An ingested mobile phone in the stomach may not be amenable to safe endoscopic removal using current therapeutic devices: A case report

INTRODUCTION

This case report is intended to inform clinicians, endoscopists, policy makers and industry of our experience in the management of a rare case of mobile phone ingestion.

PRESENTATION OF CASE

A 29-year-old prisoner presented to the Emergency Department with vomiting, ten hours after he claimed to have swallowed a mobile phone. Clinical examination was unremarkable. Both initial and repeat abdominal radiographs eight hours later confirmed that the foreign body remained in situ in the stomach and had not progressed along the gastrointestinal tract. Based on these findings, upper endoscopy was performed under general anaesthesia. The object could not be aligned correctly to accommodate endoscopic removal using current retrieval devices. Following unsuccessful endoscopy, an upper midline laparotomy was performed and the phone was delivered through an anterior gastrotomy, away from the pylorus. The patient made an uneventful recovery and underwent psychological counselling prior to discharge.

DISCUSSION

In this case report, the use of endoscopy in the management when a conservative approach fails is questioned. Can the current endoscopic retrieval devices be improved to limit the need for surgical interventions in future cases?

CONCLUSION

An ingested mobile phone in the stomach may not be amenable for removal using the current endoscopic retrieval devices. Improvements in overtubes or additional modifications of existing retrieval devices to ensure adequate alignment for removal without injuring the oesophagus are needed.

Unforeseeable presentation of Chryseobacterium indologenes infection in a paediatric patient

Background

We report for the first time a case of community acquired Chryseobacterium indologenes soft tissue infection in an immunocompetent patient.

Case presentation

A 11 year female child, from South-Asia of Indian origin presented with fever, pain and swelling in right leg for 3 days with no significant past history. Incision and drainage was done and pus was sent for culture and sensitivity. Radiological investigation showed subtle irregular soft tissue density. Pus culture grew multidrug resistant C. indologenes.

Conclusion

Though of low pathogenicity, our case emphasises its unpredictable nature and the need to determine minimum inhibitory concentration breakpoints for therapy.

Florid pustular dermatitis of breast: A case report on a unusual complication from acellular dermal matrix use

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Red Breast syndrome is a known complication with acellular dermal matrix use.

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Pustular dermatitis like presentation is previously unreported with the use of acellular dermal matrix.

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Like red breast syndrome, systemic signs are characteristically absent even in the presence of significant local symptoms.

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Surgical interventions and removal of implants may be avoided if this condition is considered as a possibility in fitting clinical cases.

Introduction

Idiopathic erythematous reaction of the breast (Red breast syndrome) is a known complication following breast reconstruction with acellular dermal matrix. However pustular dermatitis like presentation is not previously known.

Presentation of case

We present a 42-year-old lady who developed bilateral pustular dermatitis like appearance following breast reconstruction with acellular dermal matrix slings. Though surgical washout was done, both expanders and flex HD could be preserved.

Discussion

Acellular dermal matrix use is the only possible explanation for such a presentation and this can be considered a variant of red breast syndrome.

Conclusion

Pustular dermatitis like presentation can be associated with acelluar dermal matrix use and should be considered in similar clinical presentations, since this can avoid unnecessary surgical procedures.

The slipping rib syndrome: A case report

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The slipping rib syndrome is a condition hard to recognize.

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By performing a hooking maneuver the diagnosis slipping rib syndrome can be made.

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When pain medication is not sufficient, resection of the rib can be performed.

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Knowledge of the syndrome can prevent unnecessary comprehensive treatment.

We present a case report and review of literature about slipping rib syndrome, a syndrome rarely recognized and often un or misdiagnosed. In literature there is no clear consensus about the diagnosis and treatment. We present a case of a 47 year old man who was diagnosed with slipping rib syndrome after a cycling incident 8 years ago. Also, we developed a flow chart according the diagnostic and therapeutic steps in the treatment of slipping rib syndrome.

Central massage

Knowledge and treatment of the slipping rib syndrome can prevent chronic complaints and unnecessary comprehensive treatment.

Well leg compartment syndrome after surgery for ulcerative colitis in the lithotomy position: A case report

INTRODUCTION

Well leg compartment syndrome (WLCS) is an uncommon and severe complication that occurs after colorectal surgery in the lithotomy position.

PRESENTATION OF CASE

The current patient was a 28-year-old male suffering from ulcerative colitis. He was underwent elective proctectomy, including ileal J pouch formation and anal anastomosis with temporary loop ileostomy. The ileoanal pouch procedure was quite difficult, and during this procedure, the high lithotomy and head down tilt positions were continued for 255min. After the operation, the patient complained of severe cramping pain, swelling and serious tenderness on palpation in both legs. On the first postoperative day, the patient's complaints gradually worsened. The intra-compartmental pressure was measured, and WLCS was diagnosed. Emergency bilateral fasciotomy was performed. Initially, the patient had a sensory deficit and analgesia, however, his sensory disturbance and pain had almost recovered two months after fasciotomy by rehabilitation.

DISCUSSION

In the current case, the important factors associated with the development of WLCS are thought to be a prolonged operative time in which the patient is placed in the high lithotomy position during ileoanal pouch procedure.

CONCLUSION

We would thus like to emphasize that operations for the ileoanal pouch procedure to treat ulcerative colitis have a high potential for inducing WLCS, because it usually requires a prolonged operative time in which the patient remains in the high lithotomy position.

Empyema necessitans caused by actinomycosis: A case report

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Pulmonary actinomycosis often presents as a chronic infection.

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Early misdiagnosis as a neoplasm is common.

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We present a rare case of rapid progression and actinomycosis empyema necessitans.

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Early operative intervention may allow for limited intervention and shortened antibiotic duration.

Introduction

Pulmonary actinomycosis is an uncommon clinical entity that the practicing thoracic surgeon rarely encounters. Empyema necessitans represents an even less common presentation of this pathology, and the often indolent disease course leads to early misdiagnosis in many cases. Familiarity with the varied presentations and possible operative strategies is essential to obtaining successful outcomes.

Presentation of case

A 56-year-old male presented with swelling and pain over the lateral chest wall. Initial imaging studies demonstrated a mass concerning for infection vs. neoplasia. Further studies were obtained to confirm the diagnosis, with rapid progression of the mass. Surgical exploration with aggressive debridement of the chest wall without thoracotomy was performed. Actinomyces was identified on final pathology, confirming the diagnosis of Actinomycosis empyema necessitans.

Discussion

Traditional management strategies often involve pulmonary resection in addition to extended duration antimicrobial therapy. This report describes the uncommon clinical presentation and successful management of actinomycosis empyema necessitans with early limited operative intervention.

Conclusion

In the event of minimal pulmonary involvement and absence of lung abscess, as was seen in this case, a thoracotomy with pulmonary resection can be avoided, and antibiotic duration limited.

Complete spontaneous necrosis of hepatocellular carcinoma confirmed on resection: A case report

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Spontaneous necrosis of hepatocellular carcinoma without any pretreatment or angiography is extremely rare.

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Spontaneous necrosis of HCC was highly suspected given the history of alcoholic hepatitis, based on the elevation of AFP and the CT findings.

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The mechanisms of spontaneous regression are still unclear.

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Recurrence after regression or viable malignant cells in resected specimen are reported.

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The ideal management strategy for this disease is surgical intervention if the liver function is acceptable.

Introduction

Complete spontaneous necrosis of hepatocellular carcinoma (HCC) without any pretreatment or angiography is rare. We present a rare case of spontaneous complete necrosis of HCC, as confirmed after hepatectomy.

Presentation of case

The patient, a 74-year-old man with a history of alcoholic hepatitis, was referred to our hospital for confirmation of suspected HCC. In March 2015, abdominal ultrasonography detected a low echoic mass in segment 8 (S8) of the liver. Contrast-enhanced computed tomography (CT) imaging revealed interval growth of this tumor and showed that the tumor was well enhanced in the arterial phase and washed out in the portal and delayed phases. The serum alpha-fetoprotein level was elevated at 30.8 ng/mL and the percentage of the L3 isoform was 25.5%. Two months later, CT imaging showed that the tumor was of low density and had decreased in size; no contrast enhancement of the tumor was seen. Spontaneous necrosis of the HCC was considered; however, as we could not exclude viable malignant cells in the tumor, we performed S8 segmentectomy of the liver. The resected tumor specimen had a thick fibrous capsule. Histopathological findings showed only granulation and necrotic tissue accompanied by bleeding and hemosiderosis. No viable tumor cells were observed. The serum alpha-fetoprotein level returned to the normal range one month after surgery.

Discussion

If spontaneous regression has occurred, there is a possibility of HCC recurrence and of remnant viable tumor cells.

Conclusion

We present a rare case of complete spontaneous necrosis of HCC and strongly recommended surgical intervention.

How to apply case reports in clinical practice using surrogate models via example of the trigeminocardiac reflex

Case reports are an increasing source of evidence in clinical medicine. Until a few years ago, such case reports were emerged into systematic reviews and nowadays they are often fitted to the development of clinical (thinking) models. We describe this modern progress of knowledge creation by the example of the trigeminocardiac reflex that was first described in 1999 by a case series and was developed over the cause-and-effect relationship, triangulation to systematic reviews and finally to thinking models. Therefore, this editorial not only underlines the increasing and outstanding importance of (unique) case reports in current science, but also in current clinical decision-making and therefore also that of specific journals like the Journal of Medical Case Reports.

Delayed-onset descemet membrane detachment after uneventful cataract surgery treated by corneal venting incision with air tamponade: a case report

Background

Descemet membrane detachment (DMD) is a significant complication noted during or early after cataract surgery. Review of literature revealed a few cases of delayed-onset DMD with presentation ranging from weeks to months after cataract surgery but most of them were treated with pneumatic descemetopexy and a few ended in penetrating keratoplasty. We report this case, to highlight the usefulness of corneal venting incision with air tamponade in late-onset DMD cases not responding to pneumatic descemetopexy.

Case presentation

A retrospective case review of a 66 year old male who presented with diminution of vision in right eye 17 days after uneventful cataract surgery was done. Visual acuity in this eye was 20/200 at presentation. DMD was noted 3 days later (approximately 3 weeks post-operatively) and Anterior Segment Optical Coherence Tomography & Scheimpflug imaging were done in view of diffuse corneal edema. Pneumatic descemetopexy was attempted thrice (twice with SF6, once with air) over a week’s span with limited success at re-attaching the DM. Finally, corneal venting incision with air tamponade was done resulting in egress of supra-descemet’s fluid and DM appeared apposed to stroma. Bandage contact lens (BCL) was applied at the end of the procedure. DM was seen attached the next day. Corneal edema cleared completely in 1 week. Best corrected visual acuity (BCVA) at 6 weeks follow-up was 20/30.

Conclusion

Delayed-onset DMD should be considered as a differential diagnosis in cases with late-onset corneal edema post-cataract surgery. Anterior segment Optical Coherence Tomography (AS-OCT) and Scheimpflug Imaging are useful tools in cases with dense corneal edema. Corneal venting incision with air tamponade is an option in cases where methods like pneumatic descemetopexy fail.

A rare case report of Solid Pseudopapillary Tumor of the pancreas with portal hypertension

INTRODUCTION

Solid Pseudopapillary Tumor of the pancreas (SPT) is a rare pancreatic tumor and represents 1-3% of all pancreatic tumors. It usually presents in young females with abdominal pain, nausea, vomiting and abdominal fullness. The first case report was documented in 1959 and since then multiple case reports have been documented on the various surgical approaches for SPT. However, there are not many reported cases where surgery has been performed on SPT with portal hypertension.

PRESENTATION OF CASE

In our case report, a 19 year old girl presented with a mass in the left side of the abdomen with associated dragging pain. Ultrasound Abdomen and CT (computed tomography) confirmed an SPT with portal hypertension, with the lesion involving the body and tail of pancreas.

DISCUSSION

Although few reports are available on SPT with portal hypertension, ours is the first report on a benign SPT with sinistral portal hypertension treated with a distal pancreatectomy. The presence of portal hypertension made the excision of the tumor and delineation of the vessels very difficult. However, when great care is taken while handling the dilated vessels, dissection can be completed with minimal blood loss.

CONCLUSION

Meticulous surgical technique along with accurate identification of vasculature will aid in the resection. Although some SPTs behave aggressively, most of them are benign and patients with SPT have an excellent prognosis.

Cecal bascule after spinal cord injury: A case series report

Introduction

Cecal bascule is a rare cause of intestinal obstruction associated with upward and anterior folding of the ascending colon. We report three patients who presented with spinal cord injury complicated with a cecal bascule. Diagnosis and management of cecal bascule is discussed.

Presentation of cases

Patient 1: 59-year-old male sustained a traumatic brain injury and cervical spinal cord injury after a motorcycle crash. He had abdominal distension and the diagnosis of cecal bascule was made. Cecopexy was performed.

Patient 2: 51-year-old male sustained an unstable C7 vertebral fracture with a cord contusion and quadriplegia after a diving incident. After an unsuccessful medical management of the colonic distension, the patient was taken for a laparotomy and cecal bascule was found. A cecostomy and a cecopexy were performed.

Patient 3: 63-year-old male was transferred after a fall. He had diffuse degenerative changes in the thoracic and lumbar spine. He was found to have a perforated cecal bascule. He had a right hemicolectomy with an ileocolic anastomosis.

Discussion

We suggest the possibility of spinal cord injury being a risk factor for cecal bascule. Currently, right hemicolectomy is recommended for the treatment of cecal bascule. Cecopexy is also acceptable treatment option for a case in which the patient will be undergoing an operation with an insertion of hardware.

Conclusion

The diagnosis of cecal bascule should be considered for trauma patients with cecal distention without delay in order to prevent disastrous complications.

Rapid chondrolysis of the medial knee compartment after arthroscopic meniscal resection: a case report

Background

Rapidly destructive osteoarthritis of the hip and rapid chondrolysis of the lateral compartment of the knee or the shoulder are rare, but have been previously described in the medical literature. To the best of our knowledge, no case of medial femorotibial compartment chondrolysis after arthroscopy has yet been described. We therefore submit the first case report.

Case presentation

A 64-year-old white European man presented with right knee pain due to a medial meniscal tear with no other abnormality found on examination or imaging. An arthroscopic partial medial meniscectomy was performed and early evolution was favorable with no signs of infection. He developed knee pain 2 months later. X-rays showed a thinning of the medial compartment which was confirmed by computed tomography arthrogram. There was no articular effusion, mobility was conserved (0/0/125°), there was no laxity, and pain was localized to the medial femorotibial compartment, with no meniscal signs. There was a 8° varus deviation (versus 3° for his uninjured left knee). His blood work was normal. As there were no signs of infection, no aspiration was performed. Viscosupplementation was offered but refused by the patient. He is now waiting for a partial knee replacement.

Conclusions

To the best of our knowledge, this is the first description of such a case. Rapid chondrolysis has been described in the hip, shoulder, and the lateral compartment of the knee. Infiltration of bupivacaine and lateral meniscectomy are the most frequently sited offending procedures. Concerning the medial compartment, cases of avascular necrosis have been reported after meniscectomy or use of radiofrequency devices. This case underlines the necessity of a thorough physical examination and complete radiological work up before any surgery. It must also drive us to use caution regarding meniscectomy, especially in patients over 60 years of age, and reminds us that patients must be informed of this potential complication.

Familial tetrasomy 4q35.2 associated with congenital diaphragmatic hernia and unilateral renal agenesis: a case report

Background

Previous reports of chromosomal aberrations in different forms of congenital diaphragmatic hernia have been described as comprising aneuploidies (for example, trisomy 21), microdeletions, and duplications (for example, monosomy 15q24, 22q11.2).

Case presentation

We describe the first association of a de novo partial tetrasomy 4q35.2 in a father with left-sided, isolated renal agenesis and left-sided, isolated congenital diaphragmatic hernia in his son, who inherited the chromosomal aberration from his father.

Conclusions

Given that the aberration occurred de novo in the father and was transmitted to his son, with both presenting with unilateral left-sided developmental field defects, we suggest a gene dosage effect of the tetrasomic region to be involved in the phenotype of our two patients. Furthermore, we suggest performing a genetic workup in multiplex families with congenital malformations.

A rare case of a transabdominal impalement after a fall from a ladder

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The stick penetrated the patient at his left lumbar region, while its tip was palpable on his right abdomen.

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A computed tomography was performed due to the stable condition of the patient.

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When patient is unstable an emergency exploratory laparotomy should be performed.

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Drains were left until the 6th postoperative day due to increased levels of amylase.

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Antibiotic administration was discontinued on the 7th postoperative day because of the presence of gut perforation.

Introduction

Impalement injuries are caused by objects that penetrate and remain inside the human body. They are rare and often lead to complex surgical problems, demanding immediate measures and intensive care.

Presentation of case

We report a case of a 39 year old male who presented in our emergency department with a history of fall from a 3 m high ladder, landing on a wooden stick that penetrated the patient from his left lumbar region, leading to a trans-abdominal impalement injury.

Discussion

Nowadays impalement injuries although rare, demonstrate a challenging presentation for emergency providers. Their complexity often raises concerns about the proper surgical approach and postoperative management. In many cases, they may cause severe morbidity or even be lethal.

Conclusion

The article describes a case of a transabdominal impalement injury and pinpoints the strategies followed regarding the prehospital care, as well as the intra- and postoperative management.

Surgical correction of persistent truncus arteriosus on a 33-year-old male with unilateral pulmonary hypertension from migration of pulmonary artery band

BACKGROUND

Persistent truncus arteriosus is a rare congenital condition with which survival into adulthood is dismal without surgery. This is the oldest patient reported to our knowledge demonstrating the feasibility of assessing operability in persistent truncus arteriosus with unilateral pulmonary stenosis, and performing full corrective surgery in adulthood.

CASE PRESENTATION

We report a Chinese male with successful correction of Type I persistent truncus arteriosus at 33 years of age. He had unilateral pulmonary hypertension from migration of pulmonary artery band from the main to the right pulmonary artery, severe truncal valve regurgitation from previous infective endocarditis, and progressive congestive heart failure. Improvement of lung perfusion was demonstrated 21 months post operation.

CONCLUSION

This case demonstrated that in patients with persistent truncus arteriosus and two pulmonary arteries, pulmonary vascular disease or underdevelopment of one lung does not preclude a full corrective surgery so long as the other vascular bed is normal. It is important to emphasize the importance of assessing patient's operability in totality.

Aneurysm in the anterior inferior cerebellar artery-posterior inferior cerebellar artery variant: Case report and review of literature

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We reported a case of an aneurysm in the AICA-PICA variant which was subsequently excised.

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Considerable variation exists in the anatomy of the vertebrobasilar system.

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Understanding the variations and the aneurysms that may arise from them is an important aspect of neurosurgical practice.

Introduction

There are variations in the anatomy of the vertebrobasilar system amongst which the Anterior Inferior Cerebellar Artery-Posterior Inferior Cerebellar Artery (AICA-PICA) variant is thought to have a prevalence of 20–24% (based on retrospective studies). Despite this, aneurysms of the AICA-PICA variant are rare. We present a case of an AICA-PICA aneurysm and discuss its presentation and management, along with a review of literature.

Presentation of case

We describe the case of a 35 year old female who presented with signs of meningismus. On the basis of radiological imaging it was initially misdiagnosed as a thrombosed arteriovenous malformation (AVM). The patient was eventually discharged with a plan of interval imaging and interventional radiology (if required). The patient presented again with similar signs and symptoms. Re-evaluation of imaging revealed an aneurysm of the AICA-PICA variant which was managed surgically.

Discussion

Aneurysms of the AICA-PICA variant are rare. The radiological features and surgical management represent a unique clinical entity and are discussed below.

Conclusion

The prevalence of the AICA-PICA variant might be high but aneurysms in this vessel are rare. The scant knowledge available on this subject makes it a diagnostic difficulty.

Intrasellar arachnoid cyst: A case report and review of the literature

INTRODUCTION

Arachnoid cysts (ACs) are frequently found on intracranial imaging studies but intrasellar arachnoid cysts are rarely encountered.

PRESENTATION OF CASE

We present a 49-year old patient who had headaches for 6 months and cystic sellar mass was found in his cranial imaging. We operated him by transnasal transsphenoidal route. Our intraoperative diagnosis was an arachnoid cyst and pathologic studies verified our observation. He did well postoperatively and after a 1year follow-up he was left free from future follow-ups.

DISCUSSION

As common cystic lesions occupying the sellar region can simulate ACs both clinically and radiologically, neurosurgeon can fail to include ACs in making the initial diagnosis preoperatively.

CONCLUSION

Although a rare entity, arachnoid cysts should be considered in the differential diagnosis of sellar region.

Inflammatory myofibroblastic tumor of the small intestine: A case report

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Inflammatory myofibroblastic tumor (IMT) is a rare benign tumor.

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In this case, a five-year-old child experienced the sudden onset of symptoms and the enlargement of abdominal mass 20 days before referral.

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In the laparotomy, a large and sticky solid mass, attached to the ileum with the mesenteric origin, sized 10 × 8 cm was observed and completely resected.

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Despite using some radiographic methods such as medical ultrasound and computerized tomography (CT) scan to diagnose the disease, the definitive diagnosis is merely possible thorough complete surgical resection.

Introduction

Inflammatory myofibroblastic tumor (IMT) is a rare benign tumor. Usually seen in children and adolescents, this inflammatory tumor can affect all the organs.

Presentation of case

In this case, a five-year-old child experienced the sudden onset of symptoms and the enlargement of abdominal mass 20 days before referral. The patient did not have any symptoms of nausea, vomit, and abdominal pain. In the laparotomy, a large and sticky solid mass, attached to the ileum with the mesenteric origin, sized 10 × 8 cm was observed and completely resected.

Discussion

This tumor rarely emerges in the small intestine, and there are a few patients with intestinal manifestation. In this case report, the tumor had an origin of the small intestine mesenteric and it had invaded to the ileum.

Conclusion

Despite using some radiographic methods such as medical ultrasound and computerized tomography (CT) scan to diagnose the disease, the definitive diagnosis is merely possible thorough complete surgical resection.

Synchronous neuroendocrine tumors in both the pancreas and ileum: A case report

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This is the first case of synchronous pancreatic and ileal NET in a non-MEN 1 patient.

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Both morphologic and immunophenotypic findings were different.

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The synchronous occurrence of these tumors may be considered as a chance occurrence.

Introduction

Although it is well-known that in multiple endocrine neoplasia type 1 (MEN 1) disease, multiple endocrine lesions frequently occur, synchronous or metachronous neuroendocrine tumors (NETs) in non-MEN 1 patients are extremely rare.

Presentation of case

An asymptomatic 72-year-old woman with an ileal NET was referred to our hospital. Abdominal computed tomography revealed another circular tumor within the pancreatic head. She was classified as a non-MEN 1 patient. An operative procedure was performed with a preoperative diagnosis of synchronous NET, which was confirmed by pathological examination.

Discussion

Both morphologic and immunophenotypic findings were different between in the ileum and pancreas. Therefore, it was reasonable to consider that both tumors were primary tumors. The synchronous occurrence of these tumors is unusual, and it may be considered as a chance occurrence.

Conclusion

We here report the first case of synchronous pancreatic NET and ileal NET in a non-MEN 1 patient.

Mixed squamous cell and glandular papilloma of the lung resembling early adenocarcinoma: A case report

Introduction

An extremely rare case of mixed squamous cell and glandular papilloma of the lung is reported. The correlation between the radiological and the pathological features as well as the clinical pitfall in making a diagnosis is discussed.

Presentation of case

An asymptomatic 68-year-old female with a cigarette smoking habit presented with a small nodule in her peripheral lung. A wedge resection was performed though it failed on-site diagnosis which was instead obtained following pathological scrutiny. The postsurgical course was excellent with no recurrence of disease.

Discussion

A small ground glass nodule gradually enlarged and transformed to a partially solid nodule a year and a half later. This transformation falsely made us suspect an early adenocarcinoma development. Eventually, the extremely rare subtype of pulmonary papilloma, with biphasic glandular and squamous cells, had been demonstrated to obstruct the peripheral bronchiole; and the adjoining alveoli had filled with a large volume of mucus. These pathological features seemed to have constituted the inner solid portion and the marginal ground glass portion respectively in the CT images, mimicking invasive lepidic adenocarcinoma.

Conclusion

Both pre- and intra-operative diagnoses are difficult mainly because of the rareness of the disease, however, mixed squamous cell and glandular papilloma may be considered in case the presence of primary adenocarcinoma is not validated.

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Mixed squamous cell and glandular subtype is extremely rare pulmonary papilloma.

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Initial presentation of this benign tumor had resembled early adenocarcinoma.

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This disease should be taken into account in making a differential diagnosis.

Locked volar distal radioulnar joint dislocation

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Volar dislocation of the distal radioulnar joint is a rare injury and can be easily missed.

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The stability of the DRUJ is enhanced by ligaments and muscles, and The triangular fibro cartilage complex (TFCC) is the most important stabilizer.

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In cases of volar dislocation, there is a history of hyper supination and the patient is unable to pronate.

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In cases of volar dislocation, there is a history of hyper supination and the patient is unable to pronate.

Introduction

Volar dislocation of the distal radioulnar joint is a rare injury which is commonly missed in the emergency departments. A thorough review of literature showed very few reported cases and the cause for irreducibility varied in different cases, Lack of suspicion and improper X-ray can delay the diagnosis.

Case presentation

Our article discusses a case 40 year old construction worker, who presented to the Emergency with work-related injury, complaining of left wrist pain, deformity and inability to rotate his forearm. X-rays revealed a volar dislocation of distal ulna which was reducible after manipulation under General Anesthesia (GA). The joint was stable after the reduction.

Discussion

Isolated dislocation of the distal radioulnar joint can be either volar or dorsal, although dorsal dislocation is more common. The distal radioulnar articulation plays an important role in the rotational movement of the forearm. It allows pronation and supination which are essential for the function of the upper limb. Pronator Quadratus muscle spasm is an important blockade to reduction and was preventing reduction in this case.

Methods

The work has been reported in line with the CARE criteria [9].

Conclusion

Volar locked dislocation of Distal Radio ulnar joint is a rare injury. High degree of clinical suspicion and proper X-ray is required for prompt detection.

The importance of this case is to raise the awareness among physicians in treating these kind of injuries by careful assessment of the patient and radiographs, and to consider pronator quadratus as an important cause for the blockade to reduction.

One case of small intestinal submucosal hemorrhage caused by warfarin overdose

Warfarin overdose induced spontaneous intestinal intramural hematoma is a rare complication of anticoagulant treatment, which can cause subacute intestinal obstruction. Patients may present with symptoms of abdominal pain and significant coagulopathy, accompanied by nausea, vomiting, and anemia, and they are often misdiagnosed with mesenteric thrombosis or acute abdominal disease and given thrombolysis or surgical treatment.

A literature review and case report of hand, foot and mouth disease in an immunocompetent adult

Background

To report an uncommon case of hand, foot and mouth disease, (HFMD) in an immunocompetent adult; a highly infectious disease, characterized by the appearance of vesicles on the mouth, hands and feet, associated with coxsackieviruses and enteroviruses; including a literature review.

Case report

A 23 year Caucasian male with no medical or surgical history, no allergies, was not taking any medication and smoked ten cigarettes a day, suffering from discomfort in the oral cavity; itching, burning and pain when swallowing associated with small erythematous lesions located on the hard palate, and small ulcers in tonsillar pillars and right buccal mucosa. Mild fever of 37.8 °C and general malaise. The patient reported he had had contact with a child diagnosed with HFMD. From his background and symptoms, the patient was diagnosed with HFMD. Following symptomatic treatment, the symptoms remitted in 7 days.

Methods

A literature review in MEDLINE (PubMed). The inclusion criteria were for studies on humans over the last 5 years, using the keywords HFMD.

Results

We found 925 articles, which were subsequently reduced to 52 documents after applying the inclusion criteria. Maculopapular lesions were found on hands and feet.

Conclusions

Dentists may have a key role diagnosing the disease. A surveillance system to predict future outbreaks, encourage early diagnosis, put appropriate public health measures in place and research vaccine development is vitally important in order to control the disease.

Right iliac fossa lymphoma in an HIV positive patient: A diagnostic dilemma

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An association has been established between HIV and lymphoma.

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Lymphoma can present with non-specific or unusual symptoms.

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Lymphoma can also present in patients with well-controlled HIV.

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Lymphoma in HIV patients is an important differential but is often diagnosed at a late stage in the UK.

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It is important that suspicion of lymphoma is raised in patients with HIV.

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It is important that a multidisciplinary approach to diagnosis is taken early on to allow prompt management of this condition

Lymphoma should be considered early in patients with HIV when there is a history of weight loss. Although B-cell lymphoma is an AIDS-defining cancer, and many reports of lymphoma in HIV positive patients exist in the literature, this case report illustrates that even in patients with well-controlled HIV the diagnosis must be considered, and puts forward an unusual presentation in an otherwise asymptomatic patient.

A 52 year old woman presented for a routine HIV follow-up appointment and was found to be experiencing weight loss. An abdominal examination revealed a right iliac fossa mass. Subsequent CT thorax, abdomen, pelvis imaging confirmed a large mass but did not allow determination of the primary source. Serological tumour marker investigations were unyielding. Trans-vaginal ultrasound guided biopsy of the mass demonstrated diffuse large B-cell lymphoma.

This case report emphasises the importance of having a high index of suspicion for these cancers even in patients with low viral load who are on anti-retroviral treatment. It also demonstrates the importance of taking a multidisciplinary approach to diagnosis of the condition to enable prompt treatment and thus improve the outcome for the patient.

Pancreatic manifestations in von Hippel-Lindau disease: A case report

INTRODUCTION

Pancreatic manifestations in Von Hippel-Lindau (VHL) disease can present as a multitude of forms, and their management can be challenging.

PRESENTATION OF THE CASE

A 66-year-old woman presented with increasing abdominal girth without other associated symptoms of nausea, vomiting, abdominal pain, weight-loss, and jaundice. Her medical and surgical histories were significant for type II diabetes, cerebral tumor resection, bilateral nephrectomies, and laser photocoagulation of retinal hemangiomas. Computed tomography (CT) of the abdomen showed a massive multi-cystic lesion in the pancreas and the patient was referred to our hepatopancreatic biliary center.

DISCUSSION

The findings on the subsequent cross-sectional MRI imaging signified pancreatic manifestations in VHL disease.

CONCLUSION

The management of VHL disease-associated benign pancreatic cystic lesions involves interval monitoring with cross-sectional imaging for malignant changes/development.

Primary omental gangrene mimicking appendicular perforation peritonitis-A case report

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Patient presented as a case of appendicular perofration with pyoperitoneum leading to localized peritonitis which is a common surgical emergency.

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Primary omental torsion is a rare diagnosis and very difficult to diagnose at the emergency room.

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We report a patient with omental torsion and further gangrene of the omentum leading to pyoperitoneum mimicking appendicuar perforation peritonitis.

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A review of literature is also included.

Introduction

Primary omental torsion is a rare cause of acute abdomen in adults and presents with variable signs and symptoms. Establishing a preoperative diagnosis may be difficult in the emergency setting. It is rarely diagnosed preoperatively as it mimics common surgical emergencies such as acute appendicitis, appendicular perforation, acute cholecystitis and perforated peptic ulcers and can lead to the clinical deterioration of patient if missed

Presentation of case

A 47 years old male was taken to the operating room with a diagnosis of appendicular perforation peritonitis and during surgery was found to have a primary omental gangrene with pyoperitoneum, for which omentectomy and peritoneal lavage was performed.

Discussion

Torsion of the omentum is a condition in which the organ twists on its long axis to such an extent that its vascularity is compromised. Omental torsion can be primary (idiopathic) or secondary, depending on an underlying cause. Primary omental torsion was first described by Eitel in 1899. However, very few cases have been reported. Our case was a rare case presenting with omental gangrene with pyoperitoneum mimicking appendicular perforation peritonitis.

Conclusion

Primary omental torsion is a rare diagnosis. A high index of clinical suspicion is required for a preoperative diagnosis. In doubtful cases a CT scan may be helpful. Surgical excision of the omentum remains the treatment of choice; however, conservative management may be attempted in an uncomplicated omental torsion.

Exsanguinating Hemorrhage during Open Biopsy in a Primary Breast Angiosarcoma: A Case Report

Angiosarcomas are endothelial cell neoplasms in the lining of the blood vessel wall and account for about 0.04% of all breast malignancies with a high rate of error in primary diagnosis. The breast angiosarcoma is a rare and uncommon pathology and has been described mostly as case reports. Indeed, only a limited number of cases have been published. Accordingly, the natural history of this tumor and its clinical course remain unclear, and as a consequence, no uniform treatment strategy exists. We present the clinical course and challenges in the diagnosis of a primary angiosarcoma of the breast in a young woman, presenting with a mass in her left breast. Fine-needle aspiration and core needle biopsy failed to confer a correct diagnosis. She suffered severe bleeding at the time of open biopsy and underwent total mastectomy, followed by adjuvant chemotherapy. Young women with solid breast tumors, especially those that are highly vascular, should be considered malignant until proven otherwise. Accurate diagnosis may be difficult. Open biopsy can be diagnostic, although exsanguinating bleeding may occur. Thus, performing open biopsy in locations other than equipped operating rooms may be hazardous and should be avoided.

A novel technique of Roux-en-Y gastric bypass reversal for postprandial hyperinsulinemic hypoglycaemia: A case report

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Postprandial hypoglycemia may be a serious adverse effect following Roux-en-Y gastric bypass surgery.

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Most patient can be treated with diet and pharmacological agents, but some patients need surgical reversals.

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This Roux-en-Y gastric bypass reversal alleviates severe postprandial hyperinsulinaemic hypoglycaemia.

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The technique retains some component of rapid transit of food into a shorter alimentary limb in an attempt to reduce weight regain.

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This new surgical procedure also attenuates s-GLP-1 and s-insulin responses along with improved p-glucose.

Background

We describe an evaluation of the effects of partial Roux-en-Y gastric bypass (RYGB) reversal on postprandial hyperinsulinaemic hypoglycaemia, insulin and GLP-1 levels.

Case summary

A 37 year old man was admitted with neuroglycopenia (plasma–glucose 1.6 mmol/l) 18 months after RYGB, with normal 72 h fasting test and abdominal CT. Despite dietary modifications and medical treatment, the hypoglycaemic episodes escalated in frequency. Feeding by a gastrostomy tube positioned in the gastric remnant did not prevent severe episodes of hypoglycaemia. A modified reversal of the RYGB was performed. Mixed meal tests were done perorally (PO), through the gastrostomy tube 1 (GT1), 4 weeks (GT2) after placement and 4 weeks after reversal (POr), with assessment of glucose, insulin and GLP-1 levels.

Results

Plasma–glucose increased to a maximum of 9.6, 5.4, 6.5 and 5.8 mmol/l at the PO, GT1, GT2 and POr tests respectively. The corresponding insulin levels were 2939, 731, 725 and 463 pmol/l. A decrease of plasma–glucose followed: 2.2, 3.0, 3.9 and 2.9 mmol/l respectively and insulin levels were suppressed at 150 min: 45, 22, 21 and 14 pmol/l, respectively. GLP-1 levels increased in the PO test (60 min: 122 pmol/l, 21 fold of basal), but was attenuated in the two latter tests (12–23 pmol/l at 60 min).

Conclusions

Reduction of plasma–glucose, insulin and GLP-1 excursions and symptoms were seen after gastric tube placement and partial RYGB reversal. This attenuation of GLP-1 response to feeding could reflect an adaptation to nutrients.

A recurrent solitary fibrous tumor of the thigh with malignant transformation: A case report

INTRODUCTION

We describe an unusual case of a uniformly high-grade malignant solitary fibrous tumor (SFT) of the thigh with recurrence after wide resection in a 31-year-old man.

PRESENTATION OF CASE

Our current case showed a long-term benign course before the operation, although the subcutaneous tumor was larger than 10cm at presentation. The SFT was diagnosed by needle biopsy, and wide resection was performed. Histological findings showed proliferation of capillaries surrounded by masses of spindle-shaped cells without any cytologic atypia, and the percentage of MIB-1-positive nuclei was 2.1%. However, a rapidly enlarging recurrent tumor was observed 11 months after the operation. A second wide resection for the recurrent tumor was performed. Histologically, the tumor cells uniformly displayed significant cytologic atypia and pleomorphism, and had 40-50 mitoses per 10 high-power fields. The proportion of MIB-1-positive nuclei was 48%. Consequently, the tumor was diagnosed as a SFT with malignant transformation.

DISCUSSION

The malignant transformation described in past studies showed high-grade areas within benign, low-grade, or intermediate-grade SFTs. Therefore, in contrast to our case, uniformly high-grade malignant histological findings at recurrence were not described.

CONCLUSION

Even if a tumor is non-malignant during the clinical course, as confirmed by tissue biopsy, the possibility of tumor progression to high-grade sarcoma at recurrence should be considered, and the treatment strategy should be determined carefully.

Anterior interosseous nerve syndrome diagnosis and intraoperative findings: A case report

INTRODUCTION

Anterior Interosseous Nerve (AIN) is a motor branch from the Median nerve and runs deep in the forearm along with the anterior interosseous artery. It innervates three muscles in the forearm; an isolated palsy of these muscles is known as AIN Syndrome. There are several documented causes of AIN syndrome but its pathophysiology remains unclear.

PRESENTATION OF CASE

A 48-year old male that presented with right elbow pain and inability to flex his right interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. MR images denoted mild atrophy of the radial half of the flexor digitorum profundus and the pronator quadratus. Although there were no compressing lesions identifiable on MRI, Electrodiagnostic studies suggested compression neuropathy affecting the AIN. During surgical decompression of the median nerve in the proximal forearm, the operative findings were several tendinous fasciae and a tight fibrous arch of the flexor digitorum superficialis compressing the median nerve at the level of the AIN branch.

DISCUSSION

Different treatment schemes with reasonable outcome have been reported. Both nonsurgical and surgical intervention have been described in most of these schemes but differed in the timing of intervention with variable outcome.

CONCLUSION

Clinical suspicion should arise in the presence of isolated paralysis of the AIN-supplied muscles. MRI and electrodiagnostic studies will confirm the diagnosis and identify the etiology. The optimal treatment of AIN syndrome has not been established. We recommend surgical intervention in confirmed AIN syndrome from compression neuropathy, refractive to conservative therapy.

Analysis of case reports submitted to the European Annals of Otorhinolaryngology Head & Neck Diseases

OBJECTIVES

To assess flaws, rejection rate and reasons for rejection of case reports submitted for publication in the European Annals of Otorhinolaryngology Head & Neck Diseases.

MATERIALS AND METHODS

A prospective analysis of flaws noted in reviewing 118 case reports from 29 countries consecutively submitted to the European Annals of Otorhinolaryngology Head & Neck Diseases during the period Sept. 1, 2014 to Sept. 30, 2015.

RESULTS

The most frequent flaws, noted in 74.5% of cases, were: lack of originality (more than 15 such cases previously reported in the medical literature) and lack of new data contributing to the medical literature. Overall, 5% of the cases were accepted for publication, 7% were not resubmitted by the authors, and 88% were rejected. On univariate analysis, none of the variables under analysis correlated with acceptance or rejection of the submitted case. Editorial decision time varied from 1 to 7months (median, 1 month). In 16.3% of the 104 cases of rejection (17/104), the editors suggested resubmission in the section "Letter to the Editor" or "What is your diagnosis?"; 15 of the 17 reports were resubmitted, and 10 (66.6%) were ultimately accepted for publication.

CONCLUSION

The editorial committee of the European Annals of Otorhinolaryngology Head & Neck Diseases hope that the present data and review of the literature will provide authors with a framework to avoid major errors leading to rejection and will speed publication of the case reports they submit to our columns in the near future.

Cutaneous plasmacytoma adjacent to Bowenoid actinic keratosis on the scalp: Is there a link?

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Cutaneous plasmacytoma is rare.

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Surgical excision has a favourable outcome.

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Correlation between Bowens disease and plasmacytoma is tested here.

Introduction

Cutaneous extramedullary plasmacytoma without bone marrow involvement is very rare. We present a plasmacytoma on the scalp with an adjacent Bowenoid disease.

Presentation

An 86 year old man presented to our unit with an ulcerated lump on the vertex of the scalp. Excisional biopsy showed plasmacytoma with adjacent Bowenoid actinic keratosis. Blood tests did not show any systemic multiple myeloma. However, skeletal survey showed possible osteolytic lesions in some areas. Sixteen months afterwards, the patient remains well on follow up.

Discussion

As far as we know, this is the first reported case of a cutaneous plasma cell tumour next to an area of Bowenoid actinic keratosis. Relevant literature is investigated here for possible correlation.

Conclusion

Within the limitations of this study, solitary primary cutaneous plasmacytoma can be treated surgically with a favourable outcome. A hypothesis of correlation between Bowenoid actinic keratosis and plasmacytoma is investigated here. Further research is needed to confirm this finding.

Whole clavicle sequestration from chronic osteomyelitis in a 10 year old boy: A case report and review of the literature

Chronic osteomyelitis is a childhood disease and so it is not uncommon to diagnose it in a 10 year old boy who is suffering from pains and discharging sinuses from the left shoulder girdle. What is not common is the involvement of the clavicle in this infective process and even more uncommon is for the whole length of the clavicle to sequester. This case report describes a rare case of chronic osteomyelitis of the left clavicle in which the entire length was removed as a sequestrum during surgery. And despite the removal of an entire length of the clavicle in the patient, there was no functional deficit and there was also no shoulder asymmetry.

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Chronic osteomyelitis is common in childhood and clavicular involvement is less common than femur, tibia or humerus.

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In this clavicular osteomyelitis, the entire bone was sequestered.

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It is not absolutely important to have huge involucrum before sequestrectomy since it is not a weight bearing bone.

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The whole sequestered clavicle was necessarily removed despite the thin involurcum.

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Regardless, the removal of the entire bone was not associated with functional deficit or shoulder asymmetry.

Isolated omental metastasis of renal cell carcinoma after extraperitoneal open partial nephrectomy: A case report

INTRODUCTION

Metachronous metastatic spread of clinically localized renal cell carcinoma (RCC) affects almost 1/3 of the patients. They occur most frequently in lung, liver, bone and brain. Isolated omental metastasis of RCC has not been reported so far.

CASE PRESENTATION

A 62-year-old patient previously diagnosed and treated due to pulmonary sarcoidosis has developed an omental metastatic lesion 13 years after having undergone open extraperitoneal partial nephrectomy for T1 clear-cell RCC. Constitutional symptoms and imaging findings that were attributed to the presence of a sarcomatoid paraneoplastic syndrome triggered by the development this metastatic focus complicated the diagnostic work-up. Biopsy of the [18F]-fluorodeoxyglucose (+) lesions confirmed the diagnosis of metastatic RCC and the patient was managed by the resection of the omental mass via near-total omentectomy followed by targeted therapy with a tyrosine kinase inhibitor.

DISCUSSION

Late recurrence of RCC has been reported to occur in 10-20% of the patients within 20 years. Therefore lifelong follow up of RCC has been advocated by some authors. Diffuse peritoneal metastases have been reported in certain RCC subtypes with adverse histopathological features. However, isolated omental metastasis without any sign of peritoneal involvement is an extremely rare condition.

CONCLUSION

To our knowledge, this is the first reported case of metachronously developed, isolated omental metastasis of an initially T1 clear-cell RCC. Constitutional symptoms, despite a long interval since nephrectomy, should raise the possibility of a paraneoplastic syndrome being associated with metastatic RCC. Morphological and molecular imaging studies together with histopathological documentation will be diagnostic.

Jejunoileal diverticulosis, a rare cause of ileal perforation - Case report

Introduction

Jejunoileal diverticulosis (JID) is a rare condition associated with nonspecific symptoms, consisting of acquired false diverticula. It frequently co-exists with colonic diverticulosis. Diagnosis is usually made incidentally or after complications. These include hemorrhage, obstruction and diverticulitis, with or without perforation.

Presentation of case

81-year-old man presented with a painful abdominal mass in the right lower quadrant (RLQ), diffuse abdominal discomfort and fever. Abdominal examination confirmed a well-defined mass in the RLQ without rebound tenderness. Laboratory analysis revealed elevated inflammatory markers and CT scan showed a cavitated lesion with an air-fluid level in the RLQ, without evidence of intraperitoneal free air or fluid. Admitted for conservative treatment, failure to improve led to laparotomy on the 6th day of hospitalization, with identification of jejunoileal diverticulosis complicated with diverticulitis and walled-off perforation. We performed segmental enterectomy.

Discussion

The incidence of JID is estimated at 0.2–7% and it is usually diagnosed in the sixth/seventh decade of life. From a diagnostic perspective, JID is a challenging disorder, without reliable diagnostic tests. Diverticulitis is the most common complication. Perforation generally causes only localized peritonitis, as involved diverticula are often walled off by the surrounding mesentery. In selected cases, medical therapy may suffice. For all other patients prompt laparotomy with segmental intestinal resection is the treatment of choice.

Conclusion

JID remains under diagnosed. When it presents as an acute complication it may require immediate surgical intervention. In an elderly person, especially with known gastrointestinal diverticulosis, one must have a high index of suspicion for perforation.

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Jejunoileal diverticulosis is rare and it's symptoms usually nonspecific.

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Diagnosis is usually made incidentally or after the development of complications.

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Chronic symptoms are frequent, mainly abdominal pain or malabsorption.

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Diverticulitis, with or without perforation, is the most common complication.

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Although surgery is the definite treatment, medical therapy can be considered.

[Typus melancholicus and melancholia: Theoretical synthesis using a clinical case]

OBJECTIVE

The aim of this paper is to propose, starting from the description of a clinical emblematic case, a theoretical synthesis of the work of phenomenological psychopathology dedicated to melancholia and typus melancholicus (TM), a clinical concept that describes the premorbid personality vulnerable to major depression ("melancholia" for the psychopathological tradition).

METHOD

This is a phenomenological analysis of a case study of melancholia, of its premorbid personality and pathogenic triggering situation. We adopt two main phenomenological keys to understand the development of melancholia: a role-identity theory and desynchronization theory. The former understands melancholia as a disorder of identity triggered by the loss of the social role with which one has previously over-identified. The latter sees melancholia as the effect of the desynchronization from the social environment that further develops into an inhibition of the cognative-affective dynamics of life. We present the case of Jonas (64 years old), whose mother (94 years old) recently died. Before his mother's death, Jonas' life was entirely orchestrated by the caring for his mother and synchronized in time with this (e.g., he used to go to her house every 4 hours, had all his meals with her, etc.). Jonas, in addition to being hyper-synchronized and hyper-syntonic, fulfills all diagnostic criteria for TM, including "orderliness", "conscientiousness", "hyper/heteronomia" and "intolerance of ambiguity". TMs attach a disproportioned importance to their social roles (or external representations of identity) at the expense of their own ego-identity.

RESULTS

The passage from premorbid personality to melancholia is triggered by the death of Jonas' mother that entails a profound depersonalization. Desynchronization and role loss cause Jonas' fall into this severe depersonalization, the core feature of which is the feeling of the loss of feeling.

CONCLUSIONS

This original contribution demonstrates that a clinical case can contribute to the construction and refinement of theoretical and conceptual frameworks (like princeps Tellenbach's studies). Over-synchronized tempo and over-identification with social role are emblematically in this case the two sides of the same coin. A parallelism can be established between synchronization (with the mother) and respect for the role at the expense of own identity. The clinical case of Jonas highlights a conceptual bridge between the model of melancholia as loss of social role and the model of melancholia as desynchronization.

Multiple giant coronary artery aneurysms: a case report

BACKGROUND

Coronary artery aneurysm is defined as a localized area of dilatation exceeding the diameter of the adjacent normal arterial segment by 50%. Giant aneurysms are those aneurysms that measure greater than 2cm in diameter. There have been many pathologic diseases, including atherosclerosis, that have been implicated in the development of coronary artery aneurysms.

MATERIALS AND METHODS

We report a case of a 61-year-old African American male with multiple comorbidities including hypertension, congestive heart failure, abdominal aortic aneurysm, and bilateral iliac aneurysms, who was admitted to our hospital with exacerbation of congestive heart failure. Less than 2weeks after admission, the patient suffered cardiac arrest while receiving dialysis and was unresponsive to resuscitative measures.

FINDINGS

Autopsy was performed and revealed significant cardiomyopathy and giant coronary artery aneurysms involving the left anterior descending, left circumflex, and right coronary arteries. Both ventricles showed hypertrophy and dilation with multifocal areas of chronic myocardial scarring.

CONCLUSIONS

Coronary artery aneurysms and giant coronary artery aneurysms are an uncommon. As there are few reported cases in the literature, the cause, detection, and treatment of this disease are still largely unknown.

Individualized multimodal treatment strategy for anaplastic thyroid carcinoma-Case report of long-term remission and review of literature

INTRODUCTION

The prognosis of anaplastic thyroid cancer (ATC) is poor with a mean survival time of six months following diagnosis. Despite various attempts to modify common treatment modalities including surgery, external beam radiation and chemotherapy, an effective treatment is not available yet. We report, here, a patient who achieved long-term survival based on multimodal treatment, including in vitro evaluation of drug response of his tumor cells.

PRESENTATION OF CASE

A 42 years old male patient underwent total thyroidectomy with central and lateral neck dissection for ATC (pT4b, pN0 (0/36), L0, V0, Pn1, R0 cM0 - UICC-Stage: IV b). From the tumor tissue a primary cell culture was established. While the patient received a combined radio-chemotherapy cell viability assays were performed using Sorafenib, Vandetanib und MLN8054 (Aurora kinase inhibitor) as inhibitors. Cell viability was determined by MTT-assay after 72 and 144h of treatment.

DISCUSSION

All the three compounds affected cell viability in a time- and dose dependent manner. These effects were most pronounced by Sorafenib. Based on in vitro findings, the patient was treated daily with 400mg Sorafenib for 75days. 43 months after initial diagnosis, the patient had no evidence of disease as shown by MRI, CT and FDG-PET-CT imaging.

CONCLUSION

In the setting of multimodal treatment, in vitro drug evaluation of individual tumor cells of patients might be a promising tool to ameliorate the fatal prognosis of selected ATC patients.

Late hemorrhagic pseudoseptic arthritis encountered during total knee arthroplasty due to hyaluronic acid viscosupplementation

Osteoarthritis (OA) is the most common form of arthritis and affects approximately one-third of people in the United Sates aged 65 years and older. Since 2013, the American Academy of Orthopaedic Surgeons has not been able to recommended using hyaluronic acid for patients with symptomatic OA of the knee. Subsequent publications have also cautioned against the use of viscosupplementation based on lack of efficacy and the potential for harm. We present a case of late hemorrhagic pseudoseptic arthritis encountered during TKA due to hyaluronic acid viscosupplementation. Our triad of findings includes (1) acute and chronic inflammatory cells on frozen section, (2) synovitis with hemosiderin deposition, and (3) blackened cartilage with iron deposition on permanent histopathology. Our case is unique in that it shows a previously undescribed late complication of viscosupplementation.

Neuroendocrine Cancer of the Lung: A Diagnostic Puzzle

Here we report the case of a pulmonary neuroendocrine tumor (pNET) in which the pathological diagnosis was revised several times over the course of the patient's disease because of atypical behavior of the tumor; consequently, the patient was treated with various treatment schedules.

Restoration of Function With Acupuncture Following Severe Traumatic Brain Injury: A Case Report

This case report illustrates the improvement of an acupuncture-treated patient who incurred a severe traumatic brain injury (TBI) from a snowboarding accident. Over 4 years, the patient progressed from initially not being able to walk, having difficulty with speech, and suffering from poor eyesight to where he has now regained significant motor function, speech, and vision and has returned to snowboarding. A core acupuncture protocol plus specific points added to address the patient's ongoing concerns was used. This case adds to the medical literature by demonstrating the potential role of acupuncture in TBI treatment.

A case of Brooke-Spiegler syndrome with a novel mutation in the CYLD gene in a patient with aggressive non-Hodgkin's lymphoma

PURPOSE

Brooke-Spiegler syndrome (BSS, familial cylindromatosis) is a rare hereditary disease characterized by multiple tumors of the skin appendages predominantly located in the head and neck region, such as cylindromas, trichoepitheliomas, or spiradenomas. It is caused by an autosomal dominant mutation in the CYLD gene, mapped on chromosome 16q12-13. Association with secondary malignant neoplasms has been reported. Until now 51 different mutations in 73 families have been reported; 41 % of them constitute frameshift mutations, resulting in an interruption of the expression of the gene product CYLD. CYLD is a deubiquitinating enzyme and plays an important role in (NF)-κB pathway signaling, a central pathway for apoptosis regulation. Mutation-induced loss of function leads to constitutive activation of NF-κB.

METHODS

Here, we report the case of a 48-year-old female patient diagnosed with an abdominal aggressive non-Hodgkin's lymphoma. The patient presented with multiple cylindromas of the capillitium. The patient's mother also has a mild form of late-onset cylindromas. Due to the typical clinical features indicating BSS, genotyping from peripheral blood was performed. A c.2465insAACA mutation in exon 17 of the CYLD gene, leading to a frameshift, was detected in the patient and in the patient's mother.

RESULTS/CONCLUSIONS

This is the first description of this hereditary mutation in exon 17 of the CYLD gene. There have been several reports on patients with CYLD mutations and different types of malignancies. However, a coincidence with aggressive non-Hodgkin's lymphoma has not been reported yet.

Serum sample containing endogenous antibodies interfering with multiple hormone immunoassays. Laboratory strategies to detect interference

OBJECTIVES

Endogenous antibodies (EA) may interfere with immunoassays, causing erroneous results for hormone analyses. As (in most cases) this interference arises from the assay format and most immunoassays, even from different manufacturers, are constructed in a similar way, it is possible for a single type of EA to interfere with different immunoassays. Here we describe the case of a patient whose serum sample contains EA that interfere several hormones tests. We also discuss the strategies deployed to detect interference.

SUBJECTS AND METHODS

Over a period of four years, a 30-year-old man was subjected to a plethora of laboratory and imaging diagnostic procedures as a consequence of elevated hormone results, mainly of pituitary origin, which did not correlate with the overall clinical picture.

RESULTS

Once analytical interference was suspected, the best laboratory approaches to investigate it were sample reanalysis on an alternative platform and sample incubation with antibody blocking tubes. Construction of an in-house 'nonsense' sandwich assay was also a valuable strategy to confirm interference. In contrast, serial sample dilutions were of no value in our case, while polyethylene glycol (PEG) precipitation gave inconclusive results, probably due to the use of inappropriate PEG concentrations for several of the tests assayed.

CONCLUSIONS

Clinicians and laboratorians must be aware of the drawbacks of immunometric assays, and alert to the possibility of EA interference when results do not fit the clinical pattern.

Stage 5-CKD under nephrology care: to dialyze or not to dialyze, that is the question

Appropriate timing of starting chronic dialysis in patients with advanced chronic kidney disease (CKD) under nephrology care still is undefined. We systematically reviewed the most recent studies that have compared outcomes of stage 5-CKD under conservative versus substitutive treatment. Eleven studies, most in elderly patients, were identified. Results indicate no advantage of dialysis over conservative management in terms of survival, hospitalization or quality of life. This information is integrated with a case report on a middle-aged CKD patient followed in our clinic who has remained for 15 years in stage 5 despite severe disease. The patient is a diabetic woman who underwent right nephrectomy in 1994 because of renal tuberculosis. In 1999, she commenced regular nephrology care in our clinic and, since 2000, when she was 53 years old, her estimated glomerular filtration rate (eGFR) has been ≤15 ml/min/1.73 m(2). Over the last decade, despite, several episodes of acute kidney injury and placement of permanent percutaneous nephrostomy in 2001, renal function has remained remarkably stable, though severely impaired (eGFR 7.7-5.6 ml/min/1.73 m(2)). Our systematic analysis of the literature and this case report highlight the need for further studies, not limited exclusively to elderly patients, to verify the efficacy of non-dialysis treatment in stage 5-CKD patients. Meanwhile, nephrologists may consider that their intervention can safely prolong for several years the dialysis-free condition in ESRD independently of age.

Postoperative thrombocytosis: An unusual case report

Thrombocytosis is often an incidental finding seen in 35–50% of cases and the cause determination creates a diagnostic challenge. Extreme thrombocytosis is rare and seen in 2–5.8% patients only. Among the various causes of increased platelet count, surgical procedures have attracted much attention in both experimental and clinical domain. The appearance of thrombocytosis after surgery needs to be diagnosed to establish the type of thrombocytosis (clonal or reactive), as treatment and prognosis are quite different between them. This case report is vital because of two reasons: First, the increase in platelet count is difficult to rationalize than many of the other thrombocytoses, such as those related to primary augmentation of the function of the bone marrow; second, the association of platelets with the clotting process has led to the belief that their increase after a surgical procedure is connected with the occurrence of postoperative thrombosis. This case presents an interesting finding from a patient who has undergone major abdominal surgery and has shown an unexpected perpetual increase in platelet count.

Chemical Facial Cellulitis Due to Inadvertent Injection of Formalin into Oral Tissue Space

This paper reports the accidental injection of formalin into oral tissue space, in an 8-year old child resulting in chemical facial necrotizing cellulitis and its management. The common practice of keeping formalin in local anesthesia vials should be avoided by dental clinics, to prevent such unfortunate incidents.

Brain Metastasis in Wilms' Tumor: a Case Report

Wilms' tumor is the most common abdominal tumor of childhood, and its cerebral metastasis is apparently very rare. The authors report an 18-month-old girl with Wilms' tumor and brain metastasis.