A 32 year old man was referred because of left knee pain. Six months before he had a subtotal meniscectomy of the medial meniscus for a bucket handle tear. He was a local policeman that could not develop his work because of non-responsive pain in prolonged stand up position and severe limitation for running and other sports activities.
Physical examination revealed a varus morphotype with positive meniscal maneuvers and medial joint pain. Radiographic imaging showed impingement of the medial compartment corresponding to a Fairbank grade II. The report of magnetic resonance imaging indicated a small medial meniscus remnant, almost absent in body and no posterior horn attachment with a focal osteochondritis of the medial femoral condyle. An arthroscopic evaluation was recommended and different therapeutic options were explained.
After informed consent and pre-surgical study, knee arthroscopy was performed under epidural anesthesia and preventive ischemia of the left lower extremity. Arthroscopy showed absence of part of the body and posterior horn of medial meniscus (Figure A and B). The anterior part of the meniscal tissue showed degenerative signs. In the lateral area of the medial femoral condyle near the notch, a focal Outerbridge chondral injury grade III was observed. The remaining meniscal tissue was regularized until reaching a healthy-look tissue and the meniscal wall was reconstructed with autologous graft with a double semitendinosus tendon. The tendon was identified through an oblique incision over the tibial insertion of the hamstrings. The graft was introduced through the antero-medial portal across the anterior capsule, pulling on the sutures through a tibial tunnel that was previously drilled in antero-posterior and medio-lateral direction pointing to the insertion of the posterior horn (Figures B and A). The graft was fixed with sutures “outside-in” to the menisco-tibial ligaments and then sutured to the anterior horn remainder, “inside-out” in the body, “all inside” in the posterior horn and a tibial staple distally to the tibial tunnel (Figure A and B).
The knee was immobilized at 20 degrees of flexion for 3 weeks. Partial weight bearing was authorized at the third post-operative week. Then, range of motion was allowed from 0 to 90 degrees until the sixth week. Postoperative physical examination was made, showing only mild effusion of the knee. After six weeks, progressive flexion was permitted. A 1.5 Tesla MRI in coronal plane (FigureA) showed that the double semitendinosus tendon reached the lateral margin of the lateral tibial plateau. In sagittal plane (FigureB) a bulky posterior graft was adapted to the posterior tibial plateau.
Five months later he underwent a new arthroscopy. The new reconstructed “meniscal wall” with semitendinosus tendon was stable and invaded by a synovial tissue similar to the native tissue (Figure A and B). The anterior horn showed an oblique tear with degenerative appearance in the graft union and the osteochondral lesion reduced its size with some fibrocartilage areas. The anterior horn of medial meniscus was regularized and a collagen meniscal implant of 40 mm was inserted. The CMI was attached to the new meniscal rim with sutures “all-inside” in the posterior horn (Figure A) and sutures “outside-in” for the body and anterior horn (Figure B). In addition, microfractures were performed in the area of osteochondritis with stabilization of the edges of the cartilage defect with a radiofrequency terminal.
In the postoperative period, the knee movement was limited from 0° and 30° during the first week, until 60° between first and third week and up to 90° between third and sixth week. Then, free range of motion was allowed and a progressive partial weight bearing was authorized in the third post-operative week.
Two months after the last surgery, the patient’s physical examination revealed a joint range of motion of 0º to 120°, without effusion, moderate quadriceps atrophy and some occasional discomfort related with sustained load bearing.
After 3 months, the patient was admitted in other Hospital because of an acute truncal viral encephalitis of unknown etiology. However, after a complete neurological examination any correlation with the knee surgery was discarded.
At 5 months, the patient only presented occasional discomfort in the popliteal region, mild atrophy of the quadriceps and minimum non inflammatory effusion that was drained and sent to microbiological study. The magnetic resonance imaging demonstrated that both grafts were correctly placed in middle and posterior zones with moderate anterior extrusion and marked synovitis. In the sample cultures, there was growth of colonies of Staphylococcus simulans. Despite that the culture results were considered to be a contaminating agent rather than a pathogen, antibiotic therapy was prescribed according to the antibiogram.
At 7 months, a diagnostic arthroscopy was performed because of persistent knee effusion with no local or systemic signs of infection. A marked generalized synovitis was observed, and three samples were taken for pathologic and microbiologic studies. Then, a partial synovectomy and joint toillette was performed. The meniscal implant was stable with complete integrity. The chondral defect of medial femoral condyle was covered with fibrocartilage. The results of the studies reported inflammatory synovitis with no pathogens growth.
Ten months after the placement of the CMI, the patient only complained of occasional discomfort related with periods of increased physical activity. MRI showed reduced synovitis and no osteoarthritis progression neither posterior extrusion of the implant were observed (Figure A and B).
After two years of the CMI surgery, the patient had no medial compartment pain neither activity daily living limitations and only complained of non specific discomfort with intense activities. In the Lysholm-Gillquist score 92 points was obtained. The varus deformity was not increased. The MRI revealed the correct fitting and complete integration of implants except moderate extrusion of the anterior horn. No significant degenerative changes were observed. (FigureA andB).


S.S.F. is a 66-year-old female patient who complained of eyelid angioedema, ocular itching, and facial and cervical erythema that occurred into the first 30 minutes after receiving various analgesics, including aspirin, pyrazolone, and ketoprofen. According to the patterns previously proposed, this patient was pharmacologically classified as cross-reactor and clinically, because of the presence of cutaneous and ocular symptoms, as mixed (blended). There was no history of other allergic or atopic diseases, and immediate-type skin hypersensitivity (prick) tests with 20 inhalant and 21 food allergens were negative. Double-blind oral provocation test results were as follows:
One hour after receiving 7.5 mg of meloxicam, eyelid edema, breathlessness, dysphonia, and a sensation of laryngeal swelling were reported by the patient. Treatment with epinephrine (1:1000) 0.3 mL subcutaneously and chlorphenir-amine 100 mg intravenously were administered. The patient was discharged after total recovery 2 hours later.
Thirty minutes after a 100-mg provocative dose of celecoxib, an itchy erythematous rash was observed in the face, neck, and chest (Figure ). Oral chlorpheniramine 8 mg and montelukast 10 mg induced the disappearance of the rash in approximately 30 minutes.
A challenge with 100 mg was tolerated (Figure ).


A 47-year-old woman, beginning her first sexual relation at the age of 23, 2 sexual partners and 1 gestation completed at the age of 27. No previous sexual transmission disease (STD) recorded. No cervical injuries found during exploration. Cytology diagnosis provided by the specialist: Negative to malignity = No alterations. The result of the system is shown in .


A 43-year-old woman, beginning her first sexual relation at the age of 16, 1 sexual partner and 7 gestations completed at the age of 28. No previous sexual transmission disease (STD) recorded. No cervical injuries found during exploration. Cytology diagnosis provided by the specialist: AGC. The result of the system is shown in .


A 50-year-old woman with first sexual relation at the age of 19, 3 sexual partners, and 7 gestations completing the first at the age of 20 via vaginal channel. No STD recorded. Cervical injuries found during exploration. Cytology diagnosis provided by the specialist: Adenocarcinoma = precursor injury of CN. The result of the system is shown in .
In , the obtained results from the 10 diagnosed cases in HRRB are shown. Although it is true that the results obtained from the tests cannot show a significant reduction of false positives or false negatives, in these cases, 100% correlation between the doctors and the system was reached; however, a further test with more cases is expected. It is expected that with the implementation of this tool the percentage in the reduction of false positives and false negatives can be quantified.
The expert system is a supportive tool in the cervical cancer diagnoses at the HRRB, but the final decision is made by the specialist. However, in this section it is proven that tools and techniques such as image processing and fuzzy logics are as capable of emulating a decision-making process as much as a specialist. The image processing turns out to be a very interesting tool since it is through these kinds of techniques that detailed and accurate information can be consulted rather than just the subjectivity of the human eye in manual diagnosing. At the same time that fuzzy logics is a helpful tool for meeting criteria, it also helps model knowledge and expertise from specialists. Finally, the implementation of interfaces helps users to understand and interact in a simpler and easier way with the expert system.
As far as the data is reliable, the system will be able to make a diagnostic suggestion which helps the specialist to offer patients an opportune and appropriate treatment.


A two and a half year old male proband was found to be highly myopic with a facial phenotype (maxillary hypoplasia and a flattened nasal bridge) suggestive of Stickler syndrome. No sensorineural hearing loss was demonstrated, but there was a history of recent glue ear. Examination revealed a beaded vitreous phenotype and a high-arched palate, but no midline clefting. Deletions of exons 41 and 42 [c.3025-3168, p.Gly1009-Val1056] were detected by MLPA (Figure D), as probes for exons 40 and 43 are included in the two probe sets no further analysis was required.
Two additional mutations were detected in DNA from other patients with Stickler syndrome (Figure C and F). These were a deletion of a single exon, 39 [c.2863-2916, p.Gly955-Gln972] and a deletion of exons 49–58 [c.3655-4302, p.Gly1219-Met1434]. In this latter case it could not be confirmed whether or not exon 48 was included in the deleted region, probably due to the large size of the region needed to be amplified by long range PCR.


A 67-year-old male with stage IIIB gastric adenocarcinoma treated with Billroth-II gastrojejunostomy, adjuvant chemotherapy with oxaliplatin and 5-fluorouracil, and external beam radiation therapy presented one year following completion of adjuvant therapy with abdominal pain and inability to tolerate oral intake. Imaging studies including computed tomography (CT) of the abdomen and pelvis revealed a malignant gastric outlet obstruction at the gastrojejunal anastomosis (). Following nasogastric decompression, he underwent endoscopic placement of a 90 mm × 22 mm WallFlex Enteral Stent (Boston Scientific, Natick, MA) across the stricture (Figures –). There were no immediate complications, his abdominal pain resolved, and he resumed oral intake. He was initiated on docetaxel therapy and discharged home.
Four months later, after four cycles of docetaxel, he presented with severe acute abdominal pain with peritoneal signs. Laboratories revealed white blood cell count of 17,720/μL (reference: 3.28–9.29 × 103/μL) with 93.0% neutrophils. CT imaging () showed migration of the stent 20 cm distally into the mid-jejunum, resulting in visceral perforation, stent erosion into the anterior abdominal wall, leakage of enteric contents, and peritonitis. He emergently underwent operative resection of the perforated segment of jejunum () with primary re-anastomosis. His postoperative course was unremarkable and he was discharged home tolerating a regular diet. He has subsequently done well on continued chemotherapy.


Our patient, a fifteen year old male, resident of Bihar had complaints of longstanding fever, abdominal distention, weight loss and generalized weakness since ten months. He then reported to the local district hospital where the rK39, rapid diagnostic test for kala azar was done and found positive. He was given three injections of amphotericin deoxycholate to which he reacted with fever and hypotension. No further medication was given or investigations carried out. The parents were migrant laborers and the boy was brought to the outpatient department of our hospital in New Delhi after another two months when symptoms persisted.
On examination, he was febrile, undernourished, with massive splenomegaly and hepatomegaly. Hematological investigations showed moderate pancytopenia, Hb 8.3g/dl, TLC 2000/mm3, platelet count 75,000/mm3. rK 39 Rapid Diagnostic test was repeated and was negative. ELISA tests for HIV, HbsAg and HCV were all negative. Mantoux test was also negative. Liver and renal function tests were within normal limits. Bone marrow aspiration showed reactive plasmacytosis (10%) and no Leishmania donovani (LD) bodies were seen. Napier's aldehyde test was performed which was strongly positive. In view of the strong clinical suspicion of VL and the positive aldehyde test, splenic aspiration was done. Aspirates showed both intracellular as well as extracellular amastigote forms of LD bodies, thus confirming VL (). A combination therapy was started with pulse liposomal amphotericin B (10 mg/kg body weight) i.e. 250 mg as a single dose therapy followed by tablet miltefosine 50mg O.D. for one week. Patient responded well to the therapy. He became afebrile with improvement of the blood counts and regression of the spleen size.


We present the case of a 90-year-old diabetic male and medically managed three-vessel coronary artery disease with evidence of an oval, nonmobile echo-density located on the posterior mitral valve annulus measuring two centimeters in diameter without significant impingement of the mitral valve on initial screening echocardiogram ().
Initially, it was thought that the mass may represent prominent mitral annular calcification, a manifestation of metastatic disease, or perhaps a primary cardiac tumor. Cardiac magnetic resonance imaging (CMR) was performed shortly thereafter which suggested the mass was either a myxoma or a metastatic tumor. Due to the patient's advanced age, comorbidities, the patient and the treating physician elected for a course of close clinical follow up with serial echocardiograms. The patient remained symptom free with minimal change to the size or echocardiographic appearance of the mass at his three and six month followup visits. Due to the possible suspicion of caseoma when repeat echocardiogram was performed and compared with CMR, a cardiac computed tomography (CCT) was performed to complement the initial imaging modalities for a confirmatory diagnosis. Multimodality imaging can be a valuable adjunct to distinguish between caseoma, tumors, or abscesses. In this instance, correlating the echocardiographic findings with imaging on CCT and CMR enabled an appropriate diagnosis of caseoma without invasive studies ().


A 64-year-old Japanese man reported dyspnea and general fatigue two months before admission. He was referred to our hospital due to acute lymphoblastic leukemia, and chemotherapy was introduced in accordance with the CALGB 8811 protocol [] on 54th day before the lobectomy of the left upper lobe (−54th). On -46th day, the patient exhibited a fever (38°C), and chemotherapy-induced neutropenia was confirmed with a peripheral neutrophil count (PNC) of 0 per microliter. Further, on -39th day, chest CT revealed GGO in the left upper lobe (Figure A). On -31st day, septum cytology revealed a small number of mold species and treatment comprising intravenous liposomal amphotericin B at 3 mg/kg/day was started. On -28th day, subsequent chest CT revealed RHS comprising both a central GGO and an outer rim recognized as a ring-shaped high-density area replacing the outside parenchyma of GGO (Figure B). The chest CT showed an increasing in thickness the outer rim on −20 day, and revealed RHS with air crescent-like small air slit between a part GGO and the outer rim on -11st day (Figure C), while serum Beta-D-Glucan levels failed to reach a normal level. The patient therefore underwent the operation. The PNC on the 54th, 46th, 44th, 39th, 31st, 28th, 20th, and 11st day before the operation was 1800, 0, 0, 340, 4400, 7735, 4623, and 2542 per microliter, respectively (Figure ).


A 52-year-old Chinese woman was admitted to our hospital for watery diarrhea and febricity for one day, palpitation and debilitation for 6 hours. She had a history of immunologic thrombocytopenic purpura, femoral head necrosis and connective tissue disease. But she had not complained of headache and had no history of hypertension. The sonography of abdomen showed a space-occupying lesion in caput pancreatis. But the magnetic resonance imaging (MRI) (Figure ) confirmed a 6 cm heterogeneous right retroperitoneal mass, with enhancing rim and central low attenuation on the enhancement scanning of T1-weighted images. The inferior caval vein and portal vein were deformed by the compression of the mass. ST-T abnormalities were seen on the electrocardiogram. The serum carbohydrate antigen 19–9 and carcinoembryonic antigen were normal. And troponin I was 4.4 ug/l, creatine kinase-MB was 15.3 ug/l. During the laparotomy, the retroperitoneal mass lied at the left posterior to hepatoduodenal ligament, right of aorta abdominalis, which compressed forward the inferior caval vein and left renal vein. Then the patient underwent mass resection for biopsy. The findings on pathology examination were consistent with retroperitoneal composite pheochromocytoma-ganglioneuroma. The patient recovered well after tumor resection, without adjuvant chemotherapy or radiotherapy. And Long-term follow-up was suggested.


An 18-year-old healthy male with a chief complaint of spontaneous pain and pain to cold and heat in the left posterior maxilla was referred to the Endodontic Department, Dental School, Tehran University of Medical Sciences. Medical history of the patient was non-contributory and there was no history of dental trauma.
In clinical examinations, left maxillary first molar had extensive coronal caries and a pulp polyp. The tooth was not sensitive to percussion and palpation. In periodontal examinations the probing depths were normal (<3 mm), with normal mobility. While the adjacent teeth responded normally, the first molar showed a prolonged response to cold test (Roeko Endo-Frost, Coltene Whaledent, Germany) and a very sharp response to electric pulp test (Parkell Inc., Farmingdale, NY, USA) in lower degrees.
In radiographic examinations, extensive external root resorption was seen in all roots (, ). Considering the lingering pain and patient’s complaint, an emergency pulpotomy was performed on the first molar for immediate pain control. Since the whole of the palatal root could not be seen in periapical radiographs taken with different angulations, cone beam computed tomography (CBCT) images were obtained. They confirmed the presence of the extensive external root resorption in all roots with no periradicular osseous lesion (, ). Hematological investigations, including complete blood count, serum calcium, phosphorus, parathormone and alkaline phosphates levels were taken to exclude any systemic disorders. All were found to be within normal limits.
A pulpal diagnosis of irreversible pulpitis with pulp polyp was made for the tooth. Since the palatal root, which is required for dowel crown restoration, showed extensive resorption the prognosis for tooth retention was poor. Therefore, extraction and implant replacement was indicated.


A 32-year-old woman diagnosed in 2009 with International Federation of Gynecology and Obstetrics (FIGO) stage IIA2 cervical cancer(squamous cell carcinoma), presented to our hospital emergency room with exertional dyspnea lasting four days. The patient had previously received multimodality treatment from a multidisciplinary oncology group, which, because the patient was young and wanted to preserve ovarian function, included the following treatment: radical hysterectomy along with ovarian transposition and pelvic and para-aortic lymph node dissection and concurrent chemoradiation with six cycles of weekly cisplatin, including tomotherapy in pelvic and para-aortic lymph node area.
Thirteen months after completion of adjuvant treatment, 18-fludeoxyglucose positron emission tomography-computed tomography (18-FDG PET-CT) revealed no evidence of recurrence. However, just two months later, she was examined on admission with chest CT (Figure A), which reported a finding of thromboemboli in several segmental branches of the right middle and lower lobe pulmonary arteries and in left lower lobe posterior basal segment arteries. Therefore, she was anticoagulated with warfarin and enoxaparin, a low-molecular-weight heparin. However, unfortunately, the patient still showed clinical deterioration with increasing shortness of breath and developed signs of rightheart strain, suggestive of further episodes of pulmonary embolism.
For evaluation of the embolic source, we performed echocardiography and deep vein thrombosis three-dimensional CT (DVT 3D CT) angiography. The examinations revealed cardiac masses occupying the right ventricle and right atrium and no evidence of deep vein thrombus (Figure B).
In view of the threatened outflow obstruction caused by the right ventricular mass, the patient underwent an open excision of the intracardiac mass (Figure A). At the opening of the right atrium, whitish fungating, friable masses were seen arising from the free wall of the right atrium, extending through the tricuspid valve into the right ventricle. The masses were also seen arising from the free wall of the right ventricle through the opened tricuspid valve and occupied 90% of the right ventricular lumen, nearly resulting in right ventricle outflow tract obstruction. The masses were partially sucked out through suction tubes. The remnants of the masses were excised and collected. They were originally torn to pieces because the cardiac mass was so friable. Therefore, we fitted them together into one (Figure B).
The histopathology of the surgical specimen revealed this to be a cardiac metastasis from known cervical squamous cell carcinoma (Figure A). Additional HPV DNA genotyping of the metastatic lesion revealed HPV-16 consistent with the primary lesion. Cardiac metastasis should be the cause of the pulmonary embolic events and right heart failure that she had suffered.
After the patient’s condition was stable, she was transferred to a medical oncologist for recurrence management. She underwent carboplatin with paclitaxel chemotherapy for palliative treatment at the medical oncology department. On a follow-up chest CT and echocardiogram after three cycles of the chemotherapy, cardiac mass and pulmonary thromboemboli were no longer seen. The patient was supposed to undergo six more cycles of the chemotherapy. She tolerated the chemotherapy well, but during the last month of her life, the recurrent cancer mass surrounding the celiac axis caused extensive hepatobiliary obstruction. The cancer mass in her heart was still regressed. She died of cachexia one year and four weeks from diagnosis of cardiac metastasis.


A 13-year-old Pakistani boy presented to our clinic with cyanosis, an intermittent cough, decreased exercise tolerance and episodes of bluish discoloration of his hands and feet that had been ongoing for one year. A clinical examination revealed clubbing and cyanosis with room air oxygen saturation of 88% in the supine position and 87% while sitting. There was no history of jaundice, cholangitis, hematemesis, melena or rashes. The chest was clear and there was no heart murmur. An abdominal examination revealed no abnormalities. There was no hepatosplenomegaly. Skin examination showed no stigmata of chronic liver disease. The patient had an increased alveolar-arterial gradient (A-a PO2 gradient) of 26mmHg and was started on two liters of oxygen that improved his oxygen saturation to 97%. His chest X-ray and echocardiogram were normal. Spirometry revealed normal percentages of predicted FEV1 (forced expiratory volume in one second) 90%, FVC (forced vital capacity) 86%, and FEV1/FVC 89%. Cardiac catheterization showed normal pulmonary pressure. His chest computed tomography (CT) scan was normal. An incidental finding of a prominent liver surface and collateral vessels connecting a dilated portal to the dilated terminal inferior vena cava (IVC) and mild splenomegaly was noted. Sonography of his abdomen along with the portal venous Doppler study showed a dilated portal vein. A magnetic resonance imaging (MRI) scan of his abdomen showed attenuated hepatic veins and normal intrahepatic portal vein branches with a maintained texture pattern. The main portal vein was replaced by multiple prominent collaterals transforming to a portal cavernoma (Figure
).
His liver function tests, coagulation profiles, serum ceruloplasmin, alpha-1 antitrypsin, antinuclear antibodies (ANA), and antineutrophil cytoplasmic antibodies (ANCA) were all normal. Endoscopy of his upper gastrointestinal tract showed no esophageal varices. An ultrasound-guided liver biopsy showed hepatocytes in lobules without significant inflammation or necrosis, surrounding portal fibrosis and bile duct proliferation in the fibrosis areas with bile stasis and little inflammation, all suggestive of congenital hepatic fibrosis (Figure
A, B).
Contrast-enhanced echocardiography with agitated saline (CEE) and a 99m Technetium-macroaggregated albumin perfusion lung scan (99mTc-MAA) were compatible with an intrapulmonary right-to-left shunt. CEE is considered diagnostic if the bubbles are in the left heart cavities at least three beats after their visualization in the right cavities, as was found in our patient
[]. 99mTc-MAA is an injectable radiopharmaceutical used in nuclear medicine. It consists of a sterile aqueous suspension of Technetium-99m (99mTc) labeled to human albumin aggregate particles in the pH range of 3.8 to 8.0. 99mTc-MAA perfusion scanning is a more sensitive procedure as it allows quantification of the degree of intrapulmonary shunting. 99mTc-MAA particles >20mm in diameter are entrapped in pulmonary vasculature and undergo decay
[]. In patients with a right-to-left shunt, the 99mTc-MAA enters the systemic circulation and distributes to systemic organs, as was found in our patient.
The patient underwent a successful living-related liver transplantation with no serious complications. Histopathology of his liver resection confirmed congenital hepatic fibrosis. The patient required oxygen in the initial postoperative three months until his PO2 improved to 90mm Hg in room air and he did not require further oxygen therapy.


The patient was a 53-year old female with multiple cardiovascular factors, including hypertension, hypercholesterolemia, diabetes mellitus, coronary artery disease, and history of heavy smoking (60 pack-years; quit 3 years ago), who presented with bilateral lower extremity intermittent claudication, right worse than left, forcing her to stop after 3 minutes of walking. On physical examination, her bilateral femoral, popliteal, dorsalis pedis and posterior tibialis pulses were not palpable. At rest, her ankle-brachial index (ABI) measured 0.57 on the right and 0.58 on the left. She underwent a computed tomographic angiography (CTA) that showed complete occlusion of the distal abdominal aorta, including the origin of the inferior mesenteric artery, as well as the bilateral common iliac arteries (CIAs), with reconstitution at the level of the iliac bifurcations. The diameter of the abdominal aorta was 12 mm at the proximal aspect of the occlusion and decreased to 9 mm at the level of the bifurcation, as seen on the preplanning CTA. The right external iliac artery (EIA) was 4 mm and the left EIA was 5 mm in diameter. The occluded right CIA was 6 mm and the occluded left CIA was 7 mm in diameter. The patient declined open surgery and opted for endovascular therapy. Left brachial arterial access was obtained under ultrasound guidance using a micropuncture access kit (Cook Medical, Bloomington, IN, USA). A 5 French sheath was placed and a 5 French pigtail flush catheter (Cook Medical, Bloomington, IN, USA) was advanced into the abdominal aorta. An aortogram was performed and showed complete occlusion of the distal infra-renal aorta and bilateral CIAs, with reconstitution at the iliac bifurcations (Figures and ). Bilateral retrograde common femoral artery (CFA) access was obtained using ultrasound guidance and a micropuncture access kit. Five French sheaths were inserted in the CFA bilaterally and upsized later to an 8 French sheath on the left and 7 French on the right. Unfractionated heparin was injected intravenously in boluses throughout the procedure to maintain the activated clotting time (ACT) >250 seconds. A 5 French Davis catheter (Cook, Bloomington, IN, USA) and 0.035′′ Glidewire (Terumo, Somerset, NJ, USA) were used to perform antegrade subintimal recanalization of the right CIA from a brachial approach. The Glidewire was retrieved from the right femoral sheath () and then exchanged for a Rosen wire (Cook, Bloomington, IN, USA). Subintimal recanalization of the left CIA from a femoral approach was unsuccessful, with failure to reenter the true aortic lumen. Attempts to recanalize the left CIA from a brachial approach were also unsuccessful, as the wire and catheter continued to advance into the recanalized right CIA, following the path of the least resistance. To overcome this problem, the recanalized right CIA was occluded at its origin with a 5 mm × 40 mm UTD balloon catheter (Boston Scientific, Natick, MA, USA) inserted from the right femoral approach, sealing the origin of the right CIA. The 5 French Davis catheter was advanced from the brachial approach into the distal abdominal aorta to the level of the occluded left CIA. With the tip of the catheter pointed toward the occluded left CIA, the stiff back end of a 0.035′′ Glidewire was advanced to initiate a sharp recanalization of the occluded left CIA (). The presence of the occlusion balloon prevented the Davis catheter from advancing into the recanalized right CIA and forced it in the direction of the occluded left CIA. The catheter was advanced over the wire into the occluded left CIA. At this point, the floppy end of the Glidewire was advanced through the catheter, and recanalization of the left CIA continued from a brachial approach. The wire reentered the true lumen of the left EIA and was retrieved from the left femoral sheath (). The Glidewire was exchanged for a Rosen wire advanced into the abdominal aorta. From the left femoral approach, a 16 mm length Intrastent Doublestrut LD balloon expandable stent (EV3, Plymouth, MN, USA) mounted on 10 mm × 2 cm EverCross balloon catheter (EV3, Plymouth, MN, USA) was deployed in the proximal occluded aortic segment, and then further balloon dilated to 12 mm using a 12 mm × 2 cm EverCross balloon catheter (EV3, Plymouth, MN, USA) (). More distally, the occluded aortoiliac bifurcation was reconstructed using a 6 mm × 59 mm iCAST balloon expandable covered stent (Atrium, Hudson, NH, USA) on the right and a 7 mm × 59 mm iCAST balloon expandable covered stent on the left, deployed simultaneously in a kissing fashion; the iliac stents were extended further to cover the entire length of the occluded common iliac arteries, ending just above the iliac bifurcations. Final arteriogram showed reestablishment of flow through the reconstructed aortoiliac bifurcation with no significant residual stenosis (). The patient was discharged the next day on Clopidogrel 75 mg once a day for 3 months and aspirin 325 mg once a day for life. She noted significant clinical improvement with an ABI of 0.85 on the right and 1.01 on the left at her 2-week postprocedure followup. She was seen in followup at 6 months, with recurrence of intermittent claudication on the right after 15 minutes of walking. Her right ABI decreased to 0.69; her left ABI was stable and measured 1.05. A CTA showed severe stenosis at the proximal aspect of the right CIA stent. Her symptoms were subjectively described as mild and nondisabling and she declined any further intervention.


An 83-year-old woman initially presented at another hospital with an unstable trochanteric fracture (Orthopaedic Trauma Association classification 31-A2.2) of her right femur after falling from a standing height (). She was obese with a height of 148 cm, weight of 56 kg, and body mass index of 25.6 kg/m2. She had a history of hypertension, hyperlipidemia, diabetes, and cardiac arrhythmia. She underwent surgical treatment using a short Gamma 3 nail (Stryker, Tokyo, Japan) with a cervical-diaphyseal angle of 125°, a distal diameter of 10 mm, a U-lag screw, and a distal static screw. Postoperative radiography showed insufficient reduction of the fracture, with varus position of femoral head (). Full weight-bearing with a walker was allowed immediately after surgery, and she regained mobility with a walker.
At 14 months after surgery, she was referred to our institution after feeling sudden pain in her thigh without any fall or trauma and being unable to stand. Radiographs revealed breakage of the nail at the opening for the lag screw, resulting in varus angulation between the nail and the lag screw (). The fracture showed signs of nonunion with sclerosis of the bone ends.
The broken nail was removed, and cemented bipolar hemiarthroplasty was performed (). The retrieved Gamma nail had a horizontal fracture line, with no obvious damage due to drilling or screw insertion (). At 18 months after her second surgery, radiographs showed good implant alignment with no evidence of loosening. The patient was mobile with a walker and asymptomatic with no complications.


A 27-year-old male patient reported with the chief complaint of swelling in the upper front right region of the mouth 1 month ago. He had a history of trauma to right upper anterior region 12 years back. The clinical examination revealed intraoral swelling in palatal region accompanied with salty discharge with respect to teeth 11, 12, and 21, and a sinus opening with respect to the apex on buccal aspect of 12 and 13 (Figures and ). The teeth were tender on percussion and nonvital with Ellis and Davey class 4 trauma. Palpation of right upper anterior region was painful. Teeth 11 and 12 had grade 1 mobility.
The IOPA radiographic examination revealed a large radiolucent lesion with a well-defined border in the periapical area of teeth 11, 12, and 21 suggestive of periapical cyst (). CBCT examination revealed presence of periapical radiolucency with respect to 11, 12, 13, and 21 in sagittal, coronal, and axial planes and reconstructed three-dimensional image (Figures , , , and ). Oral and maxillofacial radiologist categorized the CBCT images, based on the radiodensity as periapical granuloma.


A 22-year-old male patient reported with the chief complaint of pus discharge from upper right front region of mouth for 4-5 years. The clinical examination revealed discolored fractured crown fracture with respect to tooth 11 while tooth 12 was displaced (). Teeth 11 and 12 were nonvital with Ellis and Davey class 4 trauma.
The IOPA radiographic examination revealed large radiolucent lesion with a well-defined sclerotic border in the periapical area of teeth 11 and 12, along with displacement of these teeth suggestive of periapical cyst (). CBCT examination revealed presence of periapical radiolucency with respect to 11 and 12 in sagittal, coronal, and axial planes and reconstructed three-dimensional image (Figures , , , and ). Oral and maxillofacial radiologist categorized the CBCT images, based on the radiodensity as periapical cyst.


A 47-year-old male presented with right hemiscrotal swelling and pain, one week following painful sexual intercourse. Over the course of the week, his pain worsened and scrotal swelling progressed, after which he presented to the Emergency Department for evaluation. Patient denied gross hematuria. He continued to have painful erections since symptom onset and denied any obstructive or irritative voiding symptoms. His medical, surgical, family, and social history were unremarkable.
Physical examination was significant for a right scrotal induration and tenderness extending deep into the perineum sparing both testicles. Urinalysis was unremarkable. Initially, scrotal ultrasound revealed a complex cystic structure in the right scrotal wall. This study did not establish a definitive diagnosis. Subsequently, scrotal MRI was performed, which revealed a focal tear of the tunica albuginea overlying the right proximal corpus cavernosum. Associated with this was a 1 cm intracavernosal hematoma, as well as a 4 cm hematoma tracking anteriorly through the perineum toward the right hemiscrotum.
Because of these MRI findings, the patient was sent to the operating room. The deep scrotal and perineal tissues were explored through a midline perineal incision, where a large hematoma was encountered contained within ischiocavernosus muscle. The muscle was incised and dissection was carried out to the right corporeal body in order to evacuate the hematoma. After multiple rounds of copious irrigation, hemostasis was achieved and a right 1 cm oblique corporeal tear was visualized. This was repaired primarily in a watertight fashion with interrupted figure-of-eight polydioxanone sutures (PDS). The incision was then closed in layers. We left a penrose drain in the hematoma space and delivered it through a separate perineal stab wound incision.


A 20-year-old female complained of recurrent epigastric pain for 2 years. She was diagnosed with cholecystitis with stone and underwent laparoscopic cholecystectomy in another center. Choledochal malformation was found intraoperatively. Ultrasound (USG) and cholangiogram after laparoscopic surgery revealed extrahepatic fusiform dilation of the CBD with stone (Figures and ). Two months later ward patient came to our institution due to recurrent epigastric pain. Physical examination revealed no icterus or abdominal mass. Laboratorium examination was also within normal limits.
Provisional diagnosis of type I choledochal cyst was made. During laparotomy, we found a diverticulum arising laterally from the middle portion of the CBD. The CBD itself was dilated in a fusiform fashion (type I CC). Complete cyst resection was performed. Based on USG, cholangiogram, and intraoperative findings, final diagnosis of mixed type I and II choledochal cyst was made. Reconstruction was performed with Roux-en-Y hepaticojejunostomy. Histopathological examination of the CC revealed no dysplasia. Three months later, the patient came for followup in good condition.


Case 1: The patient was a 48-year-old woman, whose asthma was diagnosed at 8 months old. Twenty one years ago she was diagnosed as bronchiectasis based on a chest CT scan, and since then she had to be hospitalized several times every year for severe exacerbations. Her symptoms were characterized as increased wheezing, chest tightness, and productive cough with massive brownish sputum which mainly occurred in the early morning. Ten years ago she started to have symptomatic GER and deteriorated exertional dyspnea. In August 2008 the patient received LF. Five years after the intervention, the patient had no GER symptoms, her episodic wheezing and chest tightness were reduced about 30% without hospitalization, and her respiratory drug consumption was cut by more than half. Although there were fewer improvements in her cough and sputum productions, the brownish sputum became occasional.


Case 2: Bronchiectasis was diagnosed in this 30-year-old woman based on typical clinical features and CT scan 7 years ago. Since she was born, the patient had intermittent symptoms of severe cough, sputum production as well as dyspnea mainly at night. Since then, she had to be repeatedly hospitalized due to exacerbations every year. She also developed mild GER symptoms, accompanied with daily respiratory symptoms and severe dyspnea on exertion and fatigue in the later 5 years. In September 2009 the patient underwent laparoscopic repair of HH with LF. She became asymptomatic and had resumed normal life without medication based on her 4-year follow-up. Although the patient reported mild cough and fatigue during her pregnancy in the later 6 months, she was still satisfied with our therapy.


Case 4: This was a 59-year-old woman who was diagnosed with asthma 20 years ago, and with bronchiectasis based on CT scans 10 years ago. Her respiratory symptoms had been accompanied with persistent GER symptoms for 20 years and had worsened with exertional dyspnea in the later 2 years. The respiratory symptoms represented as episodic throat tightness, wheezing, short of breath and productive cough. During the last 2 years, repeated emergency treatments were required due to deteriorated exacerbations. In April 2011, the patient received radiofrequency energy delivery to the LES, The SRF procedure. At the 2-year follow-up, she was on the daily dose of 20 mg Omeprazole. Her episodic throat tightness and wheezing disappeared, and short of breath and productive cough ameliorated more than half. Although not fully recovered, she was satisfied with her stable condition without hospitalization.


Case 5: The patient was a 59-year-old man who was diagnosed with asthma 30 years ago and with bronchiectasis based on chest film and CT scan 10 years ago. His symptoms were characterized by increased wheezing, chest tightness, productive cough which mainly occurred at night and early morning. He had numerous emergency visits due to severe exacerbations, in several of which he had throat tightness, inability to breath, intense stridor and syncope. The symptoms significantly worsened in the later 3 years with exertional dyspnea and incapable of less than 100 meter walk. For 4 years he also experienced symptomatic GER. In November 2011, the patient received SRF treatment. At the 2-year follow-up after the intervention, the patient had no GER symptoms and only mild productive cough without exacerbation and medication. His normal daily activity was resumed and was capable of housework and nonstop walking for two kilometers.


Case 7: This was a 22-year-old junior college student, whose asthma was diagnosed since she was born and bronchiectasis was diagnosed based on a chest CT at admission. Her symptoms were characterized by heavy wheezing, chest tightness, productive cough of massive white foamy sputum which mainly occurred at night. For 15 years, she had symptomatic GER and worsening exertional dyspneas. She had received 4 emergency treatments for exacerbations, and in one of them she lost her consciousness. In May 2012, after we gave her a LF, her episodic productive cough and wheezing disappeared without medication, the exertional dyspnea was markedly improved, and she obtained a normalized college life.


A 69-year-old man (patient 1) received radiotherapy using Novalis Tx for cervical lymph node metastases after an operation for tongue cancer. He presented with bleeding from the tongue and visited a local hospital in May 2012. He was referred to Ishikawa Prefectural Central Hospital and was diagnosed with tongue cancer with lymph metastasis (T2N1M0, stage III). He was initially treated by radiotherapy with arterial infusion chemotherapy for only tongue cancer. Next, he was treated by tongue cancer surgery with neck lymph node dissection. Pathologic examination revealed invasion to three regional lymph nodes with extracapsular extension. These findings indicated a high probability of local recurrence and distant metastases and a high risk of death. Therefore, an oral surgeon suggested radiotherapy of the neck region. Two weeks after the start of radiotherapy (12 Gy), lymphedema of the cheek progressed due to the influence of operation and radiotherapy, and the wearing of the custom-made thermoplastic cast became difficult. Therefore, 9.0 g/day of SRT was administered. After 3 days, he demonstrated a dramatic improvement in lymphedema of the cheek and we could easily fit the mask on him. shows CBCT demonstrating the improvement of lymphedema.


A 29-year-old young woman presented to the surgical out patient's department complaining of a painless lump in the left upper abdomen 10 months ago. She also stated that the lump was gradually increasing in size. There was no history of trauma, anorexia, weight loss, or paresthesia. There was no family history of the similar complaint.
On physical examination, the lump measured 6 cm transversely and was firm, nontender, and sharply demarcated. It was not fixed to the skin of the anterior abdominal wall. On contracting the muscles of the anterior abdominal wall, it became less apparent and associated with restriction of movement. All routine laboratory tests were within normal limits.
On ultrasound, the mass was encapsulated, solid, flat, and heterogeneous and was located in the anterior abdominal wall. It was hypovascular on color flow (Figures and ).
Magnetic resonance imaging was performed which showed a solid, heterogeneous mass arising in the abdominal wall. It was hypointense on T1 and heterogeneously hyperintense on T2 and fat suppressed sequences suggesting cystic degeneration (Figures , , and ). A radiological diagnosis of neurofibroma was made.
The tumor was completely resected en bloc and sent for histopathology. Macroscopically, the tumor was lobulated and pale yellow in color. (Figures and ). Microscopically, it was composed of hypocellular and hypercellular areas. There was nuclear palisading (Figures and ) although no mitotic figures were seen. Immunohistochemistry showed that the spindle cells were strongly positive for S100 protein () and a final diagnosis of benign “Ancient” schwannoma was made. No evidence of malignancy or dysplasia was seen.
The patient was discharged in good general condition and is now asymptomatic.


A previously healthy 25-year-old male conscript presented to our emergency department. He complained of bilateral leg pain, dizziness, and shortness of breath soon after completing vigorous training comprising running drills. Ten days before admission, he attended his family clinic complaining of cough and a sore throat. The rapid test for influenza A was positive and he was treated with a 5-day course of oseltamivir. Five days after completing the course, his symptoms had resolved completely and he recommenced regular military training. There was no history of trauma or illicit drug use. He also denied having fatigue, weakness, or weight loss, and the rest of his verbal review of systems was unremarkable.
Physical examination revealed the following values: temperature, 38.2°C; heart rate, 154 beats/min; respiratory rate, 26 breaths/min; and blood pressure, 93/48 mmHg. The results of his physical examination were otherwise unremarkable except for tenderness on palpation of the muscle groups of the thighs. Of note, there were no neurological deficits, and heart sounds showed no definite gallop rhythm. Laboratory investigations revealed the following values: creatine phosphokinase (CPK), 5,555 U/L with an MB fraction of 78 ng/mL; hemoglobin, 17.2 g/dL; platelet count, 348,000 cells/mm3; and total white blood cell (WBC) count, 15,840 cells/mm3 with a differential of 32% lymphocytes, 4% monocytes, 58% neutrophils, and 3% bands. The cardiac troponin I (cTnI) level was 0.46 μg/L (reference < 0.1 μg/L) and the lactate dehydrogenase level was 836 U/L (reference 135–225 U/L). His serum creatinine level was 2.3 mg/dL and his serum electrolyte levels were normal. Liver function tests indicated an elevated aspartate aminotransferase concentration of 47.8 U/L and alanine aminotransferase concentration of 58 U/L; total bilirubin, alkaline phosphatase, total protein, and albumin levels were all within normal limits. The result of a urine toxicology screen was negative. His urine dipstick test was positive for blood with a pH of 6.5 but no red blood cells or WBCs were observed by microscopy. A test for urine myoglobin had a positive result. The results of a coagulation test, thyroid function test, complement test and antinuclear antibody test were normal. The C-reactive protein level and erythrocyte sedimentation rate were initially slightly elevated but had normalized 7 days later. Cultures of blood samples tested negative, and viral studies were negative apart from detecting influenza A (H3N2) virus by polymerase chain reaction analysis of nasopharyngeal wash specimens. Chest radiography did not show any abnormalities. Electrocardiography revealed a regular narrow QRS complex but diffuse PR segment depression and localized concave upward ST segment elevation in leads aVL and V1–V3 with reciprocal changes in the inferior leads (Figure A). Echocardiography disclosed normal systolic function without pericardial effusion or valve regurgitation.
In the 3 days after admission, the CPK peaked at 34,308, and the cTnI and creatinine peaked at 1.17 and 2.46, respectively. He also developed new-onset left-sided and central chest pain. The pain was pleuritic in nature, and a pericardial friction rub was noted on auscultation. A second echocardiography demonstrated moderate circumferential pericardial effusion without any other abnormalities (Figure B), consistent with myopericarditis with a predominant pericarditic component. Based on these findings, he was treated with aspirin for acute myopericarditis and aggressive hydration and urinary alkalinization as per the local rhabdomyolysis protocol. After a total of 20 days of hospitalization, the patient’s leg pain resolved, chest pain relieved, and CPK level declined to 656 U/L. His serum cTnI and creatinine levels normalized after anti-inflammatory therapy and supportive management. Preserved ejection fraction without deterioration of the pericardial effusion was noted in subsequent serial follow-up echocardiographic assessments. The patient was discharged with a normal electrocardiogram and no further sequelae.


A 25-year-old male patient with a 5-month history of aggravated vision through blurring in the right eye was admitted to the General Hospital of Jinan Military Area Command of Chinese PLA, Shandong, China, on October 10th, 2011. An examination revealed sight impairment (vision, right eye, 0.1; left eye, 1.2), a typical temporal hemianopsia of the right eye and locally decreased vision sensitivity of the superior nasal aspect of the left eye, without other positive neurological signs. The serum concentrations of PRL, GH, T3, T4 and TSH were all within normal limits. The patient underwent head computed tomography, which revealed a round, hyperdense mass without clear edges in the sellar and suprasellar regions that was closely associated with the bilateral vessels. Magnetic resonance imaging (MRI) revealed a lobulated, isointense mass wrapped around the anterior communicating artery complex in the sellar-suprasellar region on T1-weighted imaging (T1WI) in the sagittal view. The tumor was isointense and slightly hyperintense in the sellar-suprasellar region in the coronal view. There was no clear border separating the tumor from the peripheral brain tissues. The tumor was also isointense on T2-weighted imaging (T2WI). Tumor-enhanced scanning demonstrated heterogeneous contrast enhancement (). The preliminary diagnosis was of meningioma or pituitary tumor. A tumor resection was conducted using a right pterional approach under general anesthesia on October 15, 2011. Intraoperatively, the base of the tumor was located on the sellar diaphragm of the left anterior pituitary stalk. The tumor pushed the pituitary stalk to the right posterior region, ascended to the suprasellar region, crossed the optic chiasm, invaded the lamina terminalis cistern and wrapped the bilateral A1 segment and anterior communicating artery complex. In the opposite direction, the tumor crossed the saddle-back and reached the slope, showing no clear demarcation from the hypothalamus. Severe adhesion to each side of the optic nerve caused difficulty in the separation of the tissues. The tumor tissue was tough and had an abundant blood supply. A feeding artery was present from a branch of the internal carotid artery in the base of the tumor. A total disparting resection of the tumor was performed with emphasis on left optic neuroprotection under a high-power lens. Following tumor resection, the undamaged pituitary and pituitary stalk were identified; these had been pushed towards the right posterior hypophyseal fossa by the tumor. The patient had no post-operative diabetes insipidus or idiopathic pituitary hypofunction, but had a right eye vision of 0.2, uncorrected and 1.0, corrected. The pathological diagnosis was of a solitary fibrous tumor (SFT).


A 68-year-old Italian man was admitted to our unit complaining of macrohematuria, rectorrhagia, and rectal tenesmus for about 2 months. No personal or family history of colorectal or urothelial cancer was evidenced. A physical examination revealed pain in the hypogastrium and the right iliac fossa. Laboratory tests showed an increased carcinoembryonic antigen level of 6.46ng/mL (normal range, 0 to 5ng/mL) and increased tissue polypeptide antigen (105U/L; normal range, 0 to 75U/L).
A colonoscopy showed the presence of a rectal lesion at 11cm from the anal margin, which was ulcerated, easily bled, and narrowed the colic lumen. Multiple biopsies were performed and a diagnosis of moderately differentiated adenocarcinoma was made.
Abdominal ultrasonography (US) performed subsequently to stage the rectal cancer showed the presence of two round nodules, measuring 33mm and 30mm, at the anterior aspect of the iliopsoas muscle. Moreover, US revealed a budding lesion (maximum diameter, 24.9mm) affecting the bladder. The patient underwent transurethral cystoscopy and a biopsy of the lesion in the right retrotrigonal region; the diagnosis was grade II urothelial carcinoma.
Furthermore, the patient underwent a total body computed tomography (CT) scan, which showed the rectal tumor and the two abdominal nodules detected previously by US. These nodules were interpreted as swollen lymph nodes, probably of neoplastic origin.
The patient underwent an open anterior rectal resection with a termino-terminal anastomosis and a loco-regional lymphadenectomy. An enlarged appendix and a voluminous whitish soft-tissue lesion requiring an appendicectomy were detected perioperatively. The patient also underwent transurethral resection of the bladder lesion. The postoperative course was uneventful, and the patient was discharged 11 days after surgery.
The histological examination of the specimens confirmed the presence of an ulcerated rectal adenocarcinoma, moderately differentiated and completely infiltrating the rectal wall, but not the perirectal fatty tissue (Figure ). No neoplastic invasion was detected in any of the 27 lymph nodes removed (T3, N0, M0; TNM Stage IIa). Furthermore, it was evidenced that the nodular lesions in the appendix detected preoperatively by imaging were due to accumulation of mucus in the appendiceal lumen caused by a lesion composed of mucus-secreting pseudostratified epithelium, with hyperchromic nuclei and rare pseudo-papillae, diagnosed as a cystadenoma (Figure ). Finally, a grade 2 urothelial carcinoma infiltrating the subepithelial connective tissue of the bladder was observed (Figure ). In all cases the resection margins were free of neoplastic invasion.
For mutation analysis, genomic deoxyribonucleic acid (DNA) was isolated from tumor tissue samples, using standard methods. Tumor tissues were estimated to contain at least 70% neoplastic cells by light microscopy. The complete coding sequences and intron–exon boundaries of the KRAS exons 2 to 3, BRAF exon 15, and the PIK3CA exons 9 to 20 were screened for mutations by direct sequencing, using an automated fluorescence-based cycle sequencer (ABIPRISM3100, Applied Biosystems, Foster City, United States of America). Primer sequences were as reported in the Genome DataBase.
No mutation was detected in both the KRAS and BRAF genes. For PIK3CA mutations, screening revealed that all three samples analyzed carried a variant (p.S553fs*7 in exon 9) which has been firstly reported as associated with the CRC (catabolite repression control) gene, although it has been previously described in association with an hematopoietic neoplastic disease []. Figure shows the nucleotide sequences for the somatic mutation identified in the PIK3CA gene in our patient. The PIK3CA sequence variation identified was not present in normal adjacent tissues, indicating that these variants are tumor specific and somatically acquired mutations.


Mr. A. was a 72-year-old male patient with AS, reporting symptoms of low back pain, buttock pain, shoulder pain, arthralgias, and limited spinal mobility. The intensity of the pain that the patient experienced was described from him as a severe stabbing and shooting pain, splitting and exhausting, sickening, and very fearful causing him severe discomfort. He had been suffering from AS since the age of 47. On admission in February 2008, the patient reported that during the previous two years he had been prescribed a combination of various medications for pain relief with only transient improvement. When admitted to the hospital, he was on the following treatment for the last six months: fentanyl 400 mcg sbl once a day, paracetamol 500 mg twice a day, and codeine 30 mg p.o. twice a day. On the Short-Form McGill Pain Questionnaire [], he scored I-a = 24, II = worst possible pain, III = 2, while on the Beck Depression Inventory (BDI) [] he had a score of 24. His score on BDI was mainly shaped from his reported symptoms in the subscale that measures somatic-vegetative performance complaints (consisting of the last eight items of the BDI). Pregabalin was gradually administered, with a starting dose of 75 mg once a day that over a period of two weeks increased to 75 mg four times a day. Pregabalin is a new agent that exerts its pharmacodynamic effect by modulating voltage-gated calcium channels and has a linear pharmacokinetic profile. It is completely absorbed, not bound to plasma proteins, not metabolized, and eliminated unchanged through the kidneys. Clinical trials showed that pregabalin is an effective and safe analgesic, antiepileptic, and anxiolytic medicine [–].
During this period of two weeks, codeine and fentanyl were gradually discontinued. No side-effects were observed after the initiation of pregabalin, while no opioid withdrawal symptoms were reported. During pregabalin treatment, Mr. A.'s emotional state and painful symptoms improved progressively. On discharge, 6 weeks later the mean score in SF-McGill (I-a = 10, II = Mild, III = 1) (quality descriptors and intensity) was before the administration of pregabalin 26 and reduced to 11. The score in BDI reduced to 14. The patient reported on his last assessment that he could now enjoy his daily activities, be more active, and be less fearful of his pain symptoms that now were milder.


A 77-year-old man was referred to the urology clinic for evaluation of a single episode of gross painless hematuria, abnormal urine cytology, and pelvic mass. The patient had a previous 30 pack-year smoking history but had quit 12 years prior. His past medical history was significant for hypertension, hyperlipidemia, and gout. His past surgical history included right THA 21 years prior, with revision 10 years prior to referral.
On presentation, he denied abdominal or pelvic pain, dysuria, or further episodes of gross hematuria. Physical exam was normal. Repeat voided urine cytology was negative for malignant cells. Pelvic ultrasound showed an extrinsic mass adjacent to the right bladder wall (). Review of the subsequent computed tomography (CT) of the abdomen and pelvis revealed a 5.7 × 4.6 cm mass in the right pelvis causing mass-effect distortion of the bladder. No invasion of the bladder wall was evident (). A CT-guided biopsy of the mass produced only acellular material. Cystoscopic examination revealed no evidence of urothelial tumor or lesion or foreign body intrusion. A follow-up CT performed at an interval of 3 months showed no change in the size or character of the mass, and observation was discontinued, with planned intervention only in the case of clinical worsening.


A 35-year-old Chinese woman presented to the Emergency Department (ED) after a fall 12 hours previously and with an inability to move her left limbs since then. She complained of feeling pain and numbness in her arms for the past month, as well as progressive weakness in her legs. She had never been pregnant, had no significant past medical or surgical history, nor was she on any medications such as oral contraceptive pills. There was no family history of early onset cerebral vascular accident. She denied the use of alcohol, tobacco products or recreational drugs. On physical examination, she was conscious and irritable, her heart rate was 88 beats per minute (bpm), blood pressure (BP) was recorded as 140/90mmHg upon ED presentation. She had no fever or respiratory distress. She was unable to open her right eye and had a right-sided preferred gaze with slight right-sided facial droop. There was obvious left-sided hemiparesis with a positive Babinski sign, and the skin of her left side felt cold. The radial pulse was weak on both sides. The rest of her neurological, systemic, and general physical examinations was unremarkable.
Her laboratory test results showed white blood cells (WBCs) of 13.9x109/L, hemoglobin (Hb) of 70.2g/L, and platelets (PLTs) of 288x109/L. Her basic metabolic panel was unremarkable. Her coagulation test was only significant for elevated D-dimer of 1.08mg/L, which subsequently dropped to 0.96mg/L on the third day of her hospital stay, with partial thromboplastin time (PT) and activated partial thromboplastin time (APTT) both within normal limits. The lipid panel showed slightly elevated cholesterol of 5.83mmol/L (2.85 to 5.2mmol/L), triglyceride of 1.79mmol/l (0.5 to 1.7mmol/L) and lipoprotein A of 373 (0 to 300). Her inflammatory biomarkers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were both elevated, with 26.0mg/L (0 to 8.0mmol/L) and 25mm/h (0 to 20mm/h) respectively. Rapid plasma reagin (RPR)/treponema pallidum particle agglutination (TPPA) tests were negative. Autoantibody tests showed positive for antinuclear antibody only, with a titer of 1:100, while the antiphosphlipid antibody test was negative. Her blood glucose, liver and renal functions were all normal. Her electrocardiogram (EKG) and transthoracic echocardiogram were both negative. A cerebral magnetic resonance imaging (MRI) scan showed acute ischemic infarction of the area supplied by the right middle cerebral artery (Figure ), which was proven to be occluded by later cerebral computed tomographic angiography (CTA) (Figure ). Thoracic and abdominal CTA was negative (Figure ). A Doppler sonogram of the vessels in the neck, upper and lower limbs was unable to find both axillary arteries or the left subclavian artery. It did show decreased blood flow in the arteries of her right arm, with a narrowed right subclavian artery. The arteries distal to the brachial artery were visible on both sides, with a greater blood flow on the left. Subsequent digital subtraction angiography (DSA) confirmed the incomplete occlusion of her right subclavian artery and narrowing of her right internal carotid artery (Figure ).
The diagnosis of Takayasu arteritis type I was made according to the revised Ishikawa diagnostic criteria [] and the angiographic classification of Takayasu arteritis put forward at the Takayasu Conference 1994 []. Subsequently, the recommended treatment of methylprednisolone was started with an initial dose of 40mg per day. As the antinuclear antibody test was positive, autoimmune diseases such as systemic lupus erythematosus (SLE) could not be excluded, which in the light of the existing thrombosis, could be related to a hypercoagulation state. Thus a small dose of low-molecular-weight heprin (LMWH) was started along with the steroid.
Twenty days after admission, the clinical condition of the patient was stable, and she was subsequently discharged.


A 60-year-old black man – born in the Rio de Janeiro city and living in Teresópolis, RJ, Brazil – reported that when he was taking the mail from his mailbox, he accidentally put his left arm on six specimens of light green and brown caterpillars, which had about 5 cm length. The animals were crushed by the arm of the man, who, immediately, withdrawn it. He washed the arm using soap and water, applied alcohol to the affected area and also took an anti-allergy drug (could not say which).
The site affected by the caterpillars became swollen and after 20 minutes a burning sensation started. The victim also noticed a painful lymph node in the ipsilateral axilla, which disappeared spontaneously shortly after. In the same night, after dinner, he had abdominal distension associated with discomfort and vomiting. He did not take medicines to relieve the symptoms. As there was improvement, he laid down to sleep. After that, the man woke up at dawn feeling an intense abdominal pain (flank region) and arthralgia (upper and lower limbs), which became worse when he attempted to move.
Subsequently, the patient looked for medical assistance and went to a local hospital. His clinical picture was described as pain associated with sudden anuria. He was admitted to the hospital to treatment. The man reported a previous history of nephrolithiasis and received treatment with saline solution, analgesics and urinary catheter to provide relief. He also received treatment for arterial hypertension with atenolol, 50 mg/day; until this time there was no evidence of kidney injury.
During the hospitalization, the patient had developed diffuse edema, flank pain and the anuria remained, despite of use of intravenous hydration and furosemide infusion. Laboratory and imaging tests were performed (Tables and ).
After two more days, the patient was transferred to the Hospital das Clínicas de Teresópolis Costantino Ottaviano (HCTCO), where he remained for forty-five days due to hemodialysis treatment. Four days after the admission to HCTCO, he remembered the episode with the caterpillars in the morning before the painful crisis and anuria. That was the moment when the suspicion of erucism by Lonomia aroused (seven days after the accident).
The use of SALon was not indicated because the patient did not meet the criteria for it, particularly due to the time elapsed since the accident, hospital care for more than 10 hours and less than or equal to 36 hours []. During the admission the patient showed bruises scattered on upper and lower limbs and two voluminous cases of melena. After those events, there was no spontaneous recovery of renal function, which progressed to chronic renal disease (CRD), stage V – end-stage renal disease, when the glomerular filtration rate is below 15% of normal and the patient needs, invariably, renal replacement therapy.
Lonomia caterpillar has about six to seven centimeters long, and its color ranges from light brownish-green to yellowish-brown with three longitudinal stripes of dark-brown []. Its body is covered with bristles that contain toxins. The transformation to an adult moth occurs after a in ten weeks after three to six months of larval life [,].
Lonomia is found throughout Brazil, however, numerous registered cases of erucism occurred in the southern region, mainly in Rio Grande do Sul and Santa Catarina states, and were attributed to L. obliqua[,]. In recent years, there have been accidents in Minas Gerais, Goiás, Maranhão and Rio de Janeiro states [,,].
Erucism caused by Lonomia is uncommon in the state of Rio de Janeiro. Therefore, the present study is one of the first cases reported in the state. The increased rate of envenomations – especially in areas where they were not previously described – has been attributed to deforestation of indigenous trees, natural habitat of caterpillars, which are forced migrating to fruit trees in urban areas [,].
The symptoms of Lonomia envenomation range from local cutaneous manifestations to serious and potentially fatal systemic reactions []. General symptoms such as headache, unspecific indisposition, fever, nausea, vomit, arthralgia, myalgia, conjunctivitis and abdominal pain vary depending on the species involved, the intensity of the contact and the victim’s response [,,,]. Hemorrhagic syndrome and acute renal failure (ARF) are unusual outcomes, but potentially fatal [,-].
The pathophysiological mechanisms of ARF in Lonomia envenomig are not clear yet. Probably, there is a relation between renal ischemia and systemic hypotension and/or fibrin deposition in glomerular capillaries [-]. Another hypothesis is that venom components may act directly on the kidneys [,].
Lonomia spp. venom is rich in several toxins that have procoagulant and fibrinolytic activities, which can significantly affect the blood coagulation process. For example, the enzyme lonofibrase is able to trigger a hemorrhagic syndrome similar to disseminated intravascular coagulation (DIC) by increasing fibrinogen degradation products and decreasing plasminogen, fibrinogen and factor XIII [,,,-]. Lonomia obliqua venom contains several lipocalins (protein group that transports hydrophobic molecules), among which is the Lonomia obliqua prothrombin activator protein (Lopap), involved in the increase of expression of adhesion molecules on cellular surface [-].
Erucism is diagnosed based on history of contact with the caterpillar and corroborated by data from laboratory tests. Laboratory abnormalities include slightly low platelet count, high urea and creatinine levels, slight increase of total bilirubin, and augmentation of indirect bilirubin, free hemoglobin and haptoglobin decrease in cases of hemolysis [].
Treatment consists of washing the affected area with cold water, cold compresses, local anesthetic infiltration using lidocaine 2% and topical corticosteroids. In case of bleeding, the patient should be kept resting in order to avoid traumatic intervention [,]. The antilonomic serum (SALon) is indicated according to the severity of the accident, and its early administration prevents bleeding manifestations that start from one to ten days after the contact depending on its intensity and location [,,-].


A 54-year-old female with a medical history of hypertension, hepatitis C, and cirrhosis presented with nausea, vomiting and dysphagia of 1-day duration following surveillance esophagogastroduodenoscopy (EGD) and banding from an outside hospital. She reported that her symptoms started immediately post-procedure and that she continued to have multiple episodes of mostly clear vomit with streaks of blood. She also reported throat, chest, and epigastric pain and was unable to eat anything since the procedure due to her symptoms.
Her past medical history included hypertension, hepatitis C, cirrhosis, gastroesophageal reflux disease, variceal hemorrhage, gall stones and Graves disease. She was on propranolol, lactulose, alprazolam and amlodipine at home. Social history was significant for heavy alcohol use for over 30 years, which she quit following an episode of variceal bleeding. She had no episodes of recurrent gastrointestinal bleeding since her last EGD and banding. On physical examination, she was an ill-appearing female, had dry oral mucosa, tachycardic, had epigastric and RUQ tenderness with negative Murphy's sign, and no rebound or guarding. During the interview, she vomited small amounts of non-bloody white material several times.
On presentation, her laboratory tests were as follows: WBC 13.1, Hb/Hct 14/39.7, platelets 260; Na 152, K 3.6, Cl 112, CO2 22, BUN 30, Cr 0.87, glc 146; lipase 93, Alk Phos 113, AST/ALT 48/75, lactic acid 2.0 and drug screen was positive for propofol.
The patient was admitted for dehydration due to nausea and vomiting. She was started on IV fluids, anti-emetics, pain control and kept NPO (nothing by mouth). Her dyselectrolytemia improved following hydration and her diet was advanced on the following day. She could not tolerate oral intake and reported worsening dysphagia, nausea and vomiting. Over the course of next 2 days, the patient continued to have worsening dysphagia with no relief from anti-emetics. A barium swallow was administered which showed a complete obstruction of the distal esophagus (). The differential for obstruction was thought to be either from local edema from the banding procedure, impacted food or a hematoma from the procedure. An EGD was performed; the scope was advanced to 34 cm to the level of obstruction and it was noted to have a band with entrapped varix in the center of the lumen surrounded by fibrotic material closing off the rest of the lumen (). Several attempts were made with biopsy forceps to reopen the lumen that resulted in a small amount of bleeding and the scope was removed at this point. Conservative management of the patient continued, i.e., NPO with intravenous hydration and pain control. Her symptoms improved over the course of the next 3–4 days and she started tolerating diet advancement and was subsequently discharged.
She presented the next day with a recurrence of similar symptoms, i.e., dysphagia, abdominal pain and vomiting. A repeat barium swallow showed patency of the esophagus with a parallel channel that retained contrast much later than the initial swallow, suggestive of an esophageal tear with an intramural dissection of 6 cm to the level of gastro-esophageal junction ().
The patient was kept NPO with peripheral parenteral nutrition and close monitoring for possible esopheageal perforation. Over the course of the next several days, the diet was carefully advanced with inputs from gastroenterologist and surgical consultants. After 5 days, the patient reported much improvement in her symptoms and was able to tolerate a full diet for the first time.
A repeat barium swallow was obtained prior to discharge that showed no obstruction or dissection. A small stricture was noted at the proximal margin at the origin of the prior dissection (). She was discharged with subsequent follow-up appointment at the GI clinic.


In March 2007, a 60-year-old female peasant presented with symptoms of persistent cough, with occasional blood-tinged sputum, shortness of breath, and right-side bosom unwell. Chest X-ray showed a mass in the right lung, and computed tomography (CT) scan indicated a nodule shadow approximately 4 cm long in the apical segment of the right lower lobe. Enlarged right hilar lymph nodes or any other evidence of metastatic disease were not found elsewhere. Complete blood cell count was normal, and no hepatosplenomegaly was found. Right, middle, and lower lobectomy, as well as lymph node dissection, were performed. The pathological diagnosis was squamous cell carcinoma. Following four cycles of combination chemotherapy with cisplatin (60 mg/m2, IV, day 1), cyclophosphamide (600 mg/m2, IV, day 1), and adriamycin (40 mg/m2, IV, day 1) after surgery, complete remission was achieved. The patient did not undergo any EGFR-TKI or radiotherapy after surgery. No evidence of recurrence was observed, and no further therapy was undertaken in the three years after the last treatment.
In April 2010, the patient was again referred to our department because of complaints of dizziness, fatigue, intermittent vomiting, phlegmy cough, and shortness of breath. The blood count showed severe anemia (Hb 49 g/L), leukocytosis (WBC 21×109/L, with a differential of 2% blast cells), and a platelet count of 22×109/L. Peripheral blood smears demonstrated erythrocytic anisocytosis, teardrop poikilocytosis, and immature cells (11% erythroblasts, 2% myeloblasts, 1% promyelocytes). Bone marrow aspirate cytology, cytochemistry, and cytogenic studies were conducted. The bone marrow was hypercellular, with 11.5% myeloblasts. Auer rods and megakaryocytic dysplasia, such as lymphoid megakaryocyte and mononuclear micromegakaryocytes, were observed (). Both neutrophil alkaline phosphatase and periodic acid-Schiff of the erythroblasts stain were negative. Bone marrow biopsy showed a hypercellular marrow with hemopoietic dysplasia and numerous dysplastic megakaryocytes, indicating MDS. Myeloperoxidase cytochemical staining was strongly positive, with a decreased expression of ki-67. Reticular fiber staining was positive (+++) and indicative of myelofibrosis (). The immunophenotype of the bone marrow mononuclear showed an R5 gate of 12.4% and also expressed CD34+ (47.0%), CD64+ (36.6%), CD117+ (61.4%), CD15+ (39.6%), CD13+ (66.5%), CD33+ (74.0%), CD11b+ (30.4%), CD7+ (66.7%), and HLA-DR+ (66.4%).
Cytogenetic analysis indicated a normal karyotype (46, XX [9]). The fusion gene of JAK2V617F was positive, and ultrasound scan indicated splenomegaly. Chest CT scan demonstrated normal changes following the resection of the right lung carcinoma without any special abnormality, such as new nodules. The serum tumor markers of lung carcinoma were all negative. The clinical diagnosis was MDS RAEB-2 with myelofibrosis, with an IPSS prognostic score of 2 (Intermediate-2).
One cycle of dacitabine (Dacogen) (20 mg/m2, days 1 to 5) was immediately adminstrered. Blood count and bone narrow aspirates indicated partial remission. However, the patient refused any further treatment and was discharged against advice. Seven months after discharge, the patient died from unknown causes.


A 35-year-old woman presented with five days of nightly accentuated burning pain in both legs leading to massive sleep disturbance. The pain was predominantly located in the dorsal thighs and radiated to the calves. She reported some relief through walking around at night and showering her legs with hot water. Back pain, gait or sensory disturbances and bladder dysfunction were denied. Nonsteroidal anti-inflammatory drugs did not alleviate pain, neither did pramipexole, which had been prescribed for suspected restless leg syndrome. One week before she had had a sore throat and had been clinically diagnosed for streptococcal tonsillitis and treated empirically with penicillin. Her past medical and family history was unremarkable. Clinical examination revealed no focal-neurologic signs. There were no sensory deficits and deep tendon reflexes were symmetrically normoactive. Furthermore, we found no palpable lymph node swelling and no signs of pharyngitis. Motor and sensory nerve conduction studies were normal, as were F-responses of the tibial nerve. Abdominal Ultrasound demonstrated a slightly enlarged spleen. Blood sampling showed relative lymphocytosis, and elevated liver enzymes. Cerebrospinal fluid analysis revealed 18 white blood cells/μl (90% lymphocytes, 10% monocytes), 83mg/dl protein, and blood–brain-barrier dysfunction (albumin CSF/serum quotient 12.5 × 10-3) without intrathecal immunoglobulin synthesis. Virological studies detected EBV VCA IgG and IgM in serum, whereas EBV EBNA-1 IgG was negative. Moreover, EBV-PCR (RealStar® EBV PCR Kit 1.0, altona Diagnostics GmbH, Germany) was positive in blood and CSF (1000 copies/ml each) suggesting primary EBV infection involving the nervous system. Further laboratory investigations were not indicative for infections with streptococcus, borrelia, syphilis, HIV, hepatitis virus A, B or C (serological tests in blood, borrelia and syphilis additionally in CSF), VZV, HSV or enteroviruses (VZV- and HSV-IgG-specificity-indices and PCR in CSF). Under initially started empiric therapy with intravenous acyclovir for possible VZV or HSV radiculitis and analgesic treatment with oral tramadol the patient completely recovered within a few days. After receiving negative results for VZV and HSV, acyclovir was ceased on day six.


A 72-year-old woman admitted to emergency unit with acute abdominal pain. She had a history of open heart surgery (valvuloplasty), and she was taking warfarin regularly. There was no trauma history. Her blood pressure, pulse, and respiratory rates were 78/42 mmHg, 112/min, and 28/min, respectively. There was a generalized abdominal pain that was more apparent on the right upper quadrant. Ultrasound demonstrated free abdominal fluid and an irregular lesion at the right liver lobe. Computed tomography revealed abdominal free fluid and a liver lesion on segments V, VI, and VII (). Liver pathology was not clearly diagnosed, but it was reported as a possibly ruptured hemangioma. Her hemoglobin, hematocrit, and INR values were 5.2 g/dL, 14.9%, and 6,7, respectively. Her general condition was deteriorated during examinations despite intravenous fluid supports, blood transfusions, and inotropic infusions. Emergency laparotomy was required and 1500 mL blood was aspirated from the abdomen. At the first sight, there was large subcapsular liver hematoma, which was still bleeding from a 4 cm length tear on segment V of the liver (). We packed the liver and waited for cessation of the bleeding, but it was still going on particularly from the posterior part of the liver. Right liver was mobilized from the posterior attachments, and there was a large subcapsular hematoma on the right posterior sector of the liver. Blood was coming out from a tear of the liver capsule. The liver capsule was removed to see the origin of bleeding. Active hemorrhage was coming from the liver parenchyma through the two deep lacerations at segment VI and VII (), and there was a palpable focal lesion in the liver at the same location. By Pringle maneuver, we blocked the blood inflow of the liver and packed the liver again, but prolonged INR failed the success of packing. We decided an urgent resection of the bleeding part of the liver including the mass. Under total hepatic vascular occlusion, segments V, VI, and VII were resected with endoscopic staplers (Covidien endostaplers, US). We used 10 nonvascular (blue-cartilage) staplers because there was no vascular stapler at that time in the operating room. Before applying staplers, we created tunnels in the liver parenchyma by a long clamp. Hepatectomy time took almost six minutes, and the cut surface of the liver was coagulated with bipolar cautery and covered with a hemostatic material (TachoSil, Takeda Company, Zurich). Total vascular clamping was released, and the cut surface of the liver was pressed with moisturized gauzes for a few minutes. There was no bleeding (), and surgery was ended within total 80 minutes. During surgery, total six packs of erythrocyte and four packs of fresh frozen plasma were transfused. Postoperative period was uneventful, and the patient did not require any extra blood transfusion. There was no complication, and the patient was discharged on day eight. Pathological result was a surprise for us that the mass was belonged to Fasciola hepatica. After surgery the patient was consulted with the infectious diseases unit, and Triclabendazol was recommended.


A 77-year-old man was referred for endovascular treatment after a transient ischemic attack with a right-sided facial and limb weakness. This episode occurred while the patient was undergoing medical treatment consisting of 100 mg acetylsalicylic acid and 75 mg clopidogrel 4 weeks after coronary stenting of the left anterior descending artery. The patient had a history of hyperlipidemia, hypertension, and familiar disposition with coronary heart disease. The neurological examination during the ischemic event revealed a mild right-sided hemiparesis. Brain CT and MRI showed no abnormalities. All hematological and biochemical tests were normal, with a normal platelet count and coagulation screen.
When assessed in our hospital, his blood pressure sometimes jumped up to 180/100 mm Hg. Therefore, the antihypertensive medication consisting of β-blocker, diuretic, and AT1-antagonist was intensified. Another neurological examination was normal. Color Doppler ultrasound showed a severe stenosis of the left internal carotid artery (ICA) with elevation of the peak systolic velocity at 3.9 m/s and an end diastolic velocity of 1.4 m/s (). The patient got a loading dose of 500 mg ASS and 300 mg clopidogrel and underwent left carotid stenting the next day via a femoral approach under local anesthesia. The angiography confirmed 95% stenosis of the left ICA (). CAS was frictionless performed with distal filter protection, pre- and postdilation, and a self-expandable closed-cell design stent (). The peri-interventional blood pressure varied between 140/85 to 160/95 mm Hg. The clinically stable patient was transferred to the intermediate care unit for monitoring.
20 minutes later the patient vomited, described ipsilateral headache, and became very anxious. He then developed a complete aphasia and increased right-sided weakness and became delirious. Blood pressure varied between 160/90 and 200/110 mm Hg. Immediately color Doppler ultrasound of the CCA and ICA revealed a visibly patent vessel. Brain edema and bleeding could be excluded by an urgent cranial CT. Followup within 24 hours with cranial MRI and angiography showed totally normal findings. The patient was transferred to the intensive care to control the hypertension and to monitor the vital parameters. Under intensified treatment of the blood pressure with a β-blocker, diuretic, AT1-, and Ca-antagonist, and temporary intravenous application of nitroglycerin and urapidil the neurological symptoms were totally regressed within few days. The patient was discharged after 10 days from the hospital. Follow-up examinations after 3 and 6 months were normal.


A 12-year-old adolescent male presented to the Emergency Department, in January 2010, with a febrile illness. For the last 3 days, he had been complaining of dry cough, diffuse myalgia, frontal headache, and sporadic postprandial vomiting. Two days before admission he developed intermittent high fever (axillary temperature 40°C), cervicalgia, and a progressively worsening left midfoot ache. He denied any trauma history or previous limping or pain. His personal medical history was unremarkable and he had received all the vaccines included in the National Plan, which encloses meningococcal serogroup C and Haemophilus influenzae type b immunizations but not an antipneumococcal vaccine.
On physical examination, he was alert and oriented, with normal vital signs. He had an abnormal gait, avoiding left plantar pressure. The anterior surface of his left ankle was tender, swollen, and warm to touch. Clinical examination was otherwise unremarkable, including normal breath sounds and absence of meningeal signs. Laboratory evaluation revealed a mildly elevated leukocyte count (13,540/μL) with neutrophilia (11,860/μL), as well as elevated C-reactive protein (14 mg/dL) and erythrocyte sedimentation rate (55 mm/h). There were no abnormalities on thorax, left foot, and ankle radiographs.
Considering the diagnostic hypothesis of osteoarticular infection, the patient was then admitted for further investigation. A few hours later, he presented worsening neck pain, fever, and neck stiffness. Lumbar puncture revealed clear and colourless cerebrospinal fluid (CSF), with mild pleocytosis (23/μL leukocytes, predominantly polymorphonuclear—20 of 23) and normal erythrocytes (7/μL), glucose (77 mg/dL), and protein (28.5 mg/dL) levels. Empirical antibiotic therapy with ceftriaxone and vancomycin was initiated. Pneumococcus was identified by CSF Gram-stain and latex particle agglutination tests. The same agent was later isolated from blood culture—a penicillin-susceptible Streptococcus pneumoniae, serotype 1.
An articular computerized tomography (CT) scan of the patient's left ankle disclosed a navicular bone indentation with subcortical lesion, but it could not differentiate whether it was the result of an osteochondritis dissecans or of an osteomyelitis (). A magnetic resonance imaging (MRI) of the same region revealed a talonavicular joint effusion and irregularity of the proximal articular surface of the navicular bone, with a small cortical depression, suggesting an osteochondritis dissecans (). Osseous scintigraphy brought out intense hyperfixation at the left navicular bone ().
Since the hypothesis of navicular osteomyelitis could not be excluded, the patient was given intravenous ceftriaxone for 2 weeks, followed by 4 weeks of an oral third-generation cephalosporin. Bed rest was encouraged during the first week of treatment.
There was a favorable clinical evolution, with sustained apyrexia after the first 3 days of antibiotherapy and progressive improvement of inflammatory signs. By the end of the treatment, the patient had resumed normal mobility, denying any osteoarticular symptoms, and 3 months later he was allowed to practice sports. After a 2-year follow-up he remains asymptomatic and presents normal osteoarticular, neurological, and audiologic examinations. Radiographs of the left foot corroborate the positive clinical outcome (). Basic laboratory evaluation has not disclosed any immunodeficiency.


A 39-year-old female, previously well, was admitted with a diagnosis of acute pancreatitis with concurrent acute calculus cholecystitis. The patient presented with a one-day history of acute onset sharp pain in the epigastrium, associated with nausea and vomiting. She was exquisitely tender in the epigastrium and right upper quadrant, with no peritoneal signs on examination. Laboratory investigations showed a white cell count of 14.2 × 106/L, with 81% neutrophils, 28 U/L bilirubin, 237 U/L ALT, 192 U/L AST, 145 U/L ALP 171 U/L GGT, lipase 1445 U/L, and LDH 630 U/L, and serum glucose was 7.9 mmoL/L. The patient was classed as grade 1 pancreatitis using Ranson's criteria []. Biliary ultrasound on admission showed acute cholecystitis, with gallbladder wall thickness of 5 mm and multiple calculi, the largest at 6 mm and no evidence of biliary tree dilation.
The patient was initially managed with empiric parental antibiotics; ceftriaxone 1 g daily and metronidazole 500 mg 8 hourly. On day 2 of admission, liver function became increasingly deranged, with bilirubin increasing to 77 U/L. The patient complained of acute exacerbation of pain and repeat sonography showed worsening cholecystitis with a high suspicion of a small gallbladder posterior wall perforation, associated with an increase of pericholecystic fluid collection (). Computerized tomography (CT) of the abdomen and Pelvis showed large amounts of free fluid within the gallbladder fossa, confirming gallbladder perforation. There was marked fat stranding in the upper abdomen surrounding the pancreas and extensive free fluid in the perihepatic region and perisplenic region, upper abdomen, iliac fossae and Pouch of Douglas ().
The patient underwent a semielective laparoscopic cholecystectomy. Intraoperatively, the diagnosis of perforated necrotic cholecystitis was confirmed with 600 mls of bilious free fluid within the peritoneum (). Intra-operative cholangiogram was otherwise unremarkable, though a prominent pancreatic duct was noted. There was no obvious common bile duct obstruction. The patient improved clinically over the postoperative period with rapid improvement in inflammatory markers, enabling the patient to be discharged three days postoperatively.


A 69-year-old female (patient 1 in ) developed a gait disturbance 6 months before admission and suffered from the gradual progression of weakness in her extremities. On admission, neurological examination showed proximal muscle weakness and reduced deep tendon reflex. Routine laboratory test results were unremarkable. Antinuclear antibodies, anti-acetylcholine (ACh) receptor antibody, and anti-voltage-gated calcium channel (VGCC) antibodies were negative. The results of chest and abdominal CT were unremarkable. In a nerve conduction study, CMAPs had slightly low amplitudes, and nerve conduction velocities were normal in the median and ulnar nerves. Needle EMG showed early recruitment and polyphasic MUPs with short durations and low amplitudes, suggesting the diagnosis of myopathy. Interestingly, the myopathic EMG findings were improved after sustained strong muscle contraction for 10 s; the MUP sizes returned to normal after a sustained strong muscle contraction, and the early recruitment of MUPs in the weak contraction was clearly normalized in the biceps brachii muscle (). Thereafter, we performed an RNS test because she complained of easy fatigability. The RNS test showed an obvious incremental response of the CMAP amplitude of the abductor digiti minimi muscle after high-rate stimulation of the ulnar nerve, indicating the diagnosis of LEMS [–]. We examined the patient for systemic malignancies, and the endoscopic examination of the colon revealed adenocarcinoma in the sigmoid colon. Her muscle weakness slightly improved after resection of the colon cancer.


A 58-year-old Japanese woman was introduced to our department with asymptomatic gross hematuria. Her past medical history was unremarkable. There was no history of urinary symptoms and urinary tract infection. The results of a physical examination were unremarkable. Urinalysis showed microscopic hematuria and no pyuria. Urine cytology indicated atypical cells. A cystoscopy revealed a gently raised nodule with erythema at the right lateral wall (Figure ). Contrast-enhanced magnetic resonance imaging (MRI) at 3.0 tesla also indicated thickness of the right lateral wall (Figure ), which was suspected for muscle invasion of bladder cancer.
The patient underwent transurethral resection of the bladder lesions. Histopathological findings of all the specimens revealed extensive extracellular amorphous eosinophilic deposits in the subepithelial layer (Figure ) that stained positive with Congo red and Dylon (Figure ). Furthermore all specimens showed retention of congophilic staining when treated with potassium permanganate, consistent with primary (AL) amyloid.
This was followed by biopsies of the stomach, duodenum and rectum, all of which were negative for amyloid. There was no Bence-Jones proteinuria, and serum or urine protein electrophoresis did not reveal any monoclonal band. Therefore, the patient was diagnosed with primary localized amyloidosis of the urinary bladder.
To treat residual amyloidosis of the bladder, we performed occlusive dressing therapy (ODT) using dimethyl sulfoxide (DMSO) every day. After percutaneous administration of DMSO, regression of the bladder lesions as well as improvement of gross hematuria were achieved. Five years after the initiation of treatment, cystoscopy and MRI showed no relapse of the mass-like lesion of the bladder wall. Currently, DMSO is administered every few days as maintenance therapy.


A 75-year-old man was admitted to our hospital with fever and general malaise.
A physical examination at the time of admission showed a body temperature of 38.9°C, blood pressure of 120/70 mmHg and a pulse rate of 80 beats/min. Laboratory findings showed a white blood cell count of 13,400/mm3 and C-reactive protein (CRP) of 23.7 mg/dL. A chest computed tomography (CT)-scan showed a ground-glass appearance in the right middle and lower lobes. Because the urinary antigen test for Legionella pneumophila serotype 1 (BinaxNOW® Legionella, Binax, Inc. ME, USA) was positive, he was diagnosed as Legionella pneumonia.
Several electrolyte abnormalities coexisted including hyponatremia, hypokalemia, hypophosphatemia and hypouricemia. His renal function was normal and the arterial blood gases analysis showed mild metabolic acidosis (Table ). The tubular reabsorption of phosphate (%TRP) was decreased, although the fractional excretion of uric acid (FEUA) was increased, indicating disturbed proximal tubular reabsorption. Despite the hypokalemia, his urinary potassium excretion was not suppressed. Elevations in urinary levels of β2-microglobulin (β2-MG) and N-acetyl-β-D-glucosaminidase (NAG), glycosuria and panaminoaciduria were also observed (Tables and ). Therefore, he was diagnosed as Fanconi syndrome.
In addition, his urinary osmolarity was greater than his serum osmolarity and the level of antidiuretic hormone (ADH) was improperly high for the indicated serum osmolarity. There was no sign of extracellular fluid volume depletion. Therefore, a diagnosis of the syndrome of inappropriate secretion of ADH (SIADH) was also made.
He was treated for Legionella pneumonia with pazufloxacin mesilate (PZFX) at 1,000 mg per day. After treatment, his physical status recovered and his electrolyte abnormalities improved. Furthermore, his %TRP, FEUA, urinary β2-MG and NAG normalized, and the panaminoaciduria became undetectable (Figure A).


A 57-year-old man was admitted to our hospital with fever and dysarthria.
A physical examination showed a body temperature of 39.1°C, a blood pressure of 112/48 mmHg and a pulse rate of 98 beats/min. Laboratory findings showed a white blood cell count of 6,100/mm3 and CRP of 46.7 mg/dL. A chest CT scan showed a ground-glass appearance in the left upper and lower lobes. Because of the positive urinary antigen test, he was diagnosed as Legionella pneumonia.
Several electrolyte abnormalities coexisted including hypophosphatemia, hypokalemia and mild hypouricemia. The arterial blood gas analysis showed metabolic acidosis (Table ). The %TRP was decreased, although his fractional excretion of potassium (FEK) and FEUA were increased. Furthermore, his urinary β2-MG and NAG were remarkably increased (Table ). Glycosuria and aminoaciduria were also observed (Table ). Therefore, a diagnosis of Fanconi syndrome was made. Although his renal function was deteriorated, post-renal obstructive nephropathy and congenital anomalies were ruled out by the finding of abdominal CT scan.
Treatment for Legionella pneumonia was started with PZFX at 1,000 mg per day. After treatment, his symptoms disappeared and his electrolyte abnormalities improved. In addition, his %TRP, FEK, FEUA, urinary β2-MG and NAG normalized, and the aminoaciduria became undetectable (Figure B).