, severe attrition of posterior teeth was noted. Mild attrition was noted in the anterior teeth [Figure , and ]. This case was diagnosed according to Turner and Misserlian classification[] as category 2. The patient was referred to the Department Of Endodontics for opinion on sensitivity and discoloration. As per patient's request, a more conservative method of management was preferred initially. Hence, root canal for the sensitive teeth and bleaching of all the anterior teeth was done to improve esthetics. The patient reported with a severe sensitive condition in his posterior teeth 3 months later and was dissatisfied with the bleaching. By then, the rate of attrition had not changed as measured at 36 and 13. Root canal for the posterior teeth and subsequent crowns were thought to be a more appropriate treatment plan. The loss of vertical dimension was assessed. Although there was no clinical evidence of volume of distribution (VD) loss, the patient had a freeway space of 4 mm but restoring posterior teeth alone would have resulted in a more esthetic anterior open bite. Hence, it was decided to prepare anterior teeth as well. Face bow transfer was done, and the diagnostic casts were articulated. Then a diagnostic wax up was done for provisional restoration at existing vertical dimension [Figure -]. Tooth preparation was done, retraction cords were placed and an optical impression was made with Cerec 3 system (sirona dental systems) [Figure and ]. Centric relation was recorded using extra oral tracing. Zirconia copings were fabricated with CAD/CAM designing and milling and tried in the patient's mouth [Figure and ]. After verifying the fit of the copings, full tooth morphology was created using D’sign ceramic material (Ivoclar-Viva). Apreglaze verification was done to evaluate esthetics and occlusion. Final glazing was done and the crowns were cemented with a Rely-X 3M resin cement [Figure and ]. A soft splint was advised postinsertion as a precautionary measure and the patient followed up for 1 year. At 1-year posttreatment, the patient had no complaints of sensitivity and was satisfied with the esthetic crowns


A 2-year-old neutered, female, domestic shorthair cat presented with a 1 month history of difficulty walking, pain of unknown origin and general discomfort. The use of steroidal and non-steroidal anti-inflammatory drugs (NSAIDs) improved the clinical signs temporarily. The general physical examination was normal, whereas neurological examination revealed paraparesis, diffuse back pain and urinary retention with bladder distension. No abnormality was noted on blood and urine analysis. Serological tests for toxoplasmosis, feline leukaemia virus (FeLV) and feline immunodeficiency virus (FIV) were negative. On digital radiography an irregular T8 profile appeared in lateral view. The cat underwent a CT scan and MRI. General anaesthesia was induced with a combination of methadone (Semfortan; Dechra), midazolam (Ipnovel; Roche) and dexmedetomidine (Dexdomitor; Orion Pharma) and maintained with isoflurane (Isoflo; Zoetis). The CT scan was performed with a 64 slice double gentry scanner (Somaton Definition Flash; Siemens), in the transverse, coronal and sagittal planes, with a bone algorithm, whereas MRI was performed with a 0.4 Tesla open magnet (Aperto Lucent, SN, X418; Hitachi) in T1-weighted sagittal and transverse planes, T2-weighted sagittal, dorsal and transverse planes, T2 fluid-attenuated inversion recovery (FLAIR) dorsal plane and 3D T1 transverse plane. T1 images in the transverse plane and T2 FLAIR images were also acquired following administration of intravenous contrast (0.1 mmol/kg gadodiamide [Omniscan; GE Healthcare]). The CT scan showed a right-sided bone proliferation (attenuation value of 709 Hounsfield units [Hu] vs 368 Hu for the normal adjacent bone) at the T8 level, extending from the right vertebral arch to the cranial right articular facet and pedicle, in the T7–T8 intervertebral space.
MRI confirmed an extradural lesion with a hyperintense pattern on T2 images (relative to spinal cord) with irregular enhancement after contrast injection. No focal myelopathy was detected. Right hemilaminectomy was performed, covering the whole T8 vertebral arch. The intraoperative appearance confirmed the sponge-like proliferation. Bleeding was controlled using a jelly sponge, followed by routine closure. Bone tissue was examined for histopathology and culture sensitivity. No bacterial growth was seen. Histopathology revealed bone fibrosis with benign proliferations of well-differentiated, small-calibre, arterial and venous blood vessels, consistent with vertebral angiomatosis.
After initially worsening, the cat recovered its normal gait, walking and urinary function on day 15 after surgery. Currently, 1.5 years after surgery, no clinical signs are visible.


A 22-month-old neutered, female Siamese cat presented with a 1 month history of movement reluctance and difficult defaecation. The use of NSAIDs had not improved the clinical signs. The general examination was normal. The neurological examination revealed paraparesis, back pain in the thoracic region and urinary retention with bladder distension. No abnormality was noted on blood and urine analysis except low thyroid-stimulating hormone, total thyroxine and free thyroxine levels (free triiodothyronine [T3]/reverse free T3 normal) and a high plasma cortisol concentration, consistent with euthyroid sick syndrome and chronic pain. Serological tests for toxoplasmosis, FeLV and FIV were negative. On digital radiography an irregular T4 profile appeared in the lateral and dorsoventral view. The cat underwent a CT scan and MRI. General anaesthesia was induced using the same protocol as in case 1 and the CT and MRI were carried out using the same methods as in case 1. The CT scan showed a left-sided bone proliferation (attenuation value of 651 Hu vs 351 Hu for the normal adjacent bone) at the T4 level, extending from T3 to T5 and covering the soma of T4. MRI confirmed an extradural lesion, displacing the spinal cord dorsally and contralaterally, with a hyperintense pattern on T2 images (relative to spinal cord) and irregular enhancement after contrast injection. A small focal myelopathy was detected.
Two left hemilaminectomies were performed, covering the T3–T4 and T4–T5 intervertebral spaces, with partial corpectomy of T4. The intraoperative appearance confirmed a sponge-like proliferation. Bleeding was controlled using a jelly sponge and routine closure was performed. Bone tissue was examined for histopathology and culture sensitivity. No bacterial growth was seen. Histopathology revealed new bone formation with marked benign proliferations of well-differentiated, small-calibre, arterial and venous blood vessels, consistent with vertebral angiomatosis.
In this case, serious clinical worsening led to non-ambulatory paraparesis. Despite this situation, the cat had recovered its normal gait, walking and urinary function 2 months after surgery. Currently, 1 year after surgery, no clinical signs are present.


A 64-year-old man was admitted to the Surgical Department for further examination of a 1.8-cm sized hypodense lesion incidentally found at the body of pancreas. He was under examination for a 3.6-cm sized lung mass at the left upper lobe which was diagnosed as moderately differentiated adenocarcinoma after left upper lobe lobectomy. The patient was a 44 pack-year smoker with diabetes requiring hyperglycemic agents. He had no reported history of alcohol intake, gallstones, or abdominal trauma.
His carcinoembryonic antigen (CEA) was elevated to 31.3 ng/ml. Liver function tests were normal. His serum levels were: AST, 29 IU/L; ALT, 24 IU/L; alkaline phosphatase, 71 IU/L; total bilirubin, 0.81 mg/dl;. amylase, 49 IU/L; C-reactive protein (CRP), 2.78 mg/dl; and hemoglobin A1c level, 6.9%. CT scan showed a 1.8-cm sized and low-attenuated mass at the body of pancreas with upstream pancreatic duct dilatation (). MRI demonstrated heterogeneously high intensity on T2-weighted images and low intensity on T1-weighted images (). The mass was well demarcated from the surrounding pancreas tissue. There was no apparent peripancreatic fat tissue involvement or lymph node enlargement. Positron emission tomography-computed tomography (PET-CT) scan showed hypermetabolic mass at the upper lobe of the left lung, the known lung cancer lesion site. However, no significant 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) uptake was found at the pancreas lesion (). Endoscopic ultrasound-guided fine needle aspiration was performed for pathological diagnosis. However, it failed due to inadequately retrieved specimen for determination. Under the impression of pancreas cystic neoplasm as a rare case of male solid-pseudopapillary tumor or pancreatic metastasis of lung cancer, laparoscopic distal pancreatectomy with splenectomy was performen on June 13, 2016.
Gross examination of resected specimen revealed a 1.6 cm×1.5 cm sized yellowish mass in the pancreatic body (). Microscopically, the mass had many foamy histiocytes with cholesterol clefts (), consistent with xanthogranulomatous inflammation. Thus, the cystic lesion was diagnosed as XGP. The patient recovered fully without any complication at two weeks after surgery. There were no signs of recurrence during seven months of follow up.


A 62-year-old woman with athetoid cerebral palsy experienced numbness in both hands and disturbance in walking, with worsening symptoms. She was diagnosed with cervical myelopathy based on neurological findings and imaging studies. On X-ray examination, the preoperative C2–7 angle was −4.6°, indicating slight kyphosis (). The preoperative JOA score was 9 points, and the NDI score was 10 points. Posterior fusion from C2 to T2 using a C2 pars screw and rt C5/6, lt C6/7, and bil T1/T2 transarticular screws with segmental partial laminectomy [] at C3–4, C4–5, C5–6, and C6–7 was performed (). Operative time was 268 minutes, and intraoperative blood loss was 410 g. Five years postoperatively, the C2–7 angle was 18.5°, indicating lordosis. The JOA score was 11 points, and the recovery rate of the JOA score was 25%. The NDI score was 10 points, and patient satisfaction with surgery was 70/100.


A 64-year-old Chinese man came to our hospital with right upper quadrant abdominal pain that had lasted 10 days. His medical history included chronic viral hepatitis B infection. Physical examination revealed mild tenderness and percussion pain on the hepatic region. Ultrasound evaluation showed an enlarged solid mass in the right lobe of the liver. Computed tomography (CT) scan of the whole abdomen confirmed a single low-density mass measuring 9.2 × 7.5 cm with central necrosis (), and absence of abdominal lymph node enlargement or any distant metastasis. Blood tests showed α-fetoprotein 24627.50 ng/mL (normal range = 0-13.4 ng/mL). The preoperative liver function was evaluated as Child A. Hepatic resection was performed for a hepatic tumor measuring 9.5 × 8.5 × 5.0 cm (). Pathologic examination (1302269) confirmed HCC with intravascular cancer emboli (). After 4 months, CT reexamination revealed recurrent hepatic carcinoma in the right lobe of the liver with omentum metastasis measuring 7.4 × 7.2 cm (). Blood tests showed α-fetoprotein elevating from 458.54 ng/mL to 9021.55 ng/mL. Clinical diagnosis of stage IVB recurrent HCC with omentum metastasis was made. The patient was categorized as having a poor prognosis because of the cancer relapse with potential metastasis. With the consideration of the poor prognosis of recurrent HCC and financial difficulties of the patient himself, conservative therapy with TCM was finally chosen. The composition of the formula with doses of herbs listed in was used for 1 day. The solution was mixed equitably after being boiled twice, then taken at 9:00 to 10:00 am and 15:00 to 16:00 pm each day. During the TCM treatment, herbs were supplied every 2 weeks in our hospital. α-Fetoprotein variations were detected every 6 months while image examination was recommended every 6 to 12 months. During 2 years of treatment with Chinese herbs and antiviral treatment without any other therapy, the changes of recurrent hepatic carcinoma and omentum mass by CT scans and ultrasonography presented (-) with few toxicities of the herbal formula observed. The variations of the tumor measurements with the reports of ultrasonography and CT scans are listed in . Blood surveillance showed α-fetoprotein level range of 2766.67 to 3869.90 ng/mL (). The patient has been alive over 31 months since HCC relapse.


Hip fracture in a 75-year-old woman needing hip replacement surgery. She weighs 65 kg, is cooperative and with no cognitive impairment.


Hip fracture in a 82-year-old woman needing hip replacement surgery. She weighs 115 kg, is affected by dementia and diabetes, and non-cooperative.
On the basis of current DRG systems that do not incorporate nursing intensity weights (NIW), hospitals obtain the same level of reimbursement for these two cases. Instead, from a nursing perspective these two cases require a completely different intensity of nursing care, and where the second case presents a higher level of nursing intensity (). One practical way to measure nursing intensity is to use a set of NIWs for each DRG and apply them at discharge to adjust routine care and intensive care per diem charges. For our scenario, we based our NIW on the North American Nursing Diagnosis Association (NANDA) Nursing Interventions Classification.
The patient in scenario 1 requires a much lower intensity of nursing care than the one in scenario 2, who will need a higher intensity of nursing care than the standard on which a healthcare organisation would plan its resources. However, according to current DRG systems the hospital will obtain the same level of reimbursement for the two patients.
Ideally speaking, if intensity of nursing care was included in the DRG system, these two scenarios would require nurses to assess and document the level of patient complexity upon admission, and then plan and provide care accordingly. This would also entail the availability of appropriate levels of reimbursement and therefore the staffing and resources needed to cover the higher intensity of nursing care.
However, this would require nurse administrators to use up-to-date knowledge and make decisions to implement nursing care models according to evidence-based staffing levels. If it is true that nurses in clinical setting must justify what they do, and how and why they are doing it, then nurse administrators/managers must justify what skill mix, and what nurse staffing level they are ensuring to determine good nursing practice without missed care, thus an evidence-based management approach.


A 12-year-old Asian girl with back soreness and scoliosis for a year sought chiropractic care between July 2015 and January 2016. At the initial visit, her right shoulder was slightly higher with waistline asymmetry. There was no clinical leg-length discrepancy. Adams forward bend test showed positive. Spine radiographs exhibited a double curve pattern, with Cobb angles of 26° thoracic and 23° lumbar, respectively []. To prevent the risk for curve progression in this youngster and adverse impacts upon her self-esteem, the patient was scheduled to undergo chiropractic treatment.
Chiropractic care was provided three times a week for the first 2 months, followed by twice a week for the next 4 months. The treatments first consisted of 5 min of general massage applied to the postural muscles using a G5® Machine (General Physiotherapy, Inc., St. Louis, Missouri, U.S.A) to relax muscles allowed for manual manipulation of the area. Flexion distraction was then administered while the patient lied facedown on with both ankles cuffed to the table, and the caudal section of the motorized table slowly raised and lowered to create an intermittent traction to the spine. During the flexion-distraction procedure, spinal manipulation was also employed for 10 min at each treatment. At the completion of 6-month treatment [] and at the 9-month follow-up [], patient's Cobb angles measured by consecutive radiographs were totally corrected by 6° in the thoracic curve (from 26° down to 20°) and 7° in the lumbar curve (from 23° down to 16°). The patient reported alleviated soreness, improved mobility, and more confident, visually appeared better in muscle tones and reduction in her spinal curvature.


On May 3, 2011, at 10 AM, a 50-year-old female was admitted to an outpatient department hospital at Mahad in the district of Raigad. She complained of insomnia, suffocation, fever, severe whole-body pain, and malaise over the past 4 days. On April 30, she had been examined by her family doctor. She received an unidentified injection, acetaminophen tablets, and oral chloroquine. There was no improvement of symptoms.
Since she additionally complained of chest pain, she was admitted to the Intensive Care Unit (ICU) on May 2, where her pain was attributed to unstable angina. She was closely monitored and was given nasal oxygen, intravenous fluids, a nitroglycerin drip and furosemide. In addition, a treatment with low-molecular-weight heparin 60 mg every 12 h digoxin, aspirin, clopidogrel and statin was started. There was no clinical improvement. On the 3rd day, the ICU doctor transferred her to a tertiary care hospital for further cardiac investigation to rule out ischemic cardiomyopathy.
Instead of going to Mumbai, the relatives brought the patient to the clinic at Mahad. On admission, she was fully conscious. She presented with a history of mitral valve replacement in 1994. She complained of excessive thirst and being unable to drink water for 2 days. While examining her, we asked for a glass of water. Simple by hearing the word water (Pani in vernacular language), she suddenly developed severe laryngeal spasm [, ]. This repeated laryngeal spasm in response to the word “water” confirmed that she was suffering from rabies. We asked her and the relatives regarding any history of a dog bite. She reported that 4 months ago, a furious dog had bitten four persons from her village. All of them were treated with immunization as exposure prevention by the government hospital. All the four are healthy at present. The furious dog had caught her sari (cloth), and with its claws, it caused multiple abrasions at her right foot. She cleaned the blood and the abrasions by rubbing it with her sari. She and her relatives believed that only the bite of a dog can cause the disease and hence avoided postexposure rabies immunization though it is free and freely available at the primary health center, which is 5 km away from her village. However, she reported that instead of visiting the hospital, she visited a Tantrik (village healer) who gave her some herbal medicine.
Her blood pressure was 140/80, she had no signs of myocardial failure, a grade 3/6 systolic murmur was heard at over the aortic root area, and an ejection click of the mitral valve was heard over the apex. The respiratory rate was 14/min and no pathological breathing sounds were heard over her chest. Her body temperature was 99°F. There was no any neurological deficit except laryngeal spasm.
As major symptom, she described that she experienced tingling and numbness and heaviness in her right lower limb. Troponin T was negative, and serum sodium was 128 mEq/l. Electrocardiogram showed a heart rate of 75 beats/min with minor ST-T changes []. Hemoglobin level was 14.6 g/dl, leukocyte count was 11,100 cu.mm, and blood sugar was 105 mg/dl.
She was isolated in a dark room. Very carefully, we placed a nasogastric feeding tube. She was given intravenous fluids, intravenous atropine 3 mg, magnesium sulfate (MgSO4) 2 g, midazolam 1 mg/kg body weight, and sustained acting zolpidem 12.5 mg through the nasal tube. The next day she developed a mixed form of delirium with being fully conscious in-between (lucid interval). She still occasionally developed laryngeal spasms. On the 3rd day, she presented with tachycardia, delirium, internuclear ophthalmoplegia, and plantar flexion, and the strength in all limbs was grade 5/5, but she had no neck rigidity. Moist rales were heard over the chest, and she became tachypnoeic. At 3 AM on the 4th day, she developed pulmonary edema and massive hematemesis and died of respiratory arrest. She was conscious till death. No attempt to resuscitate her was initiated following the decision of seniors and relatives.


A 62-year-old man presented with progressive swelling on his left thigh and lower leg. He had been diagnosed as DVT 2 months ago and underwent thrombolysis in other hospital. Despite of antithrombotic therapy with aspirin and rivaroxaban, leg swelling was getting worse. Clinical classification was C4 with lipodermatosclerosis []. Venous duplex ultrasonography and computed tomography venography (CTV) revealed chronic DVT from left external iliac vein (EIV) to posterior tibial vein and in great saphenous vein (GSV) (). A hybrid operation was planned including femoral endovenectomy, thrombectomy, and stenting of left EIV. Under the general anesthesia, left femoral veins were dissected via a longitudinal incision in the left groin. After venotomy, chronic thrombus and dense synechiae of fibrous tissue inside the vein were excised ().
The endovenectomy was extended cephalad to just below the inguinal ligament and caudad to 3 cm distal to femoral vein bifurcation. The deep femoral vein orifice was completely recannalized. The venotomy was closed with a left GSV patch. A 7-French sheath was inserted via the suture line and two self-expanding stents (10×60 mm, 10×80 mm) were deployed (Absolute Pro; Abbott Vascular, Santa Clara, CA, USA) in the left EIV ().
Postoperative anticoagulation was done with unfractionated heparin and warfarin. Follow-up CT on postoperative day (POD) 7 showed patent left EIV stent, but remnant stenosis in common femoral vein (CFV). Balloon angioplasty was performed and the venous flow improved (). The patient was discharged POD 10 on anticoagulation with warfarin. On 6 months follow-up, the symptoms have improved and anticoagulation is continued.


A 71-year-old man presented to our hospital complaining of a cough productive of yellow colored sputum for 3 months prior to presentation. The cough was associated with weight loss as well as generalized fatigue but the patient denied having any fevers. His past medical history is significant for hepatocellular carcinoma, treated with TACE with doxorubicin 12 months prior to presentation. The patient was hospitalized at another hospital 3 months earlier when his cough started and was treated with antibiotics for suspected pneumonia and was discharged. His cough did not improve. Physical examination revealed dullness to percussion over the right lower lung field associated with rhonchi heard in the same field. Otherwise, examination was unremarkable. His initial presenting labs were normal. A right lower lobe consolidation was seen on chest X-ray. A sputum test for bilirubin revealed a level of 6.7 mg/dL.
An HIDA scan was performed which revealed a biliary leak into the right lower lung and trachea (). The biliary leak was found to be secondary to a BBF. During hospitalization, an endoscopic retrograde cholangiopancreatography (ERCP) was performed with sphincterotomy and a 7 Fr by 5 cm temporary stent was placed in the common bile duct to manage the BBF (). The patient’s cough and biliary sputum improved significantly after the stent was placed and he currently no longer has a cough or bilious sputum.


A 55-year-old male was diagnosed with acute myeloid leukemia in May 2015. He failed to achieve the complete remission (CR) after two induction chemotherapy courses with high dose cytarabine, idarubicin and etoposide and salvage treatment with fludarabine and idarubicin. The presence of a matched unrelated donor in the International Marrow Donor Registries prompted us to proceed with an allogeneic HSCT following a “sequential” conditioning regimen. The patient was initially treated with mitoxantrone (6 mg/sqm/day), etoposide (80 mg/sqm/day) and cytarabine (1 g/sqm/day for four days), followed, 10 days later, by a conditioning which included i.v. Busulphan (3.2 mg/kg/day) and Fludarabine (50 mg/mq/day) for four days and the infusion of mobilized donor peripheral blood stem cells (PBSC). Graft-vs.-Host disease (GVHD) prophylaxis consisted of anti-thymocyte globulin, cyclosporine and a short course of methotrexate. An absolute neutrophil count higher than 0.5 × 109/L and a platelet count higher than 20.000/mcl were achieved on day + 13. On day + 33, the patient suddenly showed abdominal distension with ascites, increase in liver enzymes (AST 391 U/l, ALT 245 U/l) and in total bilirubin (1.2 mg/dL) and signs of liver and renal insufficiency (INR 1.43; aPTT 65.5″; serum creatinine value 3.04 mg/dL). The patient did not present either painful hepatomegaly or weight gain >2%, or signs of intestinal or cutaneous acute GVHD. Viral hepatitis was ruled out by microbiological testing. Ultrasonography showed normal liver parenchyma, regular biliary tract, moderate splenomegaly (15 cm) with ascites and right pleural effusion. Doppler exam ruled out portal vein thrombosis but showed increased portal vein diameter (10 mm) suggestive of portal hypertension. Paracentesis was performed and showed presence of transudate fluid (serum albumin = 3 mg/dL, ascites albumin 1.5 mg/dL, serum-ascites albumin ratio= 2).
Given that clinical symptoms and laboratory tests did not allow to discriminate between VOD, acute GVHD, toxicity or infective causes, a hepatic transjugular biopsy was performed. Histology studies showed the expansion of the hepatic sinusoid spaces, with gaps in the sinusoidal barrier which were highly suggestive of hepatic VOD in the light of the involvement of zone 3, zone 2 and partially zone 1 of the hepatic acinus ().
Intravenous defibrotide was started at the dose of 6.25 mg/kg QID on day + 37 for 21 days, along with ancillary therapy including albumin replacement and low dose diuretics; nonsteroids have been administered. Two-three days after the beginning of defibrotide, the patient showed a marked clinical improvement with gradual improvement and normalization of liver and renal function tests (). One week after the beginning of defibrotide, the patient developed hemorrhagic cystitis, treated with 2 bladder instillations of hyaluronic acid which led to progressive improvement and complete resolution upon regular discontinuation of defibrotide after 21 days of treatment. Hemorrhagic cystitis did not require an earlier discontinuation of defibrotide. During the treatment course, platelet count remained low between 10.000 to 20.000/mmc even with transfusion support. The patient was discharged on day + 76 in complete remission of his underlying disease on low doses of cyclosporine.


A 46-year old male was diagnosed with acute myeloid leukemia - normal karyotype, FLT3, and NPM1 wild-type - in May 2015. The patient was treated with idarubicin plus etoposide and cytarabine with no hematologic response. Complete remission was subsequently obtained with a course of high-dose cytarabine, followed consolidation with 2 additional courses of high-dose cytarabine. An unrelated marrow donor search was started and a partially (one-antigen mismatched) HLA-matched donor was identified. The patient received mobilized donor HSCT after a conditioning regimen with Thiotepa (5 mg/kg/day for 2 days), Busulphan (3,2 mg/kg/day for 3 days) and Fludarabine (50 mg/kg/day for 3 days). GvHD prophylaxis included cyclosporine, short course methotrexate, and anti-thymocyte globulin ATG (2,5 mg/kg/day for 3 days). Neutrophil and platelet engraftment occurred on day +14 and +12 respectively. The patient experienced a transient skin rash suggestive of grade I acute GVHD on day +19, and 3 episodes of CMV reactivation on days +27,+ 43 and + 82 successfully treated with preemptive valganciclovir and immunoglobulins.
The patient was readmitted because of severe anemia and thrombocytopenia (Hb 5,8 gr/dl; platelet 5000/ul) and complaints of right abdominal pain with melena on day +89. Significant weight gain (+7 kg) along with abdominal distension and anasarca were observed on day +91. Laboratory exams showed total bilirubin 3,30 mg/dl, AST/ALT 140/164 UI, GGT 725 Ul, INR 1,7; aPTT 41,3″, serum creatinine 2,0 mg/dl; platelet count was 20.000/mmc. An abdominal CT scan revealed ascites and hepatic veins compression. Transjugular measurement of the hepatic venous pressure gradient showed severe sinusoidal portal hypertension with a significant transhepatic/caval gradient diagnostic for severe VOD. Transjugular liver biopsy showed sinusoidal dilation and bleeding with erythrocytes in the Disse space, and significant iron overload. Histology studies were consistent with severe VOD.
Intravenous defibrotide was promptly started at the dose of 6.25 mg/kg QID for 22 days. Ancillary therapy included plasma and red blood cells transfusions, no steroid have been administered. A complete and sustained response was achieved. The patient was discharged on day +121. The patient is currently alive, 188 days after transplant, with normal liver function, no evidence of GvHD, or any other relevant clinical complication. A bone marrow aspirate showed complete remission of his underlying disease.


A 62-year-old male, nonsmoker, and diabetic for 20 years, presented with complaints of dry cough and fever with chills for the past 20 days. Patient had a history of hemoptysis (3–4 episodes) 2 days prior with no other significant past histories. He received empirical antibiotics in the peripheral hospital with no clinical response. Physical examination showed heart rate - 102/min, blood pressure - 160/90 mmHg, respiratory rate - 18/min, SpO2=93% on room air, and diminished right-sided breath sounds on chest auscultation. On blood investigations, hemoglobin was 11.6 g/dl, total leukocyte count 11300/mm 3, platelet count 3.90 k/uL, and glycated hemoglobin – 9.8%, with normal kidney and liver functions tests. Chest X-ray revealed right parahilar opacity [] and contrast-enhanced computed tomography chest showed right hilar mass compressing intermediate bronchus []. Immediately, postadmission patient had massive hemoptysis and was transferred to respiratory intensive care for stabilization, following which fiber-optic bronchoscopy was done revealing thick whitish necrotic material filling right intermediate and lower lobe bronchi []. Bronchial lavage was negative for acid-fast bacilli and pyogenic cultures were sterile. Bronchial biopsy confirmed aseptate acutely branching hyphae suggestive of mucormycosis []. Fungal culture showed no growth after 3 weeks.
Patient was started on liposomal amphotericin B at a dose of 3 mg/kg daily and increased to 5 mg/kg daily along with intensive blood sugar control with insulin. However, he continued to have high-grade fever with chills and repeat CT chest revealed collapse consolidation of right lower lobe with right-sided moderate pleural effusion []. Diagnostic pleural fluid analysis was suggestive of exudative neutrophilic effusion with low adenosine deaminase. Medical thoracoscopy was performed which showed thickened pleura with blackish deposits over both parietal and visceral surfaces. Biopsy of parietal pleura demonstrated fungal invasion by Mucorales [Figure and ]. In view of progression, dose of amphotericin B was escalated to 7.5 mg/kg/day and oral posaconazole (400 mg twice daily) was added. Despite this, patient continued to deteriorate clinically and radiologically, with accumulation of more pleural fluid with loculations. In view of rapid progression despite on dual antifungal therapy, the patient was taken up for decortication with lobectomy/pneumonectomy as a high-risk case. Periopratively, there was extensive invasion of pulmonary vessels and pericardium requiring removal of affected pericardium with en bloc pneumonectomy and parietal pleurectomy. Immediate postoperative period was uneventful, but patient continued to have fever. Pneumonectomy specimen showed extensive necrosis with nonseptated hyphae [], and third antifungal micafungin was also added. Despite three antifungals and surgical excision, patient continued to worsen and died 10 days postoperatively.


We report the case of an otherwise healthy 67-year-old man with no past medical history who presented with multiple actinic keratoses of the face, neck, and forearms. He was prescribed 0.5% 5-FU topical cream, which was to be applied to the skin daily for 30 days on his bilateral forearms. He was receiving no other medications that could have caused adverse interactions. After 1 week of topical use, he reported extreme lethargy, fatigue, fever, and mouth erosions. The medication was discontinued immediately. Physical examination revealed erythematous, scaly, and erosive plaques located on the bilateral anterior forearms (Fig. a) and multiple small ulcers of the hard palate. Several days after discontinuation of 5-FU, painful mucositis (Fig. b) and systemic 5-FU side effects occurred, including severe mucositis with mouth ulcerations, anorexia, 15-pound weight loss, and dehydration. No diarrhea was noted. The patient’s white blood cell count was normal. These systemic effects met criteria for hospitalization. Viral, bacterial, and fungal cultures of the mouth were negative, confirming a medication-induced mucositis. Complete blood count (CBC) and comprehensive metabolic panel (CMP) revealed dehydration but no signs of active infection or immunosuppression. Hematology/oncology was consulted, which stated that this presentation was likely due to a systemic 5-FU reaction, similar to the intravenous chemotherapy reaction seen with 5-FU. However, the patient refused DPD deficiency testing, so confirmation of deficiency could not be obtained. Supportive treatment along with intravenous fluids were administered for management. The medication was stopped before more possible adverse reactions, such as severe diarrhea or bone marrow suppression, were observed. The mucositis and systemic symptoms took approximately 1 month to resolve.


A 64-year-old female was referred to our Centre in September 2015. Her disease symptoms started almost 3 wk before with severe episodes of headache, dizziness visual and hearing loss (mainly right). From her past medical and family history nothing important to be mentioned. Initially, she was investigated by a computed tomography (CT) brain scan (Figure ) with no evidence of suspicious findings and pain killers were administrated with no benefit. Afterwards, steroids were administrated empirically with initial improvement of symptoms for a few days. Due to deterioration, further investigation by brain magnetic resonance imaging (MRI) revealed diffuse meningeal enhancement (Figure ). It was extended also into the internal auditory canal and optic nerves sheaths more into the right side. CT chest, abdomen, pelvis scans revealed only thickness in the area of gastric cardia and further investigation by an upper GI endoscopy confirmed the diagnosis of a poorly differentiated gastric adenocarcinoma with signet ring features (Figure ). Cerebrospinal fluid cytology (CSF) confirmed the diagnosis of LMC (Figure ). Full blood count and biochemistry tests were within normal values and tumor markers’ evaluation revealed CEA = 33.3 ng/mL. Her clinical status deteriorated rapidly, was in coma, and the other day of IT with Methotrexate (MTX, 12.5 mg) the patient died, approximately within 4 wk after the initial onset of disease symptoms.


A 51-year-old man was diagnosed with an EGJ poorly differentiated adenocarcinoma (cT3N+, M0) in July 2009. He was therefore commenced on peri-operative chemotherapy with epirubicin, cisplatin and capecitabine regimen and on 02/11/2009 he was operated (Ivor-Lewis gastrectomy, ypT2N1, R0, gr III adenocarcinoma with signet ring features, Figure ). He remained disease-free until September 2015 when he experienced neurological symptoms such as dysphasia, headaches and temporary left side paresis. Initially, investigations by CT brain (Figure ), chest, abdomen, pelvis scans revealed no evidence of disease. Subsequently, a brain MRI scan revealed findings of LMC (Figure ). A CSF cytology investigation confirmed the diagnosis consistent with GC origin (Figure ), meanwhile a flow cytometric test confirmed the presence of a non hematopoietic cell population. Full blood count and biochemistry tests were within normal values and tumor markers’ evaluation revealed CEA = 6.3 ng/mL, CA 19-9 = 98.1 μg/mL. He was treated with intrathecal MTX (12.5 mg) twice-weekly with relatively good clinical response initially. After three weeks of treatment he was put on “maintenance” application once weekly, but unfortunately his performance status was rapidly deteriorated after a couple of weeks. Therefore, his treatment was changed to MTX, Cytosine Arabinoside (40 mg) and Dexamethasone (4 mg). He received 3 and 5 applications with good clinical response, in October and in December 2009, respectively. Afterwards, the CT chest-abdomen-pelvis re-staging scans revealed no clear evidence of local recurrence or metastatic disease, meanwhile the MRI brain performed revealed slight improvement of meningeal enhancement. In July 2016, his performance status deteriorated with severe episodes of headaches, dizziness, dysphasia, visual and hearing loss and consciousness deduction. He was re-challenged with IT but with modest improvement and died in September 2016.


A 55-year-old man reported pain in the right lower jaw that had started one year previously. Because the pain increased gradually, he was referred to an oral surgeon. Gross examination revealed perforation of an ulcer in the gum on the bottom right of the jaw (). An X-ray showed a bone transmission image in the lower right jaw, floating teeth and a severe pathological fracture of the mandibular body (). A computed tomography scan showed a cystic lesion on the same site as the pathological fracture (). Because occlusal disharmony due to pathological fracture was observed, an occlusal correction using rubber traction was performed. A magnetic resonance imaging (MRI) scan showed a low signal on T1-weighted images, and a high signal on T2-weighted images (). Haematoxylin–eosin stain of the biopsy showed infiltration of eosinophils, with Langerhans cell-like cells in the periphery. Immunohistochemical staining was S100 protein positive and CD1a positive (); therefore, the diagnosis was LCH. There were no abnormal findings in fluorodeoxyglucose-positron emission tomography (FDG-PET) or MRI scans of the head. Therefore, the diagnosis was LCH confined to the mandible, and a mandibular segmental resection and reconstruction using a free fibula flap was performed ().
One month after the operation, an intermaxillary fixation was performed to obtain normal occlusion. Normal occlusion was acquired, and no recurrence was observed more than two years after surgery ().


A 7-day-old baby boy diagnosed antenatally with a large intra-abdominal mass was investigated postnataly with ultrasound and magnetic resonance imaging. It showed a large abdominal mass probably arising from the mesentery []. On admission, the baby had gross abdominal distension with dilated veins over the abdomen. Clinically, it was a large lobulated mass occupying the whole abdomen except right lumbar and iliac fossa. The alpha fetoprotein was elevated to 20,000 units and the beta human chorionic gonadotropin was 1.2 units and other routine investigations were normal.
Intraoperatively, a large tumor was adherent to the under surface of the liver and to the hilum, stretching the hepatoduodenal ligament []. Intraoperatively, the vascular pedicle comprising of portal vein, hepatic artery and the common bile duct got injured. It was repaired with the help of a vascular team. The portal vein was sutured with eight zero prolene. The hepatic artery was stented with 1 mm coronary stent and sutured with interrupted eight zero prolene A choledochoduodenostomy was done. The warm ischemic time was 45 min. The child needed massive transfusion and nearly 350 ml of blood was transfused during the procedure.
The child was electively ventilated for 3 days. The liver enzymes were elevated in the immediate postoperative period. Liver protective agent N acetyl cystine at the dose of 100 mg daily was infused for 6 days with supportive measures. The child recovered completely and the liver enzymes decreased and the alpha fetoprotein level dropped to 40 units. The child was discharged on the 12th postoperative day with Ursodeoxycholic acid. At the time of discharge, the serum conjugated bilirubin was 3 mg and indirect bilirubin was 3.4 mg. Review after 6 months showed that the liver functions normalized with serum bilirubin of 1.2 mg with conjugated fraction of 0.5 mg. The serum albumin was normal at 3.6 g.
The tumor cut surface showed predominantly solid areas with variegated appearance, focal areas of calcifications with a yellowish nodule. Histologically, the neoplasm was composed of skin with adnexal structures, fat, cartilage, bone, muscle, intestinal tissue, salivary gland tissue, and neural elements. Areas of immature intraepithelial elements were also seen which accounts for more than 3 low power microscopic fields. Liver parenchyma was not seen in sections studied. The impression was that of an immature teratoma Grade III [].


A 38-year-old nulliparous obese female patient consulted her general practioner for diffuse abdominal pain with fever. A bowel infection was diagnosed. She went back home with an antibiotic prescription. The treatment did not improve the symptoms. Two weeks later, she presented to the emergency department of the regional hospital with acute abdominal pain without nausea or vomiting. She had a body mass index (BMI) of 43 kg/m2 and smoked five cigarettes per day. She had stopped hormonal contraception 5 years ago. She had some combined oral contraceptive (COC) tablets (20 µg ethinylestradiol + gestodene) left at home and had decided to restart contraception 4 months ago without consulting her general practitioner or gynecologist. She had no personal or familial history of thrombosis. She had no previous medical condition and was not on any medication except her pill. On physical examination, she was afebrile and had diffuse abdominal pain with peritoneal signs. Laboratory examination showed increased C-reactive protein level of 102.5 mg/L (normal range, <5.0 mg/L) and LDH level of 370 U/L (normal range, 125–243 U/L). A computerized tomographic scan with intravenous contrast of the abdomen was performed. An acute venous mesenteric thrombosis with diffuse ischemia of the small intestine was identified.
The patient was anticoagulated with intravenous heparin. A laparotomy was performed which revealed small intestine ischemic necrosis and a mass on the transverse large bowel. A resection of 2 m of small intestine was performed, followed by temporary ileostomy as well as transverse colectomy with end-to-end anastomosis. Reanastomosis of the small intestine was performed 1 month later. At histopathologic examination of the large transverse bowel mass, acute inflammatory and fibrotic subserosal changes were observed. COC was stopped at the time of admission. Medroxyprogesterone acetate injection was given 1 month later at the time of small intestine reanastomosis, and the patient was switched to oral progestin 3 months later. Evaluation for prothrombotic conditions including protein C, protein S, antithrombin deficiency; factor V, prothrombin gene mutation, lupus anticoagulant, and antiphospholipid and anticardiolipin antibodies were all negative. The patient gave written informed consent for her data to be used in this publication.