[Does antibiotherapy prevent unnecessary prostate biopsies in patients with high PSA values?]

INTRODUCTION

We investigated if antibiotherapy has any role on total PSA (tPSA), free PSA (fPSA) and fPSA/tPSA ratio in patients with tPSA higher than 2.5ng/ml. We also analyzed if it has any relation with prostate cancer diagnosis rate.

MATERIAL AND METHODS

A total 108 patients older than 50 years of age with lower urinary system sypmtoms and tPSA >2.5ng/ml were included in this study. Antibiotherapy was given to all the cases for three weeks. After that, transrectal ultrasound-guided prostate biopsies were taken from all the patients. Before and after antibiotherapy, "The International Prostate Symptom Score" (IPSS) and "National Institutes of Health Chronic Prostatitis Symptom Index" (NIH-CPSI) questinories are performed and serum tPSA, fPSA and fPSA/tPSA values were obtained.

RESULTS

TPSA, fPSA and fPSA/tPSA ratio alterations prior to and after antibiotherapy did not show any statistically significant difference (p>0.05). When prostate adenocarcinoma was excluded, an statistically significant decrease was found in IPSS and NIH-CPSI scores for all cases.

CONCLUSIONS

Antibiotherapy given to patients with PSA levels higher than threshold value has not led to significant change in prostate needle biopsy decision. Prostate biopsy should be considered without trying antibiotherapy in patients with high PSA values if a suspicion of prostatitis does not exist.

Comparison of the risk factors for adverse perinatal outcomes in adolescent age pregnancies and advanced age pregnancies

OBJECTIVES

To evaluate clinical outcomes of pregnancies in adolescent, advanced and reproductive women maternal age.

MATERIALS AND METHODS

A total of 187 pregnant women were included into the study 51 (27.27%) were adolescent pregnancies, mean age 17.7 +/- 3.3 years (range, 14-18 years), 40 (21.29%) advanced maternal age pregnancies, mean age 41.4 +/- 2.6 years (range, 39-50 years) and 96 (51.33%), healthy controls, mean age 28.8 +/- 4.3 years (range, 19-37 years). The majority of the adolescent pregnant women were nulliparous, while all of the advanced age pregnant women were multiparous (mean gravidity 4.5 +/- 2.4; range, 6-12). Mean gravidity of the control group was 3.6 +/- 1.7 (range, 1-12).

RESULTS

There was statistically significant difference among the groups regarding demographic characteristics. According to the Bonferroni method, there was statistically significant difference among the three groups. Adverse fetal features were statistically different among the groups and the odd ratios were higher in the advanced maternal age group. The odds ratios (95% CI) for lower Apgar scores (Apgar score 1 and 5) and low birth weight in adolescent maternal age and advanced maternal age group were as follows: 1.88 (1.27-2.78) vs. 2.46 (1.55-3.85), 2.17 (1.18-4.00) vs. 4.79 (3.02-6.69) and 1.39 (1.14-1.68) vs. 3.06 (1.59-5.88), respectively Gestational age at birth showed minimal risk for adolescent age group but no risk was noted in the advanced age group.

CONCLUSIONS

The present study showed that pregnancies in adolescent maternal age, advanced maternal age and reproductive maternal age are different from each other in terms of clinical characteristics. According to this study advanced maternal age pregnancies are more risky and more likely to have adverse fetal outcome.

Comparative effect of lornoxicam and paracetamol in pain relief in endometrial sampling

We conducted a study to compare the analgesic effect of oral lornoxicam and oral paracetamol before endometrial sampling for benign conditions. This prospective, double-blind, randomized study was conducted on sixty women underwent endometrial sampling for benign indications, from November 2010 to April 2011. The patients were divided into two groups (lornoxicam and paracetamol group) and both administered drugs (8 mg oral lornoxicam or 500 mg oral paracetamol) one hour before the procedure. Pain scores, by VAS (Visual analog scale) pain score, were recorded 0, 30 and 60 minutes after the procedure and compared. All patients gave informed consent to the study. Statistical analyses were carried out by using the statistical packages for SPSS 15.0 for Windows (SPSS Inc., Chicago, IL, USA). There was no statistically significant difference between the groups about the demographic parameters (p > 0.05). Lornoxicam group showed lower VAS pain score than the paracetamol group (p < 0.05). A total of thirteen patients took additional analgesic in two groups (p < 0.05). According to the current study, oral lornoxicam is more effective in pain relief than oral paracetamol in patients underwent endometrial sampling.

Dorsal vein rupture after practice of taqaandan, necrotising cavernositis, penile reconstruction, urethroplasty and penile prosthesis implantation

Penile fracture is an uncommon and emergent urologic condition defined as traumatic rupture of the corpus cavernosum secondary to a blunt trauma of the erect penis. Tunica albuginea is thinned and stretched in the erect state, and a transverse tear in the corpus cavernosums may occur by a buckling force. However, penile dorsal vein tears may mimic penile fracture. Also, corporeal infection and purulent cavernositis are associated with trauma, cavernosography, priapism, intracavernosal injection therapy and penile prosthesis.

Dietary antioxidant levels in hyperemesis gravidarum: a case control study

OBJECTIVES

Dietary antioxidant intake decreases the risk of many diseases. Hyperemesis gravidarum (HG) is the most common eating disorder during pregnancy Therefore, the authors conducted this prospective and case control study to evaluate dietary antioxidant levels of women with HG and compare with healthy pregnant women.

MATERIAL AND METHODS

This prospective case control study was conducted at a government hospital in the southeastern region of Turkey from February 2010 to May 2010. A total of 100 pregnant women were included into the study Dietary antioxidant levels (DAL) were measured according to the new 92-item antioxidant nutrient questionnaire developed by Satia et al. 50 women with HG and 50 healthy pregnant women were evaluated. Statistical analyses were carried out with statistical packages for SPSS 15.0 for Windows (SPSS Inc., Chicago, IL, USA).

RESULTS

There were no statistically significant differences between the groups regarding the age of the patients, gestational age, educational status, body height and weight (p > .05). Vitamin E, E equivalent, vitamin C, carotene and vitamin A levels were significantly lower in women with HG (p < .05). The results of logistic regression method for these variables including odds ratio (95 % CI) were as follows: 10.07 (1.52-66.51), 7.37 (2.66-20.41), 4.26 (2.66-20.41), 3.66 (2.38-5.63) and 2.75 (1.56-4.85), respectively

CONCLUSION

According to this study, vitamin E, E equivalent, vitamin C, carotene and vitamin A levels of women may play a role in the pathogenesis of HG. Therefore, diet recommendations should be given by clinicians before pregnancy

Urodynamic evaluation after abdominal hysterectomies for gynecological malignancies

The aim of this study was to evaluate the effect of abdominal hysterectomy made for gynecological malign diseases on lower urinary tract functions in asymptomatic patients by preoperative and postoperative urodynamic measurements. Thirty four asymptomatic women, who were operated for gynecological malignancies by abdominal hysterectomy from September 2008 to June 2009, in Dicle University Hospital Department of Obstetrics and Gynecology, were included in this study. Urodynamic measurements were performed before the operation and in the sixth week of surgery. No statistically significant changes were detected in first urge, normal urge, and strong urge, bladder capacity before and after surgery. The evaluation of functional urethral length showed a significant difference by UPP between pre and postoperative values (p = 0.003). The decreases in values of the maximum urethral pressure and the maximum urethral closing pressure were significant (p = 0.004 and p = 0.048). The voiding time was found to be statistically increased (p = 0.002), voided volume and residual urine volume were remained unchanged. There were no significant differences in other measurements. Preoperative and postoperative urodynamic studies are necessary to determine and cure urinary dysfunctions caused by abdominal hysterectomy.

Risk factors for persistent gestational trophoblastic neoplasia

This retrospective study evaluated the risk factors for persistent gestational trophoblastic disease (GTN) and determined their odds ratios. This study included 100 cases with GTN admitted to our clinic. Possible risk factors recorded were age, gravidity, parity, size of the neoplasia, and beta-human chorionic gonadotropin levels (beta-hCG) before and after the procedure. Statistical analyses consisted of the independent sample t-test and logistic regression using the statistical package SPSS ver. 15.0 for Windows (SPSS, Chicago, IL, USA). Twenty of the cases had persistent GTN, and the differences between these and the others cases were evaluated. The size of the neoplasia and histopathological type of GTN had no statistical relationship with persistence, whereas age, gravidity, and beta-hCG levels were significant risk factors for persistent GTN (p < 0.05). The odds ratios (95% confidence interval (CI)) for age, gravidity, and pre- and post-evacuation beta-hCG levels determined using logistic regression were 4.678 (0.97-22.44), 7.315 (1.16-46.16), 2.637 (1.41-4.94), and 2.339 (1.52-3.60), respectively. Patient age, gravidity, and beta-hCG levels were risk factors for persistent GTN, whereas the size of the neoplasia and histopathological type of GTN were not significant risk factors.

Clinical experience of adnexal torsion: evaluation of 143 cases

We conducted this retrospective study to evaluate the outcomes, indications and post-operative findings of adnexal torsion cases and compared the features of benign cystic teratoma with the other cases. We analyzed a series of 143 cases of adnexal torsion from 2000 to 2009 at current clinic, retrospectively. The data were collected from the patient's specific files and hospital records descriptively. The demographic characteristics, sonographic findings and post-operative invention were evaluated. Statistical analyses were carried out by using the statistical packages for SPSS 15.0 for Windows (SPSS Inc., Chicago, IL, USA). A total of 143 cases were operated for adnexal torsion during the study period at our clinic. The clinical and demographic characteristics of the cases are shown in table 1. Of all patients, forty of them were diagnosed as benign cystic teratoma and this group of the adnexal torsion cases had statistically different gravidy, mass size and torsion number from the non-benign cystic teratoma group. Age was not a statistically different between two groups. According to this study, benign cystic teratoma increases risk of adnexal torsion. When detecting benign cystic teratoma the patients should be informed about the risk of torsion and explained the signs of this situation. The early diagnosis and appropriate surgical management of adnexal torsion is the only way to prevent complications and to preserve future fertility. Being aware of the different sonographic findings of torsionated adnexa may assist in the correct diagnosis of these patients.

Adnexal masses in postmenopausal and reproductive age women

We aimed to evaluate and compare the management and clinical characteristics of adnexal masses in postmenopausal and reproductive age women. This prospective study was performed at Dicle University, School of Medicine, Department of Obstetrics and Gynecology, from January 2007 to June 2009.The data were collected from hospital records and patients files, descriptively. The cases were divided into two groups as cases with adnexal masses in postmenopausal age women (Group 1, n = 40), and reproductive age (Group 2, n = 40). All of the cases operated for benign adnexal masses. Statistical analyses were carried out by using the statistical packages for SPSS 15.0 for Windows (SPSS Inc., Chicago, IL, USA). The demographic characteristics of the cases that were enrolled in our study are depicted in Table 1.The initial compliant of the cases were abdominal pain in 62 (77.5%) of the cases and 8 (20%) vaginal bleeding and 10 (12.5%) were asymptomatic. The initial diagnose of the cases were; pelvic mass in 34 (75%) of the cases, ovarian cyst 26 (32.5%), dermoid cyst 10 (12.5%), endometrioma 7 (8.75%) and postmenopausal bleeding 4 (5%). The tumor markers were evaluated. All of the cases were subjected to laparotomy or laparoscopy. The frozen section diagnose were made by the pathology department. The postoperative characteristics of the masses were also evaluated. The adnexal masses in postmenopausal woman with benign characteristics can be followed conservatively, without surgery. Surgery may be indicated to women with family history of cancer, a mass that appears enlarging and symptomatic.

The Effect of Flurbiprofen as Prophylactic Analgesic before Hysterosalpingography

Hysterosalpingography (HSG) is associated with pain during the four-step procedure. This prospective, double-blind, randomized, placebo-controlled study was conducted to investigate the effect of the analgesic flurbiprofen, administered prior to HSG, in 60 women. Thirty women were randomized to receive 100 mg of flurbiprofen, orally, 1 h prior to HSG and a further 30 women were randomized to receive placebo. Injection of contrast medium was more painful than the other steps in the HSG procedure in both groups; however, there was no significant between-group difference in terms of pain experienced in the individual steps of HSG. Pain scores at 5 and 30 min after the procedure were compared between the two groups. There was a significant decrease in the visual analogue scale pain score in the flurbiprofen-treated group compared with the placebo-treated group at both time points. Thus, the authors recommend flurbiprofen as a prophylactic analgesic to be administered before HSG procedures.

Umbilical cord prolapse in the southeast region of Turkey: evaluation of 79 cases

OBJECTIVE

The aim of the study was to determine the risk factors and perinatal outcomes of umbilical cord prolapse (UCP).

MATERIAL AND METHODS

This study was performed at Dicle University between January 2000 and December 2008 on 79 cases in which deliveries were complicated by umbilical cord prolapse.

RESULTS

0.36% of all deliveries were complicated by umbilical cord prolapse. The presentation of the fetuses were as follows: vertex, breech and transverse lie and foot presentation. Thirty-four (43%) fetuses with UCP had a fetal weight of < or = 2500 g as compared with nine (9%) for fetuses in the control group (p < 0.05). Mothers in the study group were 1.3 times more likely to be multiparas than the control group (p = 0.16) Cesarean section was performed in 76 cases (96.2%) and there were nine (11.3%) perinatal deaths.

CONCLUSION

Umbilical cord prolapse is a risk factor of perinatal morbidity and mortality. Fetal weight < or = 2500 and abnormal fetal presentation are associated with increased risk of umbilical cord prolapse. Cesarean section resulted in a significantly decreased risk of perinatal mortality.

Clinical significance of procalcitonin in cervico-vaginal secretions of women with preterm rupture of membranes

PURPOSE

To compare vaginal fluid procalcitonin (PCT) concentrations in cases of preterm premature rupture of membranes (PPROM) and healthy pregnant women, and to determine whether the PCT concentrations are of value in the diagnosis of PPROM cases and clinical amnionitis.

METHODS

50 cases with PPROM and 50 healthy pregnant women were enrolled in the study. In the PPROM group, analysis was conducted on PCT concentrations with reference to serum leucocytosis, serum C-reactive protein level and urine analysis, as well as to presence/absence of clinical amnionitis. Statistical analyses were carried out by using the statistical packages for SPSS 12.0 for Windows (SPSS Inc., Chicago, IL, USA).

RESULTS

Procalcitonin levels in the PPROM group were significantly higher than in cases of healthy pregnant women (1.17 vs 0.05 ng/ml; p < 0.001). In the PPROM group PCT concentrations between the patients with and without clinical amnionitis were comparable. Also, a significant correlation was observed between PCT and leucocytosis (r = 0.64; p < 0.001) and C-reactive protein (r = 0.90; p < 0.001).

CONCLUSION

These findings suggest that the value of vaginal fluid PCT determinations can be useful for diagnostics of PPROM cases suspected of intrauterine infection.

The association of preoperative thrombocytosis with prognostic factors in malign ovarian tumor

PURPOSE

We assessed the association of preoperative thrombocytosis with prognostic factors in malign ovarian tumor.

METHODS

Over a five-year period, cases treated for ovarian cancer were randomly assigned. The data were collected from gynecological oncology, radiation oncology, medical oncology and pathology departments. Statistical analyses were carried out by using the statistical packages for SPSS 12.0 for Windows (Chicago, IL, USA). Survival was analyzed by the method of Kaplan and Meier, using log-rank (Mantel-Cox) analysis.

RESULTS

51 cases with ovarian cancer were evaluated. Cases with thrombocytosis were found to have greater CA-125 levels, more advanced stage disease, more ascites and shorter periods of survival.

CONCLUSION

Thrombocytosis is a poor prognostic factor in ovarian cancer. As reported previously, it is associated with aggressive tumor biology. Thus, preoperative thrombocytosis can be a used as a marker of poor outcomes.

The clinical significance of HPV screening in premalignant cervical lesions

PURPOSE

We evaluated the clinical significance of human papilloma virus (HPV) screening in premalignant cervical lesions.

METHODS

This prospective study was performed at Dicle University, School of Medicine, Department of Obstetrics and Gynecology, from January 2009 to June 2009. A total of 60 cases were evaluated. Thirty cases had premalignant cervical lesions. The prevalence of HPV was analyzed by polymerase chain reaction and types determined by Hybrid Capture II. The cases that had premalignant cervical lesions were evaluated with colposcopy. Statistical analyses were carried out by using the statistical packages for SPSS version 12.0 for Windows (Chicago, IL, USA).

RESULTS

Of all the cases, those with premalignant cervical lesions had higher prevalence of HPV DNA. The cases that had high oncogenic HPV type had more abnormal colposcopic findings.

CONCLUSION

Premalignant cervical lesions should be evaluated by cervical cytology, colposcopy, HPV DNA screening and cervical tissue sampling. In this way, development of cervical cancer can be prevented.

Risk factors for postmenopausal osteoporosis: anthropometric measurements, age, age at menopause and the time elapsed after menopause onset

OBJECTIVES

The aim of this study was to determine, how much the anthropometric measurements and age affect the femur and vertebra T-scores by using correlation and regression analysis in postmenopausal women.

METHODS

Data of 540 healthy postmenopausal women were included in this analysis. Bone mineral density was determined by dual energy X-ray absorptiometry (DXA). The data of the patients related to height, weight, age, age at menopause were obtained from records, and body mass index (BMI) was calculated (BMI = W (kg)/H(m(2))). Statistical analyses were performed with SPSS 15.0 for Windows (SPSS, Chicago, IL).

RESULTS

Mean age and standard deviation of 540 postmenopausal women was 59.3 +/- 8.4 years. The correlation coefficients among femur, vertebra T-scores, weight, the time elapsed after the menopause onset, age, BMI and height were found as follows, from higher to lower values with 0.465, 0.453, 0.411, 0.382, 0.232, respectively, and were statistically significant (p < 0.001).

CONCLUSIONS

We determined the effects of the anthropometric measurements on osteoporosis from higher to lower influence as follows: weight, menopause age, age, BMI and height. Weight and menopause age of the patients were the major determinants for osteoporosis.

Which procedure should be chosen as a salvage operation in anterior hypospadias cases, meatal-based or onlay island flap? A comparative analysis

We compared the outcome of flip-flap procedure (Mathieu procedure) with onlay island urethroplasty after previously failed repairs in anterior hypospadias cases. Charts of patients who underwent salvage flip-flap ( n=58) and onlay procedure ( n=24) were reviewed. Age range was 3-19 years (mean: 9+/-4.1) and 2-30 years (10.3+/-5.2) in the onlay and Mathieu groups, respectively ( p>0.05). In the onlay group, the flap was prepared from penile skin and preputial tissue in 5 and 19 cases, respectively. The meatal-based flap was laterally directed in 7 cases in the Mathieu group. The mean number of prior operations was greater in the onlay group when compared with the Mathieu group (1.85+/-1.53 vs. 1.41+/-0.65, respectively) although the difference was not statistically significant (Student's- t test, p>0.05). A total of 14 out of 58 (24.1%) and 6 out of 24 (25%) cases resulted in fistula formation in the Mathieu and island flap groups, respectively. Comparison of the rates of fistula formation did not reach statistical significance (Pearson chi(2), p=0.934). Skin dehiscence in one case and burying of the penis in another patient due to inadequacy of skin for coverage, occurred as complications in the onlay group. Splitting of the glans in 1, dehiscence of skin in 1 patient and complete breakdown of the neourethra in 1 case were the complications encountered in the Mathieu group. Both Mathieu and onlay island procedures have similar success rates as a salvage operation in anterior hypospadias cases if proper patient selection is done. The onlay procedure has been more commonly performed after a failed Mathieu procedure and the reverse rarely occurs.

An unusual case of postmenopausal vaginal bleeding: retention of fetal bone

Retention of intrauterine fetal bones is a rare finding in patient suffering from abnormal uterine bleeding or secondary infertility. Detailed patient history, pelvic ultrasonography and hysteroscopy are diagnostic tools. Here, we describe a case of postmenopausal persistent uterine bleeding and pelvic pain caused by prolonged retention of fetal bones after a midtrimester abortion 17 years ago.

Ten-year results of Marshall Marchetti Krantz and anterior colporraphy procedures

OBJECTIVE

To evaluate subjective results of Marshall Marchetti Krantz (MMK) and anterior colporraphy (AC) procedures.

STUDY DESIGN

Patients who had operations for genuine stress incontinence 10 years ago were surveyed regarding their current incontinence status. Results of both procedures were evaluated and compared.

RESULTS

Fourteen of 28 patients in the MMK group and 21 of 67 patients in the AC group were evaluated at 10 years, the cure rates were found to be 64% and 38%, respectively.

CONCLUSION

We conclude that the success rate of both procedures declines over time. The anterior colporraphy procedure appears to have a lower success rate than MMK, although this was not found to be statistically significant.

Effects of unilateral testicular torsion on the blood flow of contralateral testis--an experimental study on dogs

The effects of unilateral testicular torsion on the blood flow of the contralateral testis were investigated. Fourteen adult male dogs were recruited. Seven dogs underwent unilateral testicular torsion of 4 h duration, and the other seven dogs had a control operation. Testicular blood flow was determined by colour Doppler ultrasonography before and after the testicular torsion. Bilateral orchidectomy was performed at the end of the study and histopathological changes were evaluated. Values of peak systolic velocity, end diastolic velocity, and resistive index were not statistically significant between ipsilateral and contralateral testes in the study group (p > 0.05). On comparison with the control group, blood flow in the contralateral testes showed no statistically significant difference (p > 0.05). Oedema and congestion were seen on ipsilateral testes in the study group. No histopathological changes were noted on the contralateral testes. Minimal oedema and congestion secondary to manipulation were found in the control operation testes. We conclude that unilateral testicular torsion does not decrease contralateral testicular blood flow as shown by colour Doppler ultrasonography.

Evaluation of urethrovesical junction mobility by perineal ultrasonography in stress urinary incontinence

Perineal ultrasonographic measurements of the cephalocaudal and the ventrodorsal components of urethro-vesical junction (UVJ) movement at rest and stress was performed in 35 patients of stress urinary incontinence (SUI) and 20 continent controls. The cephalocaudal distance of UVJ from the pubis at rest position was almost similar in both continent and incontinent groups, but there was significant difference during stress. The cephalocaudal mobility and the ventrodorsal distance from the pubis was markedly different between the two groups, both at rest and during stress. However, the ventrodorsal mobility was similar in both groups. It is concluded that the UVJ mobility of SUI cases was higher on the cephalocaudal axis than the vetrodorsal axis. The distance between UVJ and the pubis was more on the ventrodorsal axis as compared to the control group and UVJ passed down the pubic symphysis in 63% of SUI cases during stress.

Longitudinal vaginal septum: an unusual cause of postpartum total uterine prolapse

Longitudinal vaginal septum, a rare congenital fusion defect of mullarian ducts rarely causes dystosia of labour and total uterine prolapse. Several surgical techniques were developed for repair of prolapse but no consensus has been reached on one type of operation.

Preliminary results of transurethral microwave thermotherapy in the treatment of benign prostatic hyperplasia in Turkey

This prospective study was conducted in order to evaluate the efficacy of transurethral microwave thermotherapy (TUMT) in the treatment of benign prostatic hyperplasia (BPH). A single TUMT session of 55 min was delivered as an ambulatory procedure without anesthesia to 180 patients. 20 (69%) of the 29 patients who were catheterized due to urinary retention prior to the treatment were able to urinate freely after the treatment. In 91 patients with a follow-up of 3 months, the mean maximum flow rate (MFR) was 7.9 ml/s prior to the treatment and 12.1 ml/s after the treatment (p less than 0.02). The mean residual urine after voiding (PVR) of these patients was 104 and 54 ml before and after TUMT, respectively (p = 0.0001). The mean Madsen symptom score (SS) was 14 before and 7.5 after the treatment (p = 0.0001). The patients with pretreatment MFR higher than 7.0 ml/s, PVR less than 150 ml and SS lower than 15 benefited better from TUMT. As the findings indicated, TUMT is an alternative treatment modality in BPH in selected cases, although the number and the follow-up of our series are insufficient to draw a precise conclusion yet.

Traumatic rupture of the corpus cavernosum

Penile fracture is a rare entity. Twelve patients with penile fractures were treated surgically with a very low complication rate. Our results were compared with those reported in the literature.

Bilateral perineal ectopic testes

Perineal testicular ectopia is seen very rarely, bilaterality is even more scarce and three cases have been reported in the literature. Here we present the fourth case with bilateral perineal ectopic testes.

Traumatic rupture of corpus cavernosum

Penile fracture is a rare entity. Twelve patients with penile fractures were treated surgically with a very complication rate. Our results were compared with those reported in the literature.

Solitary benign schwannoma in the psoas muscle

Solitary benign schwannoma in the psoas muscle is extremely rare. Here we present a case report of a woman who had solitary benign schwannoma in the psoas muscle not associated with von Recklinghausen's disease. This is the fifth case reported in the literature.