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[
{
"age": 0,
"case_id": "PMC11079415_01",
"case_text": "An 8-month-old child presented with progressively increasing head size since birth, global developmental delay in achieving age-appropriate milestones (the child's milestones were equivalent to 3 months as per accepted developmental milestones), and cranial bruits. The occipito-frontal circumference was 54 cm (standard for age is 43 cm-45 cm).\nMagnetic resonance imaging of the brain revealed a well-circumscribed markedly T2 hypo-intense midline lesion dorsal to the third ventricle, causing mass effect on the aqueduct with resultant dilatation of the lateral and third ventricles and a normal-sized fourth ventricle suggestive of obstructive hydrocephalus. Cerebral digital subtraction angiography confirmed a mural type of VGAM (Lasjaunias classification) with feeders from both posterior cerebral arteries and the left anterior cerebral artery (Figure 1).\nThe child proceeded to endovascular management. Right femoral arterial access was acquired with a 5 French(Fr) short sheath, and a 5 Fr guiding catheter was placed through the short sheath and negotiated into the right vertebral artery (V4 Segment). Following this, super selective cannulation of the posteromedial choroidal branches of the right posterior cerebral artery (PCA) was accomplished, and 2 mL of onyx 18 was injected on the arterial side with reflux into the large venous sac, resulting in its occlusion. Complete avascularity of the sac was achieved after occluding the VOG sac. Post embolisation MRI on day three revealed a minimal reduction in the size of the VOG sac, with minimal enhancement of the sac wall and no internal restricted diffusion, as shown in Figure 2.\nThe child was followed up at regular intervals for 2 years. There was a gradual improvement in achieving developmental milestones. Follow-up MRI after 1 month revealed a residual aneurysmal sac showing wall enhancement, restricted diffusion, and persistent hydrocephalus, as depicted in Figure 3.\nA differential diagnosis of brain abscess was considered; however, in view of the gradual improvement in cognitive function, lack of clinical deterioration, and lack of oedema in the surrounding brain parenchyma on MRI, a diagnosis of chemical abscess was made. The child was managed conservatively and followed up. There was further clinical improvement at 6 months post embolisation {developmental milestones equivalent to 10 months of age as per the Centres for Disease Control and Prevention (CDC) criteria}. On MRI there was a reduction in the size of the residual sac and hydrocephalus, albeit with continued restricted diffusion and peripheral mural enhancement, as shown in Figure 4.\nAfter 2 years, the child had achieved milestones commensurate with age. The head circumference was stabilised on examination, and no neurological deficits were present. At this stage, MRI revealed near-total regression of the sac with no residual wall enhancement.",
"gender": "Unknown"
}
] |
PMC11079415
|
[
{
"age": 16,
"case_id": "PMC11380606_01",
"case_text": "A 16-year-old male patient, with no notable personal medical history, was consulted for edema in the lower limbs. The familial medical history reveals a 25-year-old maternal uncle undergoing treatment for renal insufficiency at the hemodialysis stage. The onset of symptoms traces back to the age of 13 when the child experienced episodes of intermittent painful edema in the lower limbs. This prompted the patient to consult several doctors and undergo various assessments; inflammatory, renal, hepatic, and cardiac functions were all found to be normal. The clinical examination revealed unilateral edema in the left lower limb extending to the ankles. Additionally, multiple millimeter-sized erythematous maculo papular lesions were observed on his trunk, back, and umbilicus, corresponding to diffuse angiokeratomas, while the rest of the clinical examination was unremarkable. Fabry disease, a lysosomal disorder, was suspected due to the history of renal disease in a young relative and the presence of lymphedema and angiokeratoma. Confirmation of Fabry disease was achieved through enzymatic assay, indicating a high value of Lyso-GL-3 level (90.5 ng/ml, with a cut-off value of 0.0-3.5), and further supported by a molecular study revealing the presence of a hemizygous mutation c.602C>T (p. (Ser201Phe)). Cardiac ultrasound and ophthalmic assessment yielded normal results, and renal function showed no abnormalities with negative proteinuria. The patient was proposed for enzyme replacement therapy.",
"gender": "Male"
}
] |
PMC11380606
|
[
{
"age": 66,
"case_id": "PMC10948169_01",
"case_text": "A 66-year-old Asian man presented to Asahi General Hospital with symptoms of pruritus and anorexia. The patient had no significant medical history. He did not smoke tobacco but habitually consumed alcohol. Laboratory examinations showed elevated levels of serum total bilirubin (7.2 mg/dL), aspartate aminotransferase (353 IU/L), and alanine aminotransferase (625 IU/L) because of obstructive jaundice. The serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were 2.1 ng/mL and 2,880 U/mL, respectively, while those of squamous cell carcinoma antigen were not examined. Contrast-enhanced computed tomography revealed a tumor measuring 1.6 cm in diameter located at the AmV and distal bile duct (Fig. 1a). Dilatation of the intrahepatic and common bile ducts was also visualized (Fig. 1b). Endoscopic retrograde cholangiopancreatography revealed a tumor in the AmV (Fig. 1c). Histopathological examination of the biopsy specimen revealed an adenocarcinoma. Therefore, the patient underwent subtotal stomach-preserving pancreaticoduodenectomy (PD) with radical lymphadenectomy. No intraoperative complication occurred. The operative time was 498 min, and the estimated blood loss was 314 mL. The tumor was white in color, measured 25 x 22 x 22 mm, and infiltrated through the duodenal mucosa to the muscularis propria, pancreas, and common bile duct (Fig. 2a, b). Macroscopic vascular invasions of the tumor were found. Histopathological examination of the resected specimen revealed a combination of moderately differentiated tubular adenocarcinoma and squamous carcinoma with pavement-like arrangements (Fig. 3a-d). Infrequent invasion of lymphatic vessels was also observed. Two of the 29 dissected lymph nodes showed metastases and only had the adenocarcinoma component. Therefore, the patient was diagnosed with advanced ASC of the AmV, pT3bpN1pM0 pStage IIIA, according to the eighth classification of the Union for International Cancer Control Staging. The patient developed no postoperative complication and was discharged on postoperative day 25. We administered S-1 (TS-1; Taiho Pharmaceutical, Tokyo, Japan), containing tegafur (a prodrug of fluorouracil), gimeracil, and oteracil potassium at a 1:0.4:1 M ratio as adjuvant chemotherapy for 6 months according to the Japan Pancreas Society clinical practice guidelines for pancreatic cancer published in 2019. The patient did not exhibit any recurrence during the outpatient postoperative follow-up of 28 months.\nWritten informed consent was obtained from the patient for publication of this case report and its accompanying images. The copies of the written consent forms are available for review on request.",
"gender": "Male"
}
] |
PMC10948169
|
[
{
"age": 11,
"case_id": "PMC10715393_01",
"case_text": "We studied an 11-year-old girl suffering from RFE, with an epilepsy onset at the age of 7 years [Patient 5 in ]. She underwent a right anterior temporal lobectomy leading to seizure-freedom (Engel class 1A) but IEDs remain very frequent with a maximal amplitude over C4-T4 electrodes (Figure 1). She underwent cryogenic MEG 7 months prior to OPM-MEG recording, which showed right centrotemporal IEDs (Figure 1).\nThis study was approved by the institutional Ethics Committee (Reference: P2019/426). The patient and her legal representative gave written informed consent prior to the inclusion.",
"gender": "Female"
}
] |
PMC10715393
|
[
{
"age": 53,
"case_id": "PMC11024819_01",
"case_text": "A 53-year-old man presented to his optometrist concerned about a 1-week history of asymmetry in his pupil sizes. His optometrist confirmed the presence of anisocoria (right pupil 2 mm and left eye 3 mm) and with an otherwise normal examination referred him into the hospital eye care setting urgently for a second opinion.\n8 days later, he was reviewed by an ophthalmologist. The patient denied any symptoms, including headaches, diplopia and trauma. His past medical and ocular histories were unremarkable and he did not take any regular medication. He denied allergies and alcohol consumption. The patient commented that he had been aware of reduced/absent sweating on the right side of his face.\nOn examination his vision was noted to be right eye 6/5 and left eye 6/6. No anisocoria was noted, there was no ptosis, eye movements were full and ocular health assessment was unremarkable.\nPre- and post-exercise facial photographs were taken (Fig. 1). The anhidrosis and reduced erythema on the right side of his face was visible.\nInterestingly the patient was worked up as a Horner's case but all of the investigations (including a MRI of his head and neck and CT of his head/neck/thorax) were unremarkable and so he was diagnosed with idiopathic segmental anhidrosis with physiological anisocoria.",
"gender": "Male"
}
] |
PMC11024819
|
[
{
"age": 32,
"case_id": "PMC11345915_01",
"case_text": "The patient is a 32-year-old, HIV-negative man who presented to the emergency department with a chief complaint of swelling gradually increasing in size in the left submandibular region over the past two months.\nHis past medical history revealed a diagnosis of abdominal BL 20 years ago, for which he was diagnosed and treated in the oncology department of another University Hospital. At that time, he presented with symptoms such as weight loss, dyspnea, pleural and peritoneal effusion, and abdominal adenopathy. The diagnosis was confirmed through cytological examination of pleural fluid, revealing medium to large-sized round cells with scanty cytoplasm and one or several nucleoli. Neither bone marrow (BM) nor central nervous system (CNS) involvement was detected. The patient had not undergone cytogenetic or molecular studies at that time. Initially classified as Murphy stage III, he underwent chemotherapy following the Lymphoma Malignancy B (LMB) 89 protocol, group B. A computed tomography (CT) scan confirmed complete remission at the end of the treatment. He was followed up at the outpatient department with bi-annual consultations for 10 years. The patient later started working and was lost to follow-up for 10 years. He got married and he had three children.\nThe patient remained asymptomatic 20 years post-therapy until he presented with complaints of cervical swelling and fever. He denied weight loss, anorexia, and digestive symptoms.\nPhysical examination showed normal vital signs and revealed a mass extending from beneath the left mandible to the homolateral clavicle. The patient was referred to the ENT department for nasal endoscopy, which showed no evidence of cavum involvement.\nA series of radiological and hematological investigations were then conducted. Cervical computed tomography (CT) revealed a sub-angulo-mandibular adenopathy mass measuring 84 x 58 mm. The cervical mass displaced the left sternocleidomastoid muscle outward, resulting in the left jugular vein thrombosis.\nBased on these findings, the patient underwent a lymph node biopsy with an immunohistochemical study. Microscopic examination revealed a diffuse effacement of lymph node structure due to lymphomatous proliferation. The lymphoid cells appeared medium-sized with reduced cytoplasm and hyperchromatic nuclei, accompanied by abundant mitotic figures. The background showed numerous tingible-body macrophages. Immunohistochemical analysis demonstrated positivity for CD20, CD19, Bcl6, C-Myc, and MUM1, with increased Ki67 expression. These findings confirmed the diagnosis of a relapse of the prior BL (Fig. 1).\nThe search for factors contributing to relapse included screening for recent Epstein-Barr Virus (EBV) infection, which yielded negative results. The anti-VCA profile (IgG > 400 UI/ml, IgM = 3 UI/ml) and anti-EBNA profile (IgG > 800 UI/ml) were consistent with acquired immunity, indicative of a past infection.\nThe myelogram revealed a BM infiltration of 59 % by BL cells, with basophilic, vacuolated cytoplasm evident on a Wright-Giesma-stained aspirate smear. The cytogenetic study revealed the presence of the t(8;14) translocation in most mitoses, along with additional structural abnormalities on chromosomes 1 and 7.\nThe cervical-thoracic-abdominal-pelvic (C-TAP) CT revealed a left cervical lymph node mass measuring 10.46 x 7.35 cm, along with heterogeneous enhancement adenopathy in the right sector II measuring 2.83 x 1.98 cm. No additional nodal or extranodal lesions were detected. The cerebrospinal fluid examination was normal.\nBased on these findings, the patient received treatment according to the protocol for adult BL, LMB 02 group C1.\nHe received six cycles of chemotherapy (COP + COPADM no. 1 + COPADM no. 2 + CYVE no. 1 + CYVE no. 2 + first cycle of maintenance treatment (m1)). We considered adding Rituximab to the regimen, but it was not available.\nA mid-treatment response evaluation was conducted, revealing a partial clinical reduction in the mass from the sixth day of chemotherapy and its complete disappearance after the sixth cycle of chemotherapy.\nThe CT scan after COP demonstrated a 39 % response rate. Following CYVE no. 1, an 86 % response rate was observed, and after m1, an 89 % response rate was achieved, indicating a complete response (Fig. 2).\nA subsequent myelogram conducted after COPADM no. 1 showed no medullary involvement.\nUnfortunately, a second early lymph node relapse was observed one month after m1. Salvage treatment was initiated, and he received three cycles of chemotherapy (COP + COPADM no. 1 + COPADM no. 2). However, he passed away about three months after the second relapse of his BL.",
"gender": "Male"
}
] |
PMC11345915
|
[
{
"age": null,
"case_id": "PMC11377274_01",
"case_text": "Twenty feline patients with diagnosed MRONJ secondary to bisphosphonate therapy were included in this sample from 2015 and 2021. Inclusion criteria for cats were if they had been on antiresorptive (bisphosphonate) medications, and their clinical signs and diagnosis for MRONJ were consistent with the AAOMS 2022 Position Paper definition of MRONJ. This included visible exposed bone, or bone that could be probed through a chronic fistula of more than 8 weeks. Exclusion criteria included any patient that had known neoplasia with metastasis to the jaw, primary oral neoplasia or a history of head and neck radiation.",
"gender": "Unknown"
}
] |
PMC11377274
|
[
{
"age": 67,
"case_id": "PMC11319061_01",
"case_text": "A 67-year-old female presented for routine dialysis; however, the hemodialysis access became obstructed throughout the procedure. The patient complained of increasingly severe shortness of breath. Based on examinations, the patient was diagnosed with CKD stage V, suspected pulmonary oedema, hyperkalemia, metabolic acidosis, and type 2 diabetes mellitus. The patient's current condition is an indication of emergency dialysis. Installing access to the right and left femoral vein failed due to a suspected thrombus. The left and right internal jugular veins also cannot be used due to previous tunnelling of the double-lumen catheter. The patient was diagnosed with multiple hemodialysis access failure, meaning hemodialysis could not be carried out because the patient did not have any access. The patient has had a history of CKD stage V for the last four years and has undergone routine hemodialysis. The patient also has a history of type 2 diabetes mellitus for more than 20 years. The patient denied any history of other diseases.\nAt a team meeting, it was decided that the patient would undergo acute PD as a possible renal replacement therapy. The first acute PD was performed immediately, 1 hour after the Tenckhoff catheter was inserted (Figure 1). Trained PD nurses initiated acute PD in the supine position. The first and second PD processes are described according to Tables 1 and. The patient immediately provides an adequate response after the PD process. Complaints of tachypnea and shortness of breath decreased. Evaluation of laboratory examinations after serial PD also obtained improved results, according to Table 3. The frequency of dwelling and the amount of dialysis increased gradually during the hospital stay. Starting with 1 liter every 2 hours using 1.5% and 2.5% dialysate fluid alternately on the first day up to 1.5 liters every 6 hours using three times 1.5% dialysate fluid and at night with dialysate fluid 2.5%. The fluid balance in and out of the dwelling process slowly produces the expected results (Table 4).\nAfter eight days of treatment, the patient was allowed to be discharged from the hospital. The patient is in stable condition without complaints. Two months after outpatient, the patient had no symptoms and received an adequate response. The patient continued Continuous Ambulatory Peritoneal Dialysis and responded well.",
"gender": "Female"
}
] |
PMC11319061
|
[
{
"age": 60,
"case_id": "PMC10663166_01",
"case_text": "A 60-year-old male patient complained of a painless mass under the nipple for more than four months. No pain, itching or nipple discharge were noted. The patient had no history of cancer and no specific family history but felt that the tumor was growing. Further immunohistochemistry investigations were recommended because a diagnosis of an invasive breast carcinoma does not exclude breast polymorphic invasive lobular carcinoma or cancer with syngenetic differentiation. The results of these investigations showed that ER, PR, HER2, E-cadherin, P120, CK5/6, and P40 were all negative, although a high expression of Ki-67 was noted. The results obtained from the local hospital that initially treated the patient showed that these immunohistochemistry results were not specific to the liquid obtained from the biopsy, with histological analysis revealing an aggressive cancer morphology. Following intradepartmental consultation, the patient was diagnosed with a highly aggressive breast cancer consistent with a triple-negative breast lesion. The patient decided to receive a new adjuvant treatment, although his relatives complained and asked for further treatment options as there were no other obvious symptoms due to the patient's preexisting health conditions. This led to the patient seeking treatment at our hospital. An ultrasound examination carried out on admission showed that the larger gland was located below the nipple and measured 4.4 cm x 4.4 cm x 1.4 cm. Striped blood flow signals were observed in the region, with low echoes seen in the shallow fat layer measuring 1.1 cm x 0.5 cm. The results of real-time shear wave elastography are shown in Figure 1. The integrated ultrasound diagnosis based on the mammography reports and data systems (BI-RADS) was a type 4C right breast parenchymal occupying lesion. \nOnly a small number of tumor tissue biopsy samples were obtained for histology. Light microscopy showed a greater number of tumor cells and reduced stroma. The tumor cells were linear or trabecular, with some areas being monoline. The local lesions harbored a mixture of cells, with the tumor cells being large and containing fine chromatin and multiple mitotic images. The tumor cells exhibited deep staining and were disproportionate in size. As shown in Figures 2A-D, necrosis and bleeding were not observed. The results of the immunohistochemistry investigations were as follows: AE1/AE3 (-), EMA (+), S-100 (-), CD68 (-), CD3 (weak+), CD20 (-), Pax5 (-), CD30 (+), Bcl-2 (-), CD2l (-), CD23 (-), Bcl-6 (-), MUM1 (+), CD2 (-), CD4 (+), CD8 (-), CD5 (-), CD7 (-), TIA-1 (-), GrB (+), ALK (+), CD56 (-), EBER (-), and Ki-67 (70%+). Based on the above results the pathologic diagnosis was non-Hodgkin's anaplastic large cell lymphoma in the right breast, ALK-positive (Figures 3A-F). \nInterphase fluorescence in situ hybridization (FISH) analyses were then performed using the two-color fusion probes IRF4 and DUPS22, obtained from Ambipycin Pharmaceuticals Co., Ltd., Guangzhou, China. Where possible, at least 100 nuclei were evaluated for each probe. The FISH analyses were evaluated and recorded using ISIS Digital Image Analysis version 5.0 (MetaSystems, Altusheim, Australia). To analyze the whole genome for imbalance, DNA was extracted from the FFPE material using the QIAmp DNA FFPE tissue kit (Qiagen, Lab Division, America) and processed using the Oncoscan FFPE express 3.0 kit (Affymetrix, Santa Clara, CA, USA). Processing involved analysis of copy number aberrations (CNA) and constructing copy TuScan algorithms using Nexus Express for Oncoscan 3 software (Beijing Yuxin Biotechnology Co., China). The human reference genome GRCh37/hg19 was used for gains and deletions smaller than 100 Kb or containing less than 20 probes, and CNN-LOH for those smaller than 5000 Kb or containing deletion regions not considered in the analyses. Molecular cytogenetic analysis using interphase fluorescence in situ hybridization (FISH) analysis showed that the vast majority of cells in the tissue sections had chromosomal breakpoints that affected the fusion of the IRF4 motif and DUPS22, and chromosomal breakpoints that affected the DUPS22 motif. We also detected an additional signal for the nonrecombinant allele, suggesting a gain in the DUPS22 locus (Figure 4B). In addition, we observed a gain in the IRF4 locus without breaks. Based on these results and with reference to the current classification of lymphoma of the World Health Organization (WHO), we changed the diagnosis to \"non-Hodgkin's mesenchymal metaplastic large cell lymphoma, ALK-positive\". This malignancy was not associated with an IRF4/DUPS22 rearrangement. Chromosomal imbalance mapping using the Oncoscan Chromosomal Imbalance Mapping platform revealed mutations in the following genes: BCOR_p.Q600X, DNMT3A_p.F609fs, NOTCH1_p.P2320fs, and IDH2_p.R140Q (Figure 4A). Finally, we attempted to sequence the whole exome of the tumor, although unfortunately, this failed due to technical reasons.",
"gender": "Male"
}
] |
PMC10663166
|
[
{
"age": null,
"case_id": "PMC10921426_01",
"case_text": "The five patient cases presented here were evaluated against the RAISE score and their points were tallied (Table 3). This evaluation clearly demonstrates that the patient in Case Study 4 does not have CA, and if the RAISE score had been applied, the bone scintigraphy scan could have been avoided. These cases provide further practical validation of the RAISE score in a real-world setting, demonstrating that for AS patients the RAISE score can be used to effectively screen for CA prior to conducting a bone scintigraphy scan. Familiarity with the RAISE score by heart teams would allow for systematic preprocedural evaluation of patients who are due to undergo TAVR/SAVR. Consistent application of the RAISE score in this population of patients would allow for appropriate selection of specific patients for whom scintigraphy should be recommended. While it may be tempting to suggest that all elderly patients undergoing TAVR/SAVR evaluation should have a bone scintigraphy scan, the systematic application of the RAISE score would allow for a more judicious selection of patients, as is clearly demonstrated the patient in Case Study 4.",
"gender": "Unknown"
}
] |
PMC10921426
|
[
{
"age": 56,
"case_id": "PMC11047211_01",
"case_text": "A 56-year-old woman was referred to our department of district general hospital due to the presence of a large mass which was located on the left thigh. The lesion had been steadily increased in size during the last five years. The patient had reported pain, functional impairment and cutaneous oedema during the last 6 months. There was an episode of deep vein thrombosis of right leg in 1998 treated with Warfarin for 6 months. No substance abuse was referred. Previous surgical procedures and chronic pathologies were not reported. On physical examination, a moderate oedema of the left thigh was noted without skin impairment. A lateral displacement of abductor muscles and rectus femoris was noted. No pharmacological allergies were reported. Doppler sonography was performed and further investigated with MRI. (Figures 1 and 2).\nDeep vein thrombosis, venous reflux and lymphadenopathy were not detected. Tumor caused compression of the femoral vein without venous obstruction. Radiological aspects suggested a lipoma.\nThe cross section of the tumor size was 10 cm x 8 cm with an 18 cm long axis length.\nThe patient underwent surgical procedure of lipoma removal. The surgical equipe included a consultant and a junior trainee two years of surgical resident training. Surgeons planned a possible reconstruction of the artery, vein or femoral nerve which was not needed. Within the femoral fossa, surgeons identified a well demarcated and encapsulated mass. Tumor was dissected out and the vein was decompressed. Lipoma weighed 1,705 g. Two drains were put in aspiration. Histopathology evaluation showed a well circumscribed mass of fatty tissue reported as benign lipoma. The postoperative period was uneventful and after two days of recovery the patient was discharged. Patient was allowed to move with crutches for 6 days. After six months patient was fully satisfied.",
"gender": "Female"
}
] |
PMC11047211
|
[
{
"age": 74,
"case_id": "PMC10784300_01",
"case_text": "A 74-year-old male patient came for evaluation due to chronic dyspnea of 10 years of evolution; he has a history of smoking with a rate of 20 pack/year, suspended 30 years ago, in addition to exposure to organic particles and work with poultry for five years, as well as recurrent lower respiratory tract infections (Fig. 1). DIPD approach was performed with spirometry, reporting: exhaled volume in the first second (FEV1) 55 %, FVC 52 %, FEV1/FVC 0.82, concluding a pattern suggestive of moderately severe restriction. An extended panel of antibodies was performed, which included: P-ANCA 1:640 (positive), C-ANCA (negative), anti-protease 3 (PR3) antibodies 16 AU/mL (negative), anti-myeloperoxidase (MPO) antibodies 1203 AU/mL (positive), anti-glomerular basement membrane antibodies 10 AU/mL (negative), rheumatoid factor 8.6 (negative) and anti-CCP 60.5 (positive). Thorax tomography reported areas of cysts with predominantly subpleural and lower lobe penalization, inflammatory mediastinal adenopathy, pulmonary flow cephalization, traction bronchiectasis predominantly in the lower lobes, and diffuse interlobular septal thickening (Fig. 2). Also, echocardiogram was performed and showed left ventricular ejection fraction (LVEF) 54 %, pulmonary systolic pressure 25 mmHg, right ventricle without dilatation or alteration in its mobility, normal tricuspid annular systolic excursion, tricuspid regurgitation index of 3.1 m/s, estimated pulmonary artery systolic pressure of 55 mmHg and mean pulmonary artery pressure of 36 mmHg. Subsequently, an open lung biopsy was requested, and a diagnosis of \"acute and chronic extrinsic allergic alveolitis\" was made (Fig. 3), initiating treatment with mycophenolate mofetil, deflazacort, budesonide-formoterol, and supplemental oxygen. Therapeutic administration of an antifibrotic Nintedanib started in order to reduce the accelerated loss of lung function and quality of life.",
"gender": "Male"
}
] |
PMC10784300
|
[
{
"age": 23,
"case_id": "PMC10551165_01",
"case_text": "A rapid clinical response beginning with the first infusion was reported by all patients. Previously refractory skin lesions were improved by 50% after 1 month as measured by median CLASI - activity (CLASI-A) and nearly completely resolved within 3-12 months of treatment ( Figures 1A, C ). Importantly, this clinical response was seen in all subtypes of cutaneous lupus and even chronic discoid lesions rapidly responded to treatment ( Figure 1C , Table 1 ). Mucosal lesions in patients 4, 5, and 7 responded as rapidly as cutaneous lesions to anifrolumab treatment and did not relapse during the observation period. No patients had significant alopecia. Relief of cutaneous symptoms was associated with improvement in quality of life ( Figure 1B ). The patients did not report significant adverse events. One patient experienced a prolonged respiratory tract infection. However, this was not followed by SLE exacerbation. A 23-year-old patient also reported mild viral respiratory infections and herpes zoster. In contrast to nearly complete resolution of cutaneous symptoms, ANA were still detectable in sera of patients and declined only in one individual ( Table 1 ). In addition, we did not observe a normalization of complement levels in patients (data not shown). However, the general severity of the disease was reduced, and one patient could taper prednisolone, which she frequently requested for monthly flares, from 20 mg to 5 mg per day ( Table 1 ).\nIn parallel to the clinical response, we observed a reduction in IFN scores in blood ( Figures 1D, E ). IFN scores continued to decline over 6 to 12 months of treatment. Our data reveal that IFN scores in contrast to CLASI-A did not completely resolve during therapy in most of the patients ( Figure 1E ).",
"gender": "Female"
}
] |
PMC10551165
|
[
{
"age": 62,
"case_id": "PMC10960973_01",
"case_text": "We present the case of a 62-year-old woman with no prior medical history, who suffers from paroxysmal spasm of the right hemiface associated with cruciate pain. It occurs spontaneously and is sometimes triggered by trivial stimuli like talking or chewing, known as trigeminal neuralgia.\nStandard magnetic resonance imaging (MRI) sequences with a 1.5 Tesla (T) superconducting system (siemens) were first performed, to exclude an intracranial abnormality, rapid spin echo T1 in the sagittal plane, T2 in the axial plane, three-dimensional (3D) fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI). To assess the trigeminal nerve pathway and other cranial nerves, 3D high-resolution T2-weighted sequence and gradient recalled echo (CISS) were also obtained, revealing the presence of a well-defined mass in the cerebellopontine right angle hypo signal compared to the cerebrospinal fluid surrounding the ipsilateral Vth cranial nerve and responsible for a mass effect on its cisternal segment (Figure 1(a-c)). This mass presents a high restriction in the DWI (Figure 2(a) and (b)), no contrast uptake in 3D contrast T1-weighted imaging (Figure 3), and a hypersignal 3D FLAIR (Figure 4). All favorable of an epidermoid cyst.\nThe patient declined the recommended surgical treatment due to its intimate contact with the Vth cranial nerve and the high risk of nerve palsy and recurrence if incomplete removal, and refused any follow-up.",
"gender": "Female"
}
] |
PMC10960973
|
[
{
"age": 34,
"case_id": "PMC10467234_01",
"case_text": "A 34-year-old Egyptian gentleman presented at the emergency department with a complaint of lower abdominal pain that had been persistent for the past 2 weeks. The pain was gradually worsening over time and was not relieved by analgesics. He also reported experiencing nausea and chest discomfort, which he claimed was somewhat relieved by self-induced vomiting.\nAdditionally, the patient complained of subjective fevers that had been occurring for several days before the onset of the abdominal pain. Along with the fevers, he experienced joint pain and unilateral left-sided chest pain that worsened upon inspiration. The patient also had a new-onset skin rash localized in the right abdominal region. He denied having any cough, headache, scrotal pain, or muscular pain. The symptoms seemed to be triggered by stressful work conditions and exposure to cold weather.\nThe patient had immigrated to Tanzania 9 months ago and worked as an electrical engineer. He had a history of cigarette smoking, with a 15 pack-year index. He was a nonalcoholic and had no known history of food or drug allergies. There were no previous records of hospital admissions or surgeries. There were no previous records of FMF attacks in the patient's medical history. However, the patient did have a positive family history of FMF in his father and son.\nThe delayed clinical presentation can be attributed to a lack of knowledge regarding FMF and an attempt to attribute his symptoms to other causes, such as exhaustion and cold exposure. As FMF is relatively rare and might not be widely recognized outside of Mediterranean populations, the patient may not have been aware of the possibility of this hereditary condition. Additionally, his symptoms might have been initially dismissed as common ailments related to his work stress or exposure to cold weather. These factors might have led him to delay seeking medical attention and hindered early diagnosis and appropriate management.\nOn physical assessment, the primary survey did not reveal any remarkable findings. In the secondary survey, the patient was found to be alert and febrile, with no signs of pallor. He appeared moderately dehydrated and had no joint swelling. An erythematous rash was observed over the right hypochondrial region and back, as well as on both lower limbs with excoriation marks. No edema was noted. The abdomen was slightly obese and tender to touch, especially in the right and left lower quadrants. There was no muscle guarding or organomegaly, but the patient had positive rebound tenderness. Bowel sounds were normal, and the chest examination showed clear bilateral air entry. The rest of the systemic examinations were unremarkable.\nTo investigate the patient's condition further, an intravenous line was established, and blood samples were collected for various tests, including full blood picture, CRP, ESR, malaria screening, serum electrolytes, renal function tests, and urine routine analysis.\nThe laboratory results showed a white blood cell count of 11.8 x 109/l, with a neutrophil count of 9.79 x 109/l. The hemoglobin level was 13 g/dl and the platelet count was 289 x 109/l. Malaria screening showed no parasites. The ESR was measured at 22 mm/h and the CRP level was 38.64 mg/l. The creatinine level was 68.19 umol/l and proteinuria was observed.\nUpon arrival at the emergency department, the patient received immediate medical attention. He was administered intravenous paracetamol 1 g for pain relief, intravenous ondansetron 8 mg for nausea, intravenous esomeprazole 40 mg for gastric protection, and intravenous normal saline 1 l over 1 h for hydration. After this initial treatment, the patient's pain significantly improved, and a reassessment was conducted by the medical team, leading to his admission to the internal medicine ward.\nBased on the Tel Hashomer criteria, the patient met one major criterion and two minor criteria, including recurrent febrile episodes accompanied by peritonitis, synovitis, and pleurisy (major criterion), erysipelas-like erythema (minor criterion), and having a first-degree relative diagnosed with FMF (minor criterion). According to Livneh's criteria, the patient fulfilled all the criteria, confirming the diagnosis of an acute flare of FMF. \nUpon admission to the medical ward, the patient's oral intake was withheld until the resolution of nausea. He was maintained on intravenous ringer's lactate fluids alternating with dextrose saline fluids at 83 ml/h. Additionally, he received intravenous paracetamol 1 g every 8 h alternating with intramuscular diclofenac 75 mg for pain management, intravenous esomeprazole 40 mg daily for gastric protection, and colchicine tablets 0.5 mg daily every 12 h for FMF management. These medications led to a significant improvement in his condition.\nAfter 52 h since admission, the patient showed remarkable clinical improvement, with stable vital signs and resolution of nausea and vomiting episodes. His abdominal pain was well-controlled. As a result, he was discharged with a treatment plan to manage FMF effectively. The discharge medications included esomeprazole tablets 20 mg daily, paracetamol tablets 1 g every 8 h for 7 days, and colchicine tablets 0.5 mg every 12 h daily for 2 weeks to prevent future FMF attacks. The patient was educated about the danger signs to watch for and advised to see a rheumatologist for follow-up after a week.\nDuring the follow-up visit, it was observed that all inflammatory markers had returned to normal levels, indicating a positive response to the colchicine prophylaxis. The patient reported being pain-free and was satisfied with the treatment outcomes. After discussing the benefits of continuing with colchicine prophylaxis to prevent future flares and minimize the risk of complications, the patient agreed to maintain the medication regimen. Regular follow-up visits were scheduled to monitor the patient's progress and ensure ongoing management of FMF.",
"gender": "Male"
}
] |
PMC10467234
|
[
{
"age": 35,
"case_id": "PMC11059086_01",
"case_text": "A 35-year-old man was admitted to the Section of Andrology of Pisa University Hospital in September 2022 because of erectile dysfunction. He had a stable relationship with a female partner for 5 years. Sexual desire was present and spontaneous nocturnal/morning erections were reported. He declared that he has not used medications or smoked and did not engage in physical activity. The patient had no children.",
"gender": "Male"
},
{
"age": 16,
"case_id": "PMC11059086_02",
"case_text": "He was born from a spontaneous pregnancy. His birth weight and length are normal, but he had a short stature in childhood. Thus, he underwent treatment with recombinant human growth hormone from 5 to 16 years old. The patient had a spontaneous onset of puberty at 14 years of age.\nHe suffered from congenital pulmonary valve stenosis, atrial septal defects, and mitral valve prolapse of mild entity, requiring periodic follow-up. Electrocardiography showed left-axis deviation and incomplete right bundle branch block.\nMedical history also revealed incisor agenesis, chronic bilateral deep venous insufficiency, surgical correction of the right inguinal hernia at the age of 32 years, and removal of three nevi.\nHis elder sister was stillborn, and his parents died at the age of 52 and 64 years because of breast cancer and bowel infarction, respectively.\nOn clinical evaluation ( Figure 1 ), the following data were recorded: height 1.73 m, weight 60 kg, and BMI 20 kg/m2. Multiple nevi were present. His facial features were characterized as follows: triangle-shaped head with a tall forehead and high anterior hairline, bilateral palpebral ptosis, low-set and posteriorly rotated ears, and short neck with low posterior hairline. He also had chest deformity (superior pectus carinatum and inferior pectus excavatum) with widely spaced and low-set nipples. Genital examinations showed reduced testis size with a volume of 10 ml (Prader orchidometer).\nRecent hormonal evaluation showed a normal total testosterone level [22.2 nmol/L, normal range (n.r.) 8.7-29.1] with high serum FSH (19.3 IU/L, n.r. 1.5-12.4). Semen analysis ( Table 1 ) documented severe oligospermia (sperm concentration 1.5 x 106 per ml; total sperm number 6.2 x 106 per ejaculate).\nWe repeated hormonal analysis that confirmed normal total testosterone level (19 nmol/L, n.r. 6.2-27), high FSH level (20.7 IU/L, n.r. 1.3-19.5), and normal LH level (4.2 IU/L, n.r. 1.4-12.7). AMH and inhibin B were low-normal (AMH 1.4 microg/L, n.r. 0.73-16; inhibin B 31 pg/ml, n.r. 25-325). Thyroid function and prolactin were normal. Insulin-like growth factor 1 was in the normal range (138.5 microg/L, n.r. 85-256). Laboratory results are reported in Table 2 . Baseline coagulation screening was normal.\nTesticular ultrasound confirmed reduced testes volume (right testis volume 9 cc and left testis volume 6 cc) without focal lesions. Abdomen ultrasonography excluded hepatosplenomegaly or renal anomalies.\nWe performed next-generation sequencing (NGS) of the genes involved in the RAS/MAPK pathway (the custom panel having 19 genes including the coding sequence and the donor and acceptor splice sites: PTPN11, SOS1, SOS2, RAF1, BRAF, CBL, KRAS, NRAS, HRAS, RIT1, LZTR1, SPRED1, SHOC2, MAP2K1, MAP2K2, MRAS, PPP1CB, RASA2, RRAS2). NGS was performed through Nextera Flex IDT-custom panel (Illumina-IDT) in paired-end mode 2 x 150 using the MiSeq (Illumina) platform. Sequencing analysis demonstrated the presence of the pathogenic heterozygous variant c.742G>A, p.(Gly248Arg) of the LZTR1 gene (NM_006767.3). The variant was validated by Sanger sequencing ( Figure 2 ). The karyotype was normal (46,XY), and no Y chromosome microdeletions in azoospermia factor (AZF) regions were found.\nWritten informed consent for the publication of the article and accompanying clinical images was obtained from the patient.",
"gender": "Male"
}
] |
PMC11059086
|
[
{
"age": 55,
"case_id": "PMC10706091_01",
"case_text": "Patient X, a 55-year-old-woman, visited her local health clinic complaining of pronounced weakness, discomfort, and pain in her left subcostal area that had persisted for four months. From anamnesis it was found that the patient was not a smoker, did not suffer from hypertension, and had not had multiple pregnancies. No liver pathology was observed. There was no history suggestive of pancreatitis, peptic ulcer disease, abdominal trauma, hepatobiliary disease, previous surgery, or any other significant illness. On examination, she was comfortable with blood pressure at 100/70 and pulse rate at 82 per min-1. Pallor was absent. A well-defined, non-tender, pulsatile intra abdominal lump was palpable in the left hypochondrium, left lumbar, and epigastric region, which was oval in shape and 12 cm x 10 cm in size.\nAn abdominal CT scan was performed, revealing a 120x123 mm splenic artery aneurysm with irregularly shaped hypoechogenic thrombotic masses, occupying two-thirds of the lumen volume (Figure 1). As a result of this diagnosis, the patient was urgently admitted to the surgical clinic at Botkin Hospital and later transferred to the hepatopancreatobiliary surgery department.\nUltrasound investigation of the spleen in the projection of the splenic hilum revealed a globular aneurysmal dilatation of the arterial vessel, associated with the splenic artery and measuring up to 125x100 mm. The lumen contained hypoechogenic aneurysmal thrombotic masses and occupied two-thirds of the lumen volume. No fluid accumulations were observed in the vicinity of this splenic artery aneurysm. No other pathology was detected by X-ray and ultrasound examination. According to the laboratory investigation, the patient had moderate iron deficiency anemia (Hb - 96.1 g/l, Fe - 1.9 micromol/l).\nThe patient underwent a comprehensive preoperative examination, which included esophagogastroduodenoscopy and colonoscopy, revealing no significant organic pathologies. During EchoCG: aortic wall, aortic valve leaflets were compact, there was 1st degree mitral valve prolapse, cavities were not dilated, systolic function was good.\nThe patient subjectively noted an improvement in health status against the background of conservative treatment (antispasmodic, iron supplementation).\nHowever, due to the high risk of rupture associated with giant splenic artery aneurysms and the ineffectiveness of endovascular treatment due to the artery's size and tortuous course, the patient was prepared for elective surgery.\nPreoperative planning of surgical treatment was based on three-dimensional modeling of the anatomy of the splenic artery using multiphase abdominal computed tomography (Figure 2). In this patient, the splenic artery had a tortuous course, which was also a contraindication for endovascular treatment.\nThe patient underwent open surgical repair. Surgical intervention was performed in the form of aneurysm resection along with splenectomy and distal resection of the pancreas. After a midline laparotomy and abdominal cavity revision, a large pulsating mass was detected in the retroperitoneal space originating from the splenic artery, 12x12 cm in size, located in the body/tail of the pancreas, and occupying the upper abdominal floor, (Figure 3). Given the pronounced adhesions in the abdominal cavity, in the area of the spleen, splenic flexure of the colon, and pancreas, adhesiolysis was performed with technical difficulties. The aneurysm was tightly connected to the splenic angle of the transverse colon, the tail of the pancreas, and the spleen. Using LigaSure and bipolar coagulation, the splenic angle of the transverse colon was mobilized. Subsequently, the splenic artery and vein were isolated, and a vascular clamp was placed on the splenic artery, resulting in cessation of the pulsations in the mass, confirming the aneurysm's origin from the splenic artery. The splenic artery and vein were clipped with Hem-o-Lock clips and crossed and the splenic artery stump was sutured. The tail of the pancreas was mobilized and resected using LigaSure and bipolar coagulation. Distal pancreatic resection was performed with splenectomy and resection of the splenic artery aneurysm. The organ complex was removed and sent for histological examination. The pancreatic stump was sutured with Z-shaped sutures. A hemostatic sponge was placed on the pancreatic stump. Two drains were installed in the cavity of the removed organ complex, to the pancreatic stump, and were removed through the contra-aperture in the left mesogastric region. The approximate blood loss was 200 ml.\nOn macroscopic examination, the aneurysm was 12x10x12 cm in size and of dense consistency, fused to 13 cm of the spleen and up to 1 cm of the tail of the pancreas (Figure 4).\nUpon dissecting the aneurysm, its interior surface displayed a yellowish appearance, with areas showing calcium salt deposition (dystrophic calcification) and the aneurysm cavity contained long-standing thrombotic masses (Figure 5).\nHistopathology showed the aneurysm involved all three layers of the vessel wall, suggestive of a true aneurysm. Microscopic examination revealed a sharply dilated aneurysm, with absent endothelium in some areas. The inner sheath was thickened in places, while the middle membrane exhibited muscular layers that were markedly thinned and elongated. There was a substantial increase in the number of elastic fibers, forming compact strands that were torn in some places. The intermuscular connective tissue showed increased density and, in some areas, penetrated between the muscle fibers, separating them (Figures 6 & 7).\nIn the postoperative period, the patient received comprehensive antibacterial, anticoagulant, antispasmodic, and symptomatic therapy, with dynamic monitoring and regular checks of laboratory parameters. Fortunately, the postoperative phase was without complications, and the patient was discharged in satisfactory condition under the care of local healthcare providers. The length of postoperative care was two weeks. No adverse events occurred during 6 months of follow-up.",
"gender": "Female"
}
] |
PMC10706091
|
[
{
"age": 67,
"case_id": "PMC10994707_01",
"case_text": "A 67-year-old male was referred to the Dental Outpatient Department of Tongren Hospital, Shanghai Jiao Tong University School of Medicine, with a chief complaint of \"missing teeth and swollen gums for 3 months\". The patient had been in a partially edentulous state for several years without receiving any dental restoration. Three months prior to the visit, all remaining teeth were severely loose and subsequently extracted due to \"chronic periodontitis\". Notably, the patient reported swelling and hyperplasia of the gingival papilla observed before the tooth extraction. Seeking complete denture restoration, the patient discovered that despite the extractions, his gums remained severely swollen, affecting both edentulous jaws.\nThe patient had a three-year history of hypertension and was prescribed a drug regimen of 10 mg of nifedipine twice daily. Blood glucose level and blood pressure were within normal ranges, and routine blood test revealed normal hemoglobin, red and white blood cell count, platelet count, bleeding time, and clotting time. Upon oral examination, the patient presented with a reduced lower facial height and complete edentulous maxilla and mandible. Mucosal enlargement was evident on both edentulous ridges, displaying a pale-pink, firm, irregular, mulberry-shaped, and nodular appearance (Figure 1(a)-1(c)). The keratinized mucosa was wide and did not tend to bleed upon probing. Additionally, panoramic radiograph showed unevenly absorbed maxillary and mandibular ridges with no osseous deformities (Figure 1(d)).\nUpon medical approval, preprosthetic surgeries including flap surgery and alveoloplasty were performed (Figures 2(a) and 2(b)). Before surgery, the patient rinsed his mouth with 0.12% chlorhexidine gluconate solution as an antiseptic mouthwash for 60 seconds. For oral and maxillofacial disinfection, iodophor (Lanso, skin mucosa disinfectant, 60 ml, active ingredients and content: iodine, effective iodine content (w/v) 0.45%-0.55%, and chlorhexidine acetate content (w/v) 0.028%-0.034%) was utilized. After routine draping, local anesthesia was performed using 4% articaine (10 ml) with 1/100,000 adrenaline. An incision with no. 11 blade was made on the crest of the alveolar ridge, extending from the anterior region to the posterior molar region. Releasing incisions were made on both the mesially and distally labial sides, and the flap was turned to the bone surface. Hypertrophy tissues were excised, with partial keratinized mucosa retained, and granulation tissues were carefully scraped off. Both alveolar bone surfaces underwent trimming and reshaping using a turbine and a bone file. An incisional biopsy was obtained for pathological evaluation, revealing hyperplastic epithelium overlaying fibrous connective tissue, leading to a fibrous epulis pathological diagnosis (Figure 2(c)). Simple interrupted sutures with 4-0 silk were applied on the alveolar ridge thread for surgical closure. The prescribed postoperative care included systemic antibiotics (cefradine capsule 250 mg q6h for 3 days), anti-inflammatory analgesic drugs (compound paracetamol tablet 400 mg per day for 3 days), and a 0.2% chlorhexidine mouthwash (twice a day for 7 days). The mandibular surgery was conducted one month after the maxillary surgery. Postoperatively, the patient reported no severe discomforts or complications. Following the oral interventions, the patient consulted his cardiologist, leading to a replacement of the antihypertensive medication with valsartan 80 mg per day.\nAfter a 2-month healing period, the patient's alveolar ridges displayed a firm, regular, and well-healed appearance with no signs of recurrence or overgrowth (Figure 3(a)). Subsequently, complete denture fabrication for both arches were accomplished (Figure 3(b)), restoring the patient's masticatory function as well as enhancing lower facial aesthetic (Figure 3(c)). The patient underwent recall appointment at 18 months and 24 months after surgery, during which no recurrence of overgrowth was observed (Figure 4, Supplementary Figure 1). His dentures fitted well with good retention and aesthetic effect.",
"gender": "Male"
}
] |
PMC10994707
|
[
{
"age": 65,
"case_id": "PMC10895306_01",
"case_text": "A 65-year-old man was diagnosed with metastatic grade 1 neuroendocrine tumor in September 2021. He reported symptoms of weight loss, diarrhea, weakness, and abdominal discomfort and was found to have multifocal hepatic lesions occupying 75% of the hepatic parenchyma (largest lesion 8.9 x 7.4 x 5.2 cm) on triphasic CT (Fig. 1). A bilobed avidly enhancing lesion was also visualized within the wall of a right lower quadrant ileal segment, which was suspected to represent the primary tumor. Ultrasound-guided biopsy of one of the hepatic lesions was performed, and pathology was consistent with a metastatic well-differentiated grade 1 neuroendocrine tumor (Ki-67 <3%). CDX2 and SATB2 staining were suggestive of a gastrointestinal primary. Biochemistry showed elevated chromogranin A (662 ng/mL) and 24-h urinary 5-HIAA (602 mumol/day) (Table 1). His clinical course was complicated by CHD detected shortly after diagnosis, presenting primarily as right heart failure with anasarca and New York Heart Association (NYHA) IV dyspnea. He did not have any symptoms suggestive of intestinal obstruction. \nTransthoracic and transesophageal echocardiograms revealed torrential tricuspid regurgitation, thickened pulmonic valve with moderate pulmonary regurgitation, moderately reduced right ventricular systolic function, and severe right ventricle dilation (Figs. 2 and 3). He had an elevated N-terminal pro-brain-type natriuretic peptide (NT-proBNP) of 2017 ng/L (ref: <900 ng/L). Right heart catheterization demonstrated mean right atrial pressure 14 with v-wave to 26, pulmonary artery systolic pressure 26, and pulmonary artery diastolic pressure 14. There was equalization of pulmonary artery and right ventricular pressures in mid-diastole consistent with severe pulmonary regurgitation.",
"gender": "Male"
}
] |
PMC10895306
|
[
{
"age": 72,
"case_id": "PMC10587437_01",
"case_text": "JS is a 72-year-old gentleman who underwent JIB in the 1980s. He has no additional contributory history. Despite laxatives, he presented to the emergency department with abdominal pain, distention, nausea, vomiting, and obstipation for 3 days. A colonoscopy 1 year prior was negative for polyps. A computed tomography (CT) scan upon presentation showed a 3.4-cm stenotic segment in the mid-transverse colon. Proximal to this, the ascending colon and the transverse colon were dilated and fluid-filled, with the cecum measuring 9.5 cm. There was also a loop of small bowel anastomosed to the transverse colon just proximal to the stenosis. The patient's carcinoembryonic antigen (CEA) level was 18.2. He had a bowel movement the day following admission. The day after, he underwent a colonoscopy, which showed an anastomotic obstruction in the mid-transverse colon. There was erythematous and necrotic tissue with thick and firm mucosa. Biopsies showed adenocarcinoma. The patient was discharged 6 days following admission in stable condition, including tolerance of a diet and bowel function.\nOutpatient screening CT chest was negative for metastatic disease. Shortly after that, he was taken electively to the operating room for an extended right hemicolectomy with ileocolic anastomosis and reversal of JIB. Intraoperatively, the patient's anatomy revealed an end-to-end JIB, with 80 cm of bowel in continuity from the ligament of Treitz to the colon and the out-of-circuit small bowel anastomosed to the mid-transverse colon, in the end-to-side fashion, just proximal to the obstructing malignancy. The extended right hemicolectomy removed the malignancy and terminal ileum distal to the end-to-end anastomosis, which was roughly 20 cm from the ileocecal valve (Figures 2, 3). Next, a side-to-side small bowel anastomosis was performed from the terminal ileum that remained to the blind loop of the previously out-of-circuit bowel. During this process, a small portion of the small bowel was removed following trauma from extensive lysis of adhesions. At last, the portion of the small bowel previously anastomosed to the transverse colon was connected to the colon that remained after oncologic resection in an end-to-side manner.\nPostoperatively, the patient was started on total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC). A CT scan on post op day (POD) 7, given no bowel function, showed diffuse ileus and slow passage of oral contrast. Flatus on POD 9 prompted a clear liquid diet, advanced to a gastrointestinal (GI) soft diet the following day with bowel movements. On POD 12, he was discharged in stable condition without TPN. Six weeks later, he was seen in the outpatient setting, with only complaint of mild constipation. He was instructed to follow up in 4 months for CEA, colonoscopy, and CT. Unfortunately, he was lost to follow-up.",
"gender": "Male"
},
{
"age": 81,
"case_id": "PMC10587437_02",
"case_text": "NW is an 81-year-old woman who underwent JIB in the 1970s. She has no additional contributory medical history. She was initially admitted to the medical service for pneumonia while experiencing anemia. This prompted a workup for a GI bleed. Esophagogastroduodenoscopy (EGD) showed a 10-cm segment of salmon-colored mucosa. Biopsy was significant for Barret's. A colonoscopy the following day revealed a transverse colon mass, with the biopsy containing adenocarcinoma. At this point, general surgery was consulted. A chest, abdomen, and pelvis CT scan highlighted bilateral pulmonary embolisms and a concerning liver lesion. The liver lesion was further characterized via magnetic resonance imaging (MRI), which was significant for a 2.6-cm segment 6 mass. She subsequently began FOLFOX chemotherapy. Following four cycles, a repeat MRI scan showed stability of the area. Repeat CT chest showed a few stable lung nodules under 5 mm. a few weeks later, an abdomen and pelvis CT scan, prompted by clinical concerns of obstruction in the clinic, showed nothing acute. However, a short interval repeat CT scan showed a small bowel obstruction with a transition zone in the right lower quadrant. She was therefore admitted. Unfortunately, she was unable to advance her diet and required supplementation with TPN.\nShe underwent an urgent open extended right hemicolectomy, intraoperative liver ultrasound, and small bowel anastomosis secondary to the reversal of JIB. Biopsy of the liver lesion was not possible given its posterior location, but intraoperative communication with interventional radiology (IR) confirmed that a percutaneous biopsy would instead be achievable. Intraoperative findings were significant for about 200 cm of small bowel out of circuit with the distal end anastomosed to the transverse colon in an end-to-side hand-sewn fashion, which was the site of the colon cancer. The specimen included 5 cm of large bowel distal to the colon cancer, 5 cm of the distal defunctionalized small bowel limb, and just proximal to end-to-end anastomosis of the in-continuity small bowel. Reconnection of the bowel required the blind end of the small bowel in discontinuity to be anastomosed to the distal jejunum via stapled isoperistalic side-to-side anastomosis, followed by the distal end of the small bowel previously in discontinuity being anastomosed to the colon via stapled isoperistaltic side-to-side anastomosis. Pathology revealed moderately differentiated adenocarcinoma. Of 18 lymph nodes, none were positive. The final pathologic staging was T3N0M1.\nBy POD 8, she was tolerating a GI soft diet. She was discharged on POD 12. The patient was readmitted a few weeks later for sepsis and midline drainage, which necessitated brief admission to the ICU, vasopressors, and an infectious workup. Since this sepsis was considered secondary to her existing line, this was removed. The remainder of this hospitalization was uncomplicated, with her being discharged without further antibiotics. She presented a few months later secondary to failure to thrive, given poor PO intake. Therefore, EGD and percutaneous gastrostomy were performed without complications. An abdomen and pelvis CT scan revealed an acute PE, which was anticoagulated, and a 4-cm right hepatic lobe lesion, increased from 2 cm from previous imaging. She was ultimately discharged in stable condition on tube feeds. MRI 6 months later was significant for a 6.3-cm heterogenous lesion in the posterior right hepatic lobe and possible satellite lesions. Y 90 embolization was performed that month. A chest, abdomen, and pelvis CT scan a few months later showed disease progression, specifically numerous new bilateral pulmonary and hepatic metastases, as well as retroperitoneal and pelvic lymphadenopathy. Given the previous side effects of chemotherapy, the patient opted against further systemic therapy. She also declined hospice care. She ultimately passed away.",
"gender": "Female"
},
{
"age": 72,
"case_id": "PMC10587437_03",
"case_text": "SM is a 72-year-old woman with a relevant medical history of a JIB 45 years ago and s/p left hemicolectomy in 2013 for Lynch syndrome manifesting as adenocarcinoma. A colonoscopy and associated biopsy in 2021 diagnosed her with recurrent cancer at her colorectal anastomosis. Following a negative staging CT scan, she was taken to the operating room for a JIB reversal, total abdominal colectomy, total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), and multiple incisional hernia repair. The JIB reversal required anastomosing the previously out-of-circuit small bowel, attached to the transverse colon, proximally in the side-to-side fashion to the jejunum remaining in circuit and distally, also in the side-to-side fashion, to the rectum. The TAH and BSO were secondary to her history of Lynch syndrome. The closure repaired the incisional hernias primarily.\nPostoperatively, she tolerated a clear liquid diet on POD 5, a full liquid diet on POD 6, and ultimately a GI soft diet on POD 7. She was discharged in stable condition on POD 8. She was seen in the outpatient setting without any complaints. Following readmission 1 month postoperatively for abdominal pain, a CT scan was significant for an abdominal wall fluid collection, which was managed with an IR drain. Persistent nausea prompted a repeat CT scan a week later, which showed pneumoperitoneum and a large air-containing fluid collection with concern for associated contrast material. This prompted a return to the operating room for exploratory laparotomy. Intraoperative findings included a distal small bowel perforation, not at either prior anastomosis. This area was resected, she was left in discontinuity, and a temporary wound vacuum was placed. A day later, she returned to the operating room for an end ileostomy and mucous fistula, the latter of which was created with the small portion of distal small bowel remaining. Tube feeds were started later in the day, with extubation the following day. Four days later, she was transferred to the regular nursing floor with speech-approving thin liquids. She was discharged to a skilled nursing facility, tolerating a regular diet then.\nShe was readmitted a week later secondary to altered mental status, decreased left-sided movement, and left-sided neglect. The stroke team workup included an MRI that showed acute small bilateral parietal infarcts. Sepsis workup given altered mental status was significant for persistent fluid collections in both the abdomen and abdominal wall; however, all were smaller than previous. The intra-abdominal collection was managed with an IR drain. Her mentation and inability to protect her airway required intubation; however, she was extubated shortly after that. Repeat CT the following day showed an obvious bowel leak with contrast extending into a large encapsulated air and fluid collection in the right lower quadrant, near the IR drain, overall decreased in size, pneumoperitoneum, and an enterocutaneous fistula. She was made nothing by mouth (NPO), a PICC was ordered for TPN, and another large bore drain was placed by IR. Ongoing dark ostomy output and anemia prompted workup by GI, including negative esophagogastroduodenoscopy, ileoscopy, and computed tomography angiography (CTA). CTA findings led to an additional IR drain into the left side, which ultimately became enteric. Finally, push enteroscopy showed a possible vascular malformation, treated by argon plasma coagulation. The midline enterocutaneous fistula appearance turned blue/green with a sweet odor, characteristic of a Pseudomonas infection. Cultures reflected this. A repeat CT scan and a left-sided abscessogram showed the known encapsulated fluid collection, with the known leak appearing smaller. The left-sided IR drain was upsized, while one of the right-sided drains was removed following another abscessogram. The patient was coded with an ultimate return of spontaneous circulation following advanced cardiovascular life support. Further workup was significant for a PE, for which a heparin drip was started. Bilateral pneumothoraces, likely related to the chest compressions, required chest tubes. Not long after, the family made the decision for a palliative extubation. Shortly after that, the patient passed away.",
"gender": "Female"
}
] |
PMC10587437
|
[
{
"age": 30,
"case_id": "PMC10838058_01",
"case_text": "The index patient is a 30-year-old gravid 2 Para 1 Alive 1 (G2 P1 A1) woman, now P2 A2, with spontaneous drainage of fluid per vagina about two hours before presentation. The fluid was copious and aggravated by the slightest movement. She had no fever, abnormal vaginal discharge or bleeding, or lower urinary tract symptoms. No contractions or labor pains before or during the onset of symptoms. The patient's last menstrual period (LMP) was the 3rd of February 2022, and the estimated date of delivery (EDD) was the 10th of November, 2022. The estimated gestational age (GA) at presentation was 29 weeks + 6 days from LMP. She had a regular menstrual cycle occurring every 28 days with 3 to 4 days of normal flow. There was no history of hypertension or diabetes in the patient prior to conception or during pregnancy. There is no history of abortions, preterm delivery, or instrumental delivery. There was also no history of cervical trauma from previous vaginal delivery or postpartum hemorrhage. She was regular with her routine antenatal visits. She does not take alcohol or tobacco in any form. There was no family history of preterm deliveries, hypertension, and diabetes.\nPhysical examination revealed an anxious patient, in no obvious respiratory or painful distress, afebrile with a temperature of 36.2 C, not icteric, not pale or cyanosed, and nil digital clubbing or pedal edema. She had no signs of dehydration, and her vitals were stable. Abdominal examination showed a symphysiofundal height of 31 cm, and a fetus in transverse lie. A fetal heart check with sonic aid showed the presence of a fetal heart rate of 130 beats per minute. There were no visible or palpable uterine contractions. A vaginal examination with a sterile speculum showed clear amniotic fluid pooling in the posterior fornix of the vagina. With the Valvasa maneuver, there was leakage from an open cervix, about two centimeters dilated. The patient was admitted and management began with a provisional diagnosis of PPROM. She was commenced on intravenous fluids, antibiotics (per oral erythromycin 500 mg 6-hourly for 24 hours), salbutamol 4 mg three times daily for 48 hours, and steroids (i.e., dexamethasone 12 mg 12-hourly intramuscularly for 24 hours). Investigations were carried out, as shown in Table 1. Table 2 summarizes fetal parameters from a scan done at a previous visit.\nThe report of an ultrasound scan done at a previous visit at 22 weeks + 2 days revealed a normal second-trimester cyesis. The uterus containing a singleton viable fetus in cephalic presentation and a longitudinal lie was visualized. The placenta was normal, and the placenta was anterior. No fetal abnormality was noted, and the cervix was closed. The estimated fetal weight was 690 g noted to be normal for the age. Fetal parameters, which corresponded to GA of 23 weeks 2 days +- 2 weeks, are summarized in Table 2 above.\nThe patient was placed on bed rest for three days under close monitoring. She delivered a live female neonate with a birthweight of 1.4 kg by emergency lower segment cesarean section after 72 hours of conservative management and no improvement in presenting symptoms. Indications for surgical delivery included severe oligohydramnios secondary to PPROM, and transverse fetal lie. Neonatal APGAR scores were 9/10 and 10/10 in the first and fifth minutes respectively. The neonate was transferred to a Special Care Baby Unit (SCBU) of a Pediatric Specialist Hospital for expert care. The patient's and her baby's care required a multidisciplinary team of the obstetrician, midwife, nursing staff, pediatrician, anesthesiologist, the general physician who admitted the patient, and other supporting staff.\nInitially, the patient recuperated very well postoperatively but subsequently developed a fever (which was low-grade, intermittent, and relieved by paracetamol injections), body pains, and chest pains four days postop. There was no undue abdominal pain, lower urinary symptoms, or abnormal vaginal discharge. Chest examination showed coarse crepitation in both lung bases. Abdominal examination showed a clean and dry op-site and well-apposed edges. Lochia was normal on vaginal examination. A diagnosis of pneumonia supported by chest X-ray findings of patchy, bilateral opacities was made, and the patient was treated with antibiotics (i.e., amoxicillin/clavulanic acid 1.2 g intravenously 12 hourly for three days). She continued on oral cefixime 200 mg twice daily for another seven days. The patient was discharged seven days postop, and her baby was discharged after two weeks of intensive care at the SCBU at 1.6 kg. She presented with her baby at two weeks and six weeks post-discharge for follow-up visits, which were satisfactory. The baby continued pediatric specialist follow-up visits and has currently achieved age-appropriate milestones at one year of age.",
"gender": "Female"
}
] |
PMC10838058
|
[
{
"age": 17,
"case_id": "PMC11412753_01",
"case_text": "The patient is a 17-year-old male football player (defensive end), with no significant past medical history and a body mass index (BMI) of 27.7 kg/m2 who sustained a noncontact pivoting injury to his left knee while performing a spin move in practice (mechanism of injury: tibia external rotation, body internal rotation, valgus stress, and with the knee slightly flexed). He experienced immediate pain and swelling after he felt and heard an audible \"pop\" to his left knee while performing a spin move. Following the injury, he experienced left knee instability and was unable to continue playing. He utilized ice and over-the-counter anti-inflammatory medications with moderate relief and required crutches for mobilization. He initially presented to the clinic a week following the injury, but due to inadequate preoperative range of motion (ROM), he was prescribed prehabilitation and was seen 2 weeks following his initial visit. Although he did not have any additional injuries, at his second clinic visit, he complained of posteromedial knee pain and swelling.\nOn clinical examination, the left knee demonstrated a moderate 2+ effusion. ROM was from 0 short of full extension to 85 of knee flexion with complaints of pain and tightness. He had a 2+ positive Lachman as well as a 1+ positive anterior drawer with the foot in neutral and externally rotated positions. The posterior drawer was negative, and he was stable to varus and valgus stress testing at 30 of flexion. Pivot shift testing was unable to be performed due to pain and guarding. McMurray's testing was unable to be performed due to his limited flexion and guarding; however, he had focal tenderness over the posterior horn of the lateral meniscus. His patella was stable to lateral stress at 20 of knee flexion. Hamstring tightness and mild quadriceps atonia were also noted.\nDuring the patient's second preoperative office visit:1 day prior to surgery:his knee was reevaluated. Joint swelling improved to a modest 1+ effusion. He still lacked 5 from full extension, but his flexion had improved to approximately 130 . It was also noted that he had tenderness to palpation around the posteromedial hamstring area in close approximation to the posterior horn of the medial meniscus, consistent with a newly formed palpable Baker's cyst. The remainder of the exam was similar to his first clinic visit.\nKT-1000 arthrometer (Medmetric; San Diego, CA) testing demonstrated a 5-mm laxity at the 30-lb pull and a 7-mm of laxity at the manual maximum pull. Radiographs obtained at the office demonstrated closed growth plates as well as a positive sulcus with the lateral femoral condyle (Figure 1).\nMagnetic resonance imaging (MRI) from an outside clinic demonstrated a complete midsubstance tear of the ACL (Figure 2(A)) as well as increased signal at the posterior horn of the medial meniscus with concern for root involvement (Figure 2(B)).\nDespite the clinical tenderness over the posterior horn of the lateral meniscus, there did not appear to be any pathology noted within the posterior horn of the lateral meniscus on the MRI. The knee was otherwise ligamentously intact with the only other additional pathologic finding being a mild bone contusion involving the posterior aspect of the lateral tibial plateau.\nFollowing a thorough diagnostic arthroscopy, the patient was found to have medial and lateral meniscal root tears as well as a midsubstance ACL tear (Figures 3(a), 3(b), and 3(c)). Additional pathology included an unstable Grade 2 chondral lesion at the posterior aspect of the lateral tibial plateau (Figure 4).\nPrior to addressing the intra-articular pathology, an 11-mm-wide-by-5-mm-thick BTB graft was harvested and prepared for a complete tibial tunnel ACLR with suture tape augmentation.\nPrior to addressing the lateral meniscal root tear, a shaver was used to debride the unstable lateral tibial plateau chondral lesion. An intraoperative plan was then developed relative to the order of tibial tunnel creation, in light of the fact that the patient needed transtibial lateral and medial root repair sockets and a full tibial tunnel, to avoid tunnel coalescence. First, the lateral meniscal root attachment site was debrided with a shaver to roughen up the bone for bleeding purposes. An ACL tibial aiming device was used to create the lateral root tibial tunnel using an all-in-one guide pin and retro reamer (FlipCutter; Arthrex, Naples, FL). After the guide pin was appropriately placed at the anatomic attachment of the lateral meniscus root, the FlipCutter was then expanded to 6 mm which was used to retro-cut back through the tunnel to create a 12-mm bone socket. Next, a shuttle stitch (TigerWire; Arthrex, Naples, FL) along with its shuttling sheath (TigerStick; Arthrex, Naples, FL) was introduced through this tunnel and retrieved through the anteromedial portal with the sheath discarded. Next, two #0 FiberLink; Arthrex, Naples, FL) were passed via an arthroscopic suture passer (Knee Scorpion; Arthrex, Naples, FL) in the lateral meniscal root with each suture converted to a cinch type configuration ensuring good purchase in the unstable root tissue. The shuttle stitch was used to shuttle these two lateral meniscus sutures distally out the tibia to be fixed later on the tibia along with the suture tape (FiberTape; Arthrex, Naples, FL) used as the internal brace (InternalBrace; Arthrex, Naples, FL) for the ACLR construct.\nAttention was then directed to the medial root. The medial root attachment site was prepared using a shaver in the same manner as the lateral root attachment site. Prior to creating the tunnel, trephination was performed over the superficial medial collateral ligament (sMCL) with an 18-gauge spinal needle to allow ligament lengthening to improve the visualization of the medial meniscus and to prevent iatrogenic injury to the cartilage. Three cinch configuration sutures were passed through the medial meniscus root ensuring good purchase with the all-arthroscopic suture passer.\nWith care to avoid the lateral meniscal root repair tunnel, an 11-mm ACL tunnel drill (RetroDrill with 11-mm RetroCutter; Arthrex, Naples) was used to form a complete tibial tunnel for the ACL graft. The medial root tibial tunnel was made after the ACL tunnel to ensure no convergence. A shuttle suture in its sheath (TigerStick; Arthrex, Naples, FL) was passed and retrieved on the joint side to shuttle the three medial root sutures out of the tibia anteriorly. The ACL graft was fixed proximally using suspensory adjustable loop fixation (BTB TightRope II; Arthrex, Naples, FL). Final fixation of the internal brace and two lateral meniscus root repair sutures was done using a 4.75-mm anchor (BioComposite SwiveLock; Arthrex, Naples, FL) with the knee held in full hyperextension prior to final graft fixation (Figures 5(a) and 5(b)).\nThe BTB graft was then fixed distally using a 10-mm-diameter-by-20-mm-long interference screw (BioComposite Interference Screw; Arthrex, Naples, FL) again with the knee in full hyperextension. Finally, the three-cinch medial meniscal root repair sutures were fixed outside of their tunnel with the knee held at approximately 40 of flexion using a 4.75-mm anchor (Figure 6). The knee was then cycled approximately 15-20 times followed by retensioning of the ACL graft utilizing the femoral tightrope suspension fixation.\nKnee stability was checked following the final graft retensioning. The patient had a negative Lachman, anterior drawer, and pivot shift. The ACL graft was arthroscopically inspected demonstrating a well-placed graft with the internal brace properly placed within the posterior portion of the graft and noted to be lax in flexion. Taking the knee through a full ROM confirmed the graft was in good position with no impingement from the notch even in full hyperextension. Both compartments were assessed and demonstrated anatomical reduction of both meniscal roots.\nThe complete patient timeline is summarized in Table 1. Postoperatively, the patient was started on immediate ROM through use of continuous passive motion machine (KinexCONNECT; Kinex Medical Company, Waukesha, WI) in the recovery room which he then used at home for a minimum of 8 hours a day for the first 2 weeks after surgery. He was kept non-weight-bearing for 6 weeks.\n Table 2 summarizes the physical exam findings for all the patient's postoperative office visits. All clinical parameters showed improvement throughout the postoperative period thus far. The patient has been neurovascularly intact in all subsequent visits. The patient has full extension and flexion and remains ligamentously stable with a negative Lachman and pivot shift. The patient does not have joint-line tenderness and McMurray's maneuvers are negative. Also, he has no palpable posteromedial Baker's cyst. Quadriceps atrophy has been evident throughout the follow-up period but has much improved since initial presentation and is now comparable to the contralateral leg. KT-1000 arthrometer testing at 1-year follow-up demonstrated no degree of increased anteroposterior laxity compared to contralateral knee.\n Table 3 summarizes the patient's milestone progression throughout the postoperative period. For the first 3 months, the patient attended PT 3 times a week but following his 4-month visit was downgraded to 2 times a week.\nRadiographs were obtained during his 2-week postoperative visit which demonstrated good position of the ACL bone blocks and the suspensory fixation button on the lateral femoral cortex (Figures 7(A) and 7(B)). Bone grafting can also be appreciated in the patella and tibia from graft harvest sites.",
"gender": "Male"
}
] |
PMC11412753
|
[
{
"age": 47,
"case_id": "PMC11062891_01",
"case_text": "A 47-year-old man with a history of obstructive sleep apnoea on nocturnal continuous positive airway pressure (CPAP), prediabetes, and depression treated with citalopram presented to hospital with severe sepsis of uncertain aetiology. He was admitted to intensive care with septic shock and multiorgan failure, and required tracheal intubation, ventilation and cardiovascular support. The underlying cause of the sepsis was not identified. He remained in intensive care for five weeks.\nHis case was complicated by irreversible ischaemic injuries to all four limbs, potentially secondary to the vasopressor treatment required for the septic shock. The ischaemic injury extended above the wrist in both arms and above the ankle in both legs. The decision from the vascular surgical team was that bilateral below knee and bilateral mid forearm amputations was the only appropriate management option.\nA staged procedure was considered, but following multidisciplinary discussion, it was felt that, from a logistical and psychological point of view, it was more appropriate to proceed with all four amputations in the same procedure.\nIn the period immediately prior to surgery, the patient was suffering from pain related to the ischaemia and received regular paracetamol 1 g four times per day, gabapentin 100 mg three times per day, amitriptyline 50 mg once a day, oxycodone modified release 40 mg twice a day and oxycodone immediate release 10 mg up to once hourly.\nAll pre-operative analgesics were continued through the peri-operative period, and an analgesic plan was formulated following a patient-centred, multidisciplinary consultation. Prior to induction of general anaesthesia, we sited a combined spinal and lumbar epidural, using 0.5% heavy bupivacaine 2 ml and diamorphine 1 mg. General anaesthesia was induced with fentanyl and propofol, and neuromuscular blockade provided with rocuronium. A tracheal tube was inserted and general anaesthesia was maintained with sevoflurane in oxygen-enriched air.\nAfter transfer to the operating table, a central venous catheter was placed in the right internal jugular vein and a left femoral arterial line was inserted. Bilateral axillary brachial plexus catheters were then inserted using ultrasound guidance (Sonosite X-Porte, FUJIFILM Sonosite, Inc, Bothell, USA): a short-axis view was obtained with a linear 6-15 MHz probe before advancing a 16G Tuohy needle in-plane, superior to the artery. A bolus of 0.9% saline was used to confirm needle placement with spread around the artery and the catheters were then advanced leaving the tips posterior to the axillary arteries. A nerve catheter kit including a 'Y' connector was used to minimise the number of pumps required (Rectus Sheath kit, Pajunk GmbH, Geisingen, Germany). The block was established with 20 ml of 0.25% bupivacaine injected into the 'Y' connector.\nIntra-operatively, the patient received medications outlined in Table 1. Prior to emergence, the axillary catheters were topped up with 20 ml of 0.1% bupivacaine continued by infusion. Based on pre-operative weight and the weight of the limbs, post-operative weight was estimated at 85 kg and our calculated maximum hourly local anaesthetic dose was not exceeded. Neuromuscular blockade was assessed and reversed with neostigmine and glycopyrrolate, and the patient's trachea was extubated prior to transfer to the recovery area.\nAfter emergence, the patient complained of pain in his legs, which settled with 100 mg tramadol and optimisation of the epidural blockade with an additional bolus of 0.1% bupivacaine 10 ml. Fentanyl was administered via patient-controlled analgesia (PCA) device, with a bladder for activation placed in the patient's axilla (ArcoAir PCA Switch, Arcomed AG, Zurich, Switzerland); however, the patient was unable to apply enough pressure to activate it, so it was instead used as a nurse-controlled device. The patient was transferred to the post anaesthesia care unit where he remained for 48 h prior to transfer to the ward. During this time, the magnesium infusion and nurse-controlled analgesia were stopped and immediate release oxycodone restarted as required. The patient's pain was generally well controlled with no increase in opioid requirements compared to the pre-operative period. The quality of the analgesia allowed engagement with physiotherapy.\nThe axillary catheters and ketamine infusion were discontinued on postoperative day 4. The epidural was removed on day 5. Following this, pain was controlled with oxycodone, gabapentin and paracetamol.\nThe patient made good progress and was transferred to a rehabilitation facility before being discharged home around 12 months after the operation. He is now able to walk short distances independently and feed and dress himself with the assistance of prosthetics. He uses touchscreen devices to interact with computer equipment. He has phantom pain from his hands and some neuropathic pain in his legs. This is well controlled with oxycodone modified release 5 mg twice a day and oxycodone immediate release 5 mg (averaging around 10-20 mg daily), pregabalin 300 mg twice daily and amitriptyline 25 mg at night.",
"gender": "Male"
}
] |
PMC11062891
|
[
{
"age": 12,
"case_id": "PMC11074877_01",
"case_text": "A 12-year-old male with no specific birth or medical history became concerned about lower abdominal distention and began reducing his food intake 3 months prior to consultation. He exercised obsessively according to his food intake. Although he was considerably losing weight, he commented that his belly was fat and did not want it to get any fatter. Body image disturbances and anxiety regarding being overweight were observed. During his initial consultation, he was very lean, with a body mass index (BMI) of 11.5 kg/m2. He also had sinus bradycardia with a heart rate of approximately 40 beats/min. We attempted to improve his weight with enteral nutritional supplements while identifying underlying diseases by head magnetic resonance imaging (MRI) and abdominal ultrasound. However, he became disoriented and was emergently hospitalized 7 days after his first visit. On admission, he was 145 cm tall, weighed 20.9 kg (BMI: 9.9 kg/m2), and presented with impaired consciousness with Glasgow Coma Scale (GCS) E3V4M6, bradycardia with a heart rate of about 40 beats/min, and slow breathing with a respiratory rate of about 10 cycles/min. Blood gas analysis and blood test revealed hypercapnia, hypoglycemia, and elevated levels of creatinine, blood urea nitrogen, and transaminases (Table 1). His movements were slow but not paralytic and his cranial nerves were normal. As his hypoglycemia and dehydration were chronic, rapid correction was avoided to prevent the occurrence of refeeding syndrome, heart failure, pleural effusion, and ascites. Thus, we slowly corrected the hypoglycemia and dehydration (glucose infusion rate: 0.6-1.0 mg/kg/min; water: 20 mL/kg/day). On the second day of admission, he developed impaired consciousness, with GCS E1V1M1 and low blood pressure; he was transferred to the intensive care unit (ICU). The impaired consciousness and circulatory collapse were attributed to the marked hypoglycemia and dehydration. After these were corrected, his consciousness improved, and he was transferred to the general ward from ICU on the third day of hospitalization. On the fourth day of admission, his hepatic transaminases reached the peak levels, as follows: aspartate transaminase (AST), 4,782 U/L; and alanine transaminase (ALT), 2,265 U/L. Coagulopathy (prothrombin time (%): 28%) was also observed. An acute liver failure-like condition was considered. He was provided liver support therapy, including glucose infusion and enteral nutrition, and the AST and ALT levels were gradually improved.\nA head MRI scan was performed 6 weeks after admission when his general condition was stable. T2-weighted and fluid-attenuated inversion recovery images showed a localized high-signal area from the cortex to the white matter of the fusiform gyrus to the parahippocampal gyrus near the left hippocampus (Figure 1). The cortex in high-signal lesions is thickened, the boundary between white matter and cortex is indistinct and localized, and there is no tendency for invasion into the surrounding white matter. There was no contrast enhancement, and the imaging findings were characteristic of FCD type II. Electroencephalography and cerebral blood flow scintigraphy showed no significant results.\nOnce the patient's physical condition was stabilized, we administered several psychological tests. Wechsler Intelligence Scale for Children, Fourth Edition, showed his full-scale intelligence quotient (IQ) to be 119, which was above average for his age group (scores for each index are as follows: verbal comprehension index, 117; perceptual reasoning index, 115; working memory index, 123; and processing speed index, 99). The synthetic House-Tree-Person test showed his characteristics as low-internal energy and lack of personality richness and positivity. The Rorschach test indicated that he had a high level of vigilance and marked anxiety as prominent psychological traits. It suggested susceptibility to impairment in psychological functioning when confronted with complex or ambiguous situations. His thoughts and values lacked flexibility, showing a preference for routine work and a tendency to resist change. In addition, his mother noted that he was very particular, for example, he followed the school schedule even on days when school was not in session, which could be considered ASD tendencies. However, although his communication with others was unique, it was not to the extent that it interfered with his daily life and did not meet the criterion A of ASD according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).\nOwing to the patient's poor general condition on admission, his caloric intake was increased gradually using intravenous nutrition before starting enteral nutrition. The intake could be titrated without causing electrolyte abnormalities that are known to occur as refeeding syndrome (such as hypophosphatemia or hypokalemia). After the resolution of intestinal edema, which was confirmed by sonography, enteral nutrition was initiated and increased gradually. Although he never threw up or had self-induced vomiting, he had a very slow oral intake and was unable to reach the target oral intake, so he was fed through a nasogastric tube. After being counseled that his life was in danger due to his extreme emaciation, his oral intake gradually increased and the nasogastric tube was discontinued by week 9. BMI decreased to 8.9 kg/m2 after admission, but weight gain was steady after enteral feeding resumed. By the 12th week of hospitalization, his BMI recovered to 13 kg/m2. By the 20th week, it was 15; therefore, he was discharged (Figure 2). His BMI remained stable at approximately 16 kg/m2. Once the patient's condition was physically stabilized, psychiatric counseling and disease education were initiated. The patient has been followed up for about 2 years to date without any recurring eating disorders or weight loss. On follow-up, neither morphological changes on imaging nor the onset of epilepsy were noted.",
"gender": "Male"
}
] |
PMC11074877
|
[
{
"age": 68,
"case_id": "PMC10511292_01",
"case_text": "A 68-year-old man who was being evaluated for chronic orthostatic hypotension was incidentally found to have asymptomatic microscopic hematuria on a routine urinalysis.\nHis renal function was normal with a stable serum creatinine level of 1.0-1.1 mg/dL (eGFR: ~70 ml/min/1.73 m2) and no proteinuria. A CT scan of the abdomen/pelvis, without and with IV contrast, and CT urography (Figure 1) revealed severe bilateral ureteropelvic junction (UPJ) narrowing with severe bilateral hydronephrosis and multiple non obstructing stones in the right kidney. No aberrant crossing vessels were found. It also showed incidental segmental thickening of the terminal ileum which was later diagnosed as Crohn's disease. The furosemide washout MAG3-Tc99 the scan showed continuous radiotracer clearance from both kidneys, slower from the right kidney compared to the left. The split function was 53% left and 47% right.\nRenogram peak time (min): 18 (left) and 27 (right); half-peak time: 47 (left) and 60 (right). Furosemide renogram half-peak time (min): 11 (left) and 10 (right).\nHe has been managed conservatively with periodic monitoring of renal function and imaging without any progression of kidney dysfunction over the past 7 years.",
"gender": "Male"
}
] |
PMC10511292
|
[
{
"age": 11,
"case_id": "PMC10800665_01",
"case_text": "An 11-year-old girl sought medical advice in outpatient department who had been complaining of nasal pain and headache. Her symptoms included nasal swelling and pain without an obvious cause, accompanied by nasal discharge stained with blood, headache, nasal congestion and a runny nose, a sore throat, snoring, and no hyposmia.\nShe had a history of nasal congestion and a runny nose last year, which had been diagnosed as sinusitis in our outpatient clinic and improved after treated by Cefixime (BaiYunShan Pharmaceutical Holdings CO.,LTD, Guangzhou, China) (0.1 g po bid), Eucalyptol, Limonene and Pinene Enteric Capsules (Johamu Pharmaceutical Holdings CO.,LTD, Beijing, China)(0.3 g po tid), NASONEX (MSD Belgium BVBA/SPRL, Clos du Lynx, 5, 1200 Brussels, Belgium) (one spray, qd) for 2 weeks.\nThe patient had a history of tonsillitis, but could't indicate a clear history.\nThe patient had no previous medical history.\nHistory-taking also revealed that the patient had no other relevant medical history or family history.\nThe patient had normal vital signs. Her bilateral tonsils showed second-degree hypertrophy with pus thrombi in the crypts. Additionally, her right nasal cavity was blocked by the neoplasm, and there was an increase in soft tissue in the Posterior wall of nasopharynx.\nResults of routine blood tests, tests for immunoglobulin light chains,thyroid hormone levels, and tests for autoimmune antibodies are negative.\nNasal endoscopy showed adenoid hypertrophy and a reddish and pedicled neoplasm raised from the right posterior end of the nasal septum blocking the nostril in Fig. 1 below. CT was not taken as was not required by the outpatient doctor.\nDue to the medical history, physical examination, laboratory examination, and imaging examination. This patient was diagnosed with a nasal tumor and tonsil hypertrophy with adenoid hypertrophy.\nThis patient was admitted to our hospital on August 25, 2022 for further treatment. Endoscopic nasal tumor resection and plasma tonsillectomy were performed under general anesthesia on August 26, 2022. During the operation, a 70-degree nasal endoscope showed that the base of the nasal tumor was located at the right end of the nasal septum, which was fragile and easy to bleed from touching, the tumor was completely removed with a plasma knife. The left nasal cavity is fine under the endoscope.\nAfter surgery, Shiomarin (Latamoxef Sodium for Injection, Hainan Hailing Chemipharma Co., Ltd., Haikou, Hainan, China)(1 g bid ivgtt), SLOUNASE Injection [Hemocoagulase Injection, Zhaoke Pharmaceutical (Hefei),Co., Ltd., Hefei, Anhui China](0.5u qd iv) were taken after the operation for three days.\nHer pathology results with routine paraffin section and hematoxylin-eosin staining(H&E staining) obtained on the 5th day after the operation showed papillary hyperplasia of the glandular epithelium with atypia of the nasal tumor (Fig. 2A). Therefore, it was recommended that she consult a Higher-level hospital to ascertain the nature of the lesion. After discharge, the patient went to a top ear, nose and throat specialist hospital in China for further diagnosis with her pathological sections. Pathological consultation combined with morphology and immunohistochemistry of the nasal tumor led to a diagnosis of a low-grade malignant papillary thyroid adenocarcinoma with CK8 (+), CK19 (+), TTF-1 (+), CK20 (-), CDX2 (-), DOG-1 (-), Ki67 (5 %+), PAX_8 (-), S100 (-), SOX-10 (-), mammaglobin (-), P63 (small amount +), P16 (-), and GCDFP-15 (-). (Fig. 2 B,C,D,E,F).while doctors in that hospital suggested the examination for thyroid is not necessary.\nAt present, after two months of required follow-ups, the girl has recovered well without obvious signs of recurrence. Therefore, no further treatment has been needed.",
"gender": "Female"
}
] |
PMC10800665
|
[
{
"age": 13,
"case_id": "PMC10724029_01",
"case_text": "A thirteen-year-old, Tanzanian female child known to have sickle cell disease was seen at the outpatient clinic in late July 2021 due to cough and high grade fever and was prescribed intravenous ceftriaxone. The child s Hb electrophoresis record indicated homozygous sickle cell disease (HbSS). She did not have history of recurrent sickle cell crisis, hence she had stopped using hydroxyurea for more than six years. Her baseline hemoglobin has been 7.5g/dL. However, symptoms persisted with onset of mild chest and abdominal pain and was admitted at Aga Khan Hospital in the Paediatric Ward in Early August 2021. The child had no signs of respiratory distress, saturations in room air were 98% but had reduced air entry on the right side of the chest with crepitation. Chest x-ray showed a large right mid zone lung consolidation with few left lower zone infiltrates noted (Figure 1). A diagnosis of vaso-occlusive crisis and acute chest syndrome was made and patient managed with Intravenous (IV) Piperacillin and Tazobactam 100mg/kg every six hours, oral azithromycin 10mg/kg once daily, IV fluids, IV paracetamol 15mg/kg and oral ibuprofen 10mg/kg around the clock for pain control. During the course of stay in the hospital, fever, cough and pain subsided and patient discharged after seven days.\nClinical findings: two days later, she was re-admitted due to severe chest and abdominal pain with tachypnea and desaturation in room air. Diffuse crepitation was heard on both sides of the chest.\nTimeline of events: (Table 1).\nDiagnostic assessment: computed Tomography (CT) scan was done due to suspected pulmonary embolism which was ruled out but revealed left lower lobe consolidation with air bronchogram accompanied by peripheral sub-pleural patchy ground glass opacities (Figure 2). Laboratory studies showed white cell count of 39*109/L with neutrophil absolute count of 39*109/L, hemoglobin of 7.4g/dL and CRP of 202mg/L. In view of the above findings, a high index of suspicion for COVID-19 was made and oropharyngeal swab for COVID-19 Polymerase Chain Reaction (PCR) was obtained which confirmed the diagnosis. Additional supportive findings included a D-dimer of 5.43, ferritin of 436.37 and lactate dehydrogenase of 666.60IU/L.\nTherapeutic intervention: she was kept on oxygen via nasal prongs 3L/min, IV meropenem 20mg/kg every eight hours, oral clarithromycin 7.5mg/kg every twelve hours, subcutaneous enoxaparin 1mg/kg every twelve hours, oral dexamethasone 0.15mg/kg once daily, vitamin supplements, IV fluids, IV paracetamol 15mg/kg, oral ibuprofen 10mg/kg and IV morphine 0.1mg/kg around the clock for pain control. On the third day, oxygen was weaned off, chest and abdominal pain gradually subsided. She was discharged on the fourth day on meropenem to complete a total of 14 days, clarithromycin, oral dexamethasone to complete total of 10 days, rivaroxaban, vitamin supplements and analgesics. Parental education was given on hand hygiene, adherence to face masks and isolation of the child at home.\nFollow-up and outcomes: her follow up visits revealed that she was responding well to the treatment and the chest findings were normal on auscultation with CRP level going down up to 12.28mg/L. Treatment adherence and tolerability were assessed by close follow up. However, she was re-admitted after seven days from discharge of the second admission due to bilateral arm pain. Physical examination revealed new onset of crepitation heard on the right basal lung field without respiratory symptoms. CRP was elevated to 108mg/L. Procalcitonin level was checked and was found to be 0.25ng/L. Blood cultures were negative again. IV clindamycin 30mg/kg every 8 hours was initiated in suspicion of secondary respiratory bacterial infection due to Methicillin Resistant Staphylococcus aureus (MRSA), IV fluids, IV paracetamol 15mg/kg, oral ibuprofen 10mg/kg and IV morphine 0.1mg/kg for pain control. She was discharged after one week once pain subsided and continued with oral clindamycin to complete total of 14 days. Her follow up visits showed that she had been recovering well after the initiation of clindamycin.\nPatient perspective: the child was anxious due to recurrent illness but with her parents' support and counselling provided by the medical team, she felt emotionally better. Her parents were aware of the challenges faced in management and were supportive and satisfied with the management offered to their child.\nInformed consent: written informed consent was obtained from the patient s next of kin for publication of this case report and any accompanying images.",
"gender": "Female"
}
] |
PMC10724029
|
[
{
"age": 45,
"case_id": "PMC11182238_01",
"case_text": "A 45-year-old man with a history of hypertension being treated medically, received a third vaccination for COVID-19 in July 2022. Each was with the mRNA COVID-19 vaccine manufactured by Moderna. That day, the patient had no fever or other systemic symptoms noted, although the next morning, he noticed a severe visual impairment in his right eye and came to our department soon thereafter.\nAt the initial visit, visual acuity was limited to counting fingers in the right eye and 30/20 in the left eye. A relative afferent pupillary defect was also noted in the right eye, and additional examinations showed circumferential retinal hemorrhage, perimacular ischemic color, severe macular edema, and severe optic disc edema, indicating the presence of central retinal vein occlusion (CRVO), incomplete central retinal artery occlusion (incomplete CRAO), and papillitis ( Figure 1A ). Fluorescein angiography (FA) indicated prolonged arm-to-retina circulation and intraretinal transitional times, perimacular filling defects, and blockage of fluorescein due to the retinal hemorrhage ( Figure 1B ). Optical coherence tomography (OCT) revealed severe macular edema and hyperintensity of the inner retina ( Figure 1C ). In addition, the retina of the left eye showed increased arteriovenous crossings, suggesting the presence of retinal arteriolosclerosis, although no retinal hemorrhage was observed.\nIn addition to the simultaneous onset of CRVO and incomplete CRAO in the right eye, papillitis was suspected. Contrast MRI showed no contrast enhancement of the optic nerve itself, suggesting inflammation confined to the optic nerve disc rather than inflammation of the optic nerve itself, as seen in idiopathic optic neuritis or antibody-related optic neuropathy.\nSince the patient was thought to be affected by CRVO and incomplete CRAO, both of which can cause macular edema, it was difficult to choose an anti-VEGF drug treatment that could quickly reduce macular edema caused by CRVO. Furthermore, papillitis was also likely a complicating factor, and the resulting inflammation may have caused circulatory disturbance of retinal blood vessels; thus, steroid pulse therapy was chosen to reduce inflammation as much as possible, with a full explanation given to the patient. Although steroid pulse therapy is often completed after one or two courses, it was decided that three courses be performed over a 3-week period because the patient had severely impaired vision and was a relatively young man with no underlying disease other than hypertension. In the present case, one course of steroid pulse therapy consisted of intravenous methylprednisolone 1,000 mg/day for 3 days, followed by rest for the remaining 4 days.\nPlatelet aggregation test findings showed that the maximum aggregation rate with the use of aggregation-inducing substances increased to 80% with 1 muM of adenosine diphosphate (ADP) and 84% with 0.5 mug/mL of collagen. Blood examination results showed increased platelet aggregation; thus, oral aspirin 100 mg/day was also started. Findings of optic disc edema, macular edema, and retinal hemorrhage demonstrated gradual improvements, and visual acuity in the right eye increased to 20/1,000 ( Figures 2A, C ).\nThree months after the onset of the conditions, extensive non-perfusion areas were observed in the FA images, mainly on the nasal side. Pan-retinal photocoagulation was performed 2 months later because FA revealed retinal neovasculization. FA findings obtained at that time also indicated extensive non-perfusion areas, mainly on the nasal side, as well as leakage of fluorescein from the neovascular vessels on the superior nasal side ( Figure 2B , arrowhead).",
"gender": "Male"
}
] |
PMC11182238
|
[
{
"age": 65,
"case_id": "PMC11096476_01",
"case_text": "A 65-year-old woman was referred to our hematology service in July 2020 after a severe COVID-19 infection requiring intensive care ( Figure 1 ). The patient presented with mild monocytosis and thrombocytopenia. Her complete blood counts (CBC) were: PLT 60 x 103/microl, WBC 6 x 103/microl, ANC 3.6 x 103/microl, ALC 1.2 x 103/microl, Monocytes 1.8 x 103/microl, Hb 12 g/dl, and MCV 100.5 fL. Her physical examination was negative. After a ten month follow up showing persistent monocytosis, thrombocytopenia and macrocytosis, secondary causes were ruled out (autoimmune or infectious diseases), and a bone marrow evaluation was diagnostic for CMML-0 dysplastic type according to WHO 2016 classification in May 2021. Cytogenetics and FISH were normal, while molecular testing showed oncogenic mutations in TET2 and SRSF2 genes. CPSS and CPSS-mol risk score were low, so a watch and wait strategy was established. Soon after, the patient complained of visual loss in her left eye; the dilated fundus evaluation showed mild vitritis and a hypo-pigmented choroidal lesion with exudative retinal detachment in the mid-temporal periphery. Multimodal imaging including A- and B-scan ultrasound, dye angiography and optical coherence tomography suggested an infiltrative lesion ( Figure 2 - panels 1, 2A, 3A). A retino-choroidal biopsy, performed in December 2021, disclosed substantial involvement by medium-sized mononuclear cells, immunoreactive for CD45, CD14, and CD68R. The absence of CD34 and CD117 immunoreactivity ruled out a myeloid sarcoma and the ophthalmic lesion resulted consistent with involvement by CMML. The patient was evaluated for intensive chemotherapy and subsequent consolidation with allo-SCT considering the poor prognosis associated with ocular involvement. However, one month later (January 2022), a new ophthalmic evaluation revealed a spontaneous decrease in the lesion size. In addition, a reduction in visual acuity from 20/28 to 20/100 was reported, due to damage to the outer retinal layers resulting from subretinal exudation. CBC and marrow disease were stable and, considering the low risk according to CPSS-mol, we opted for a \"watch and wait\" strategy. The CMML ophthalmic lesion completely disappeared in June 2022 ( Figure 2 - panels 2B and 3B). At last follow up in March 2024 the patient had stable CBC; a new bone marrow evaluation, performed in November 2023, confirmed stable chronic disease, without signs of leukemic evolution and the left choroidal lesion was in complete remission with a good vision recovery.",
"gender": "Female"
}
] |
PMC11096476
|
[
{
"age": 17,
"case_id": "PMC11284136_01",
"case_text": "A 17-year-old female inpatient was referred from the Pediatrics Department to the Oral Medicine Department at Hasan Sadikin Hospital with complaints of painful mouth ulcers, dryness of the lips and difficulties in swallowing. This condition made it difficult for the patient to eat and drink, resulting in the patient's physical condition becoming weak and debilitated. The ulcer has been present for 3 days, has not improved and tends to bleed. However, the bleeding has stopped since the previous day. The Pediatrics Department administered Kenalog in Orabase in response to this patient's oral condition.\nThe patient complained of body aches, rashes and hair loss 2 months ago. This condition was examined at Kebon Jati Hospital, and the diagnosis of SLE was confirmed. Approximately 2 weeks ago, the patient complained of the same condition and finally decided to be treated at Hasan Sadikin Hospital. Comprehensive and multidisciplinary examinations established that, in addition to SLE, the patient was also diagnosed with hepatosplenomegaly, during the third week of hospitalisation. Enlargement of the liver and spleen were found during abdominal CT scan. Blood tests performed during treatment are shown in Table 1.\nDuring this two-week period, the patient took a diverse drug regimen that administered by the Pediatrics Department, which includes Levofloxacin, Amikacin, Ampicillin-Sulbactam and Ethambutol for the antibiotics. Fluconazole was given intravenously. Steroidal anti-inflammatory drugs were given IV Methylprednisolone and Triamcinolone Acetonide topically. Omeprazole and Ca. Carbonate as antacid and PPI. Vitamin D and Curcuma as dietary supplements and Paracetamol were also given.\nOn extraoral examination, the patient's conjunctiva was anemic, and there was dryness and exfoliation of the lips that tends to bleed along with hemorrhagic crusts with serous sanguinolenta. During intraoral examination, there were lesions covering on almost all areas of the oral mucosa. Multiple ulceration on the upper and lower labial mucosa. A painful ulceration on the left buccal mucosa measuring 5 x 6 mm with erythema border. Central palatal erythema was seen on the palatum durum. Candidiasis pseudomembrane was also seen on the dorsum of the tongue, accompanied by papillae elongation (Figure 1). \nNaCl 0.9% was administered and used to perform several instructions related to the patient's oral condition. Cleaning the teeth using a saline-moistened gauze was the most important thing because during the 2 weeks of hospitalisation, the patient neglected her oral hygiene. Hemorrhagic crusts on the lips and labial mucosa were also instructed to be dressed using moist gauze (NaCl 0.9%) as often as possible. This was done five times a day, with the aim of moistening lips and removing the crusts.\nThe condition of multiple and widespread ulcerations on the upper and lower labial mucosa, a topical steroid ointment mixture, was administered to the patient. A mixture containing Dexamethasone 0.5 mg mixed with Lanolin 2.5 mg and petroleum jelly added up to 25 mg was instructed for the patient to use it three times a day, after applying saline dressing. Considering other ulcerations, one of which was on the left buccal mucosa and also other ulcers that were difficult to reach by hand, 0.025% hyaluronic acid was administered to relieve inflammation locally.\nDuring the second visit, on 22 November 2022 (Figure 2), it was seen that the general condition of the patient's oral cavity had improved. The patient's tongue still showed whitish plaque, which was finally given Nystatin oral suspension, but had to be stopped after 2 days of administration regarding the hepatosplenomegaly condition. The ointment was stopped and replaced with petroleum jelly. The other medication was continued until the next evaluation, for the next 6 days. On 28 November 2022, the patient had no complaints about his oral cavity, but clinically there was still a presence of exfoliative cheilitis, coated tongue and ulcer in the left buccal mucosa, which had subsided. (Figure 3) \nThe patient was discharged 2 days later and continued outpatient care. The last visit was conducted on 16 December 2022. The patient had no complaints, could follow oral hygiene instructions and gave advice to the patient to extract radix of deciduous teeth 55 and 65. (Figure 4)",
"gender": "Female"
}
] |
PMC11284136
|
[
{
"age": 10,
"case_id": "PMC11225525_01",
"case_text": "A 10-year-old healthy female child presented with recurrent occipital headaches over 1 year. The physical and neurological examinations were unremarkable. Head computed tomography imaging showed a small, rounded, hyperdense lesion located anterior to the pontomedullary junction. On MRI, the lesion seemed extra-axial and was mostly hyperintense on T1 and T2/T2 fluid-attenuated inversion recovery, with facilitated diffusion, no chemical-shift artifact (not a fatty lesion), and no gadolinium enhancement, with a small nodule within of low signal on T1, T2, and T2*, suggestive of calcification. The lesion measured about 10 x 9 x 8 mm in size (anterior-posterior x transversal x craniocaudal) and 280 mm3 of volume and had no surrounding edema, with a slight mass effect on the BS [Figure 1]. Due to the relatively innocent clinical manifestations and dimensions of the lesion, a \"watch and wait\" strategy was initially employed.\nOn an initial conservative strategy with serial follow-up brain MRIs, there was a progressive growth of the lesion, which became more lobulated and extended to the pre-bulbar and pre-pontine cisterns, measuring 19 x 28 x 23 mm and 5400 mm3 of volume, with significant mass effect. The prepontine vasculature was further anteriorly displaced but not encased. This led to the decision of neurosurgical treatment [Figure 2].\nThe patient was positioned in a lateral position, and we performed a right retro mastoid craniotomy with an extension to the foramen magnum. On an operating microscope and neuronavigation-assisted, the cyst wall was exposed, widely fenestrated, and its fluid was drained, revealing a thick yellow liquid content. After aspiration and profuse irrigation of the cyst, part of the cyst wall was removed. The part of the cyst wall adherent to the BS and basilar artery was not removed [Figure 3].\nThe histologic findings were of a pseudo-stratified epithelium with no anaplasia, consistent with the diagnosis of a benign endodermal cyst. In the postoperative period, the patient experienced no neurological alterations, and postoperative MRI showed complete drainage of the cyst and the persistence of a small T2 hypointense nodule. At 1 year follow-up, the patient was well, active, and with no symptoms, and imaging showed no evidence of recurrence of the lesion [Figure 4].",
"gender": "Female"
}
] |
PMC11225525
|
[
{
"age": 62,
"case_id": "PMC10898597_01",
"case_text": "A 62-year-old female was referred to our dermatological department with a 6 months history of progressive oral erosion and skin erythema and blisters. The severe oral pain caused feeding disorders, leading to weight loss. Physical examination revealed that post-blistering erosions were mainly present on the left palatal mucosa (Figure 1a) and several small fluid-filled blisters and erythema were scattered on the scalp, trunk, and limbs. Histopathology of a blister on the scalp revealed that there was a cleavage between the epidermis and dermis with a few eosinophils and lymphocyte infiltrations (Figure 2a). Direct immunofluorescence testing found linear immunoglobulin G (IgG) and C3 deposits along the dermoepidermal junction (Figure 2b). A serological examination revealed elevated anti-BP180 levels (81.16 U/mL) and normal BP230 levels on enzyme-linked immunosorbent assay (ELISA) (Euroimmun, Medizinische Labordiagnostika AG, Germany). Other laboratory findings, including routine blood analysis; urine analysis; liver, kidney, and thyroid function tests; erythrocyte sedimentation rate; antinuclear antibodies; and Rheumatoid factor were within the normal range. Based on these findings, a final diagnosis of MMP was made. \nFor 2 months, the patient was placed on a high-potency topical corticosteroid and topical tacrolimus; however, no significant improvements in the symptoms were noted. The patient refused to receive the treatment of systemic corticosteroid or immunosuppressive agents for their long-term adverse events and she also refused the dupilumab therapy for its subcutaneous injection administration.\nAfter a routine blood examination, biochemistry analysis, coagulation function tests, and chest computed tomography (CT) to rule out severe infection, coagulation dysfunction, hepatic failure, renal disorder, and tuberculosis, she was prescribed 100 mg of abrocitinib per day. After 3 days of abrocitinib therapy, she reported significant improvement in pain. Two weeks later, the oral erosions had mostly subsided (Figure 1b); 4 weeks later, they had disappeared without any accompanying pain and discomfort (Figure 1c), and the skin blisters were mostly dry. The anti-BP180 levels had decreased to within the normal range. The abrocitinib was reduced to 100 mg every other day and discontinued 2 months later. No relapse or adverse events were observed during the treatment (median, 3 months) or follow-up period (median, 3 months).",
"gender": "Female"
}
] |
PMC10898597
|
[
{
"age": 4,
"case_id": "PMC10507246_01",
"case_text": "We report the case of a four-year-old female patient who was presented at the pediatrics clinic at the University Clinical Centre of Kosovo with recurrent seizures and developmental delay. The patient was born on July 2018 at the gynecology and obstetrics clinic at the University Clinical Centre of Kosovo with an Apgar Score of 9/10. She was born at term, by vaginal delivery, and after a normal and uneventful pregnancy. The body weight at birth was 3,250 grams, the body height was 53 centimeters, and the head circumference was 34 centimeters. The patient was the first child from the first pregnancy of non-consanguineous parents. She had no history of perinatal asphyxiation, encephalitis, head injury, or febrile seizures. The parents denied the use of any medications. Her family history was negative for any neurological or genetic illnesses. An echocardiography was performed six days after the birth, and aberrantly inserted chorda tendineae in the left ventricle were observed.\nIn the third month of life, the patient experienced clusters of seizures of combined focal and generalized onset, which predominately occurred during the day. Seizures were generally brief, lasting from several seconds to a minute. They included tonic-clonic activity with motor activity being confined to one part of the body, migrating to another part of the body, and commonly becoming generalized seizures. In the beginning, the patient experienced one to two cluster of seizures weekly, which persisted in the following days at a higher frequency. The patient was admitted to the pediatric clinic in the University Clinical Centre of Kosovo. In a physical examination a relative microcephaly and a bilateral decreased muscle tone were evident.\nAt the age of fifteen months, she was admitted to the neurology department of pediatrics clinic in the University Clinical Centre of Kosovo. In physical examination, a relative microcephaly, facial dimorphism (Figure 1), including micrognathia and slopping forehead, a weakness of the limbs, intellectual disability, speech delay, inability to stay seated, and inability to keep the head straight and up were observed. Moreover, the neurological exam revealed a bilateral decreased muscle tone and decreased reflex response of the limbs. At the age of 28 months the head circumference measurement was under the third percentile.\nAn electroencephalogram (EEG) during wakefulness (Figure 2) was performed and it showed regular basic electro-cerebral activity, with predomination of alpha and teta rhythm and specific elements in both hemispheres. An EEG during sleep was performed, and it showed basic activity, which considering patient's age, was not well developed and there was a slower activity in the left hemisphere compared to the right one. In both hemispheres, sharp waves were observed. Moreover, the amplitude of waves of the left hemisphere were of high and low-frequency. A high-amplitude trunk was observed, which began from the frontal-central area on the left. It did not spread and had a slow-sharp activity. An epileptic activity that began in the ictal period is seen, which was built up in the mid-temporal area and lasted approximately 60 seconds. In conclusion, this EEG revealed an epileptiform abnormality which presented in the inter-ictal period from the left frontal-central area and in the ictal period from the left mid-temporal area.\nThe patient underwent a brain MRI (Figure 3), which showed volume loss in the posterior periventricular area and parietal parenchyma and obvious myelin destruction with no sign of hypoxic involvement (gliosis). Left dominant enlargement of the lateral ventricles secondary to loss of central parenchyma was also observed. In contrast, bulbus, pons, mesencephalon, both cerebellar hemispheres, and vermis parenchyma were normal. The development of cerebral myelin was paracentral and the major cerebral vascular structures were patent. Cerebral sulcus pattern and cortex thickness were normal, and cortical dysplasia was absent.\nThis patient's symptoms and clinical signs did not allow us to pinpoint a potential clinical diagnosis. Therefore, an Exome sequencing (ES) analysis was performed. While targeted genetic testing focuses on a single gene or a limited number of predetermined genes, the ES analysis simultaneously examines all protein-coding regions in the genome (exons). The DNA obtained from the biological material of the patient was enriched using the \"QIAseq Human Exome\" kit to cover all exome regions in humans (targeting 99% of the exonic regions including CCDS, RefSeq and renecode databases). The enriched library is sequenced to an average of 100X coverage on the QIANGEN next generation sequencing platform. The reference genome used in the study is GRCh37/hg19. In the bioinformatics analysis part, IDT WES Copy of Identify Variants Exome v1.1.1 workflow recommended by QIAGEN was used. QIAGEN Ingenuity Variant Analysis (IVA) and QIAGEN Clinical Insight (QCI) were used for variant interpretation and analysis. All variants in the panel with a reading depth of 10x, allele fraction 1% and quality score higher than 10% were examined. All disease-associated variants reported in the HGMD , ClinVar or CentoMD databases, as well as variants with a frequency of less than 1% in population databases such as ExAc, 1,000 Genomes gnomAD, and NHLBI ESP were also included. In addition, it was examined with the variants found in QIAGEN's own database (Allele Frequency Community). In the evaluation of the data obtained, +/-10 base pairs of intronic regions were also included in addition to the coded exonic regions.\nThe c.101-1G>C variant in the CHD4 gene was detected in a heterozygous state. CHD4 gene is located on chromosome 12 (12p13.31) and consists of 39 exons. Heterozygous variants in the CHD4 gene are associated with Sifrim-Hitz-Weiss syndrome. The c.244dupT variant in the ACADM gene variant was detected as a homozygous state. This causes the production of shorter proteins due to the replacement of tryptophan with leucine at position 82. ACADM gene is located on chromosome 1 (1p31.1) and consists of 12 exons. Homozygous variants in the ACADM gene are associated with medium chain acyl-CoA dehydrogenase deficiency. The c.2665G>A variant of the KCNT1 gene was detected as a heterozygous state, which causes the alanine amino acid at position 934 to be converted to threonine amino acid (missense variant). The KCNT1 gene is located on chromosome 9 (9q34.3) and consists of 31 exons. Heterozygous variants in the KCNT1 gene are associated with developmental and epileptic encephalopathy-14.\nAuxiliary examinations, including routine blood examinations, serum biochemical examination, cerebrospinal fluid (CSF) examination, urine and stool examination, and autoimmunity antibodies testing were unremarkable. Blood amino acids and acyl-carnitine analyses for inherited metabolic diseases, and urine organic acids were unrevealing at the first admission to our clinic. Further tests showed no fluid or electrolyte imbalance. Testing for toxoplasmosis, rubella, cytomegalovirus, and herpes simplex virus, and their respective antibodies were negative as determined by PCR and ELISA. However, after the thyroid function examination, our patient was diagnosed with congenital hypothyreosis, and treatment with Levothyroxine sodium (15 mcg/kg/day orally) was initiated.\nA treatment regimen which consisted of multiple anti-seizure medications, such as valproic acid (450 mg/daily), levetiracetam (400 mg/daily), phenobarbital (50 mg/daily), and clonazepam (1.5 mg/daily) was initiated. Despite the regular administration and titration to the optimal dosage of the antiseizure medications, only partial control of the seizures was achieved, and the patients continued to experience tens of seizures per week. Moreover, our patient experienced a severe intellectual delay, failed to meet the developmental milestone for her age, and was frequently hospitalized in our clinic due to frequent seizures and respiratory distress.",
"gender": "Female"
}
] |
PMC10507246
|
[
{
"age": 47,
"case_id": "PMC10890900_01",
"case_text": "A 47-year-old male university professor, previously hypertensive with adequate blood pressure control, developed hypoparathyroidism after a total thyroidectomy for papillary thyroid carcinoma performed 15 years ago. More than one year after the procedure, he had a PTH of less than 2.5 pg/mL and calcium of 7.9 mg/dL (Table 1). At the time, he was asymptomatic, with no changes in the physical examination suggestive of hypocalcemia, and was using levothyroxine 150 mcg, calcium carbonate 1000 mg/day, and calcitriol 0.25 mcg, in addition to antihypertensive drugs (amlodipine, losartan, and hydrochlorothiazide). Medication adjustments led to calcium-level normalization. About ten years after starting follow-up, the patient had a total calcium of 9 mg/dL (Table 1), using calcium carbonate 1500 mg/day and calcitriol 0.25 mcg. He remained asymptomatic without clinical, imaging, or laboratory signs of thyroid carcinoma recurrence.\nAfter a few years with irregular medical follow-up and no calcium-level evaluation, the patient returned for a consultation with a cardiologist with vague complaints of mental confusion, fatigue, and weight loss (approximately 3 kg). Laboratory tests performed at that time showed worsening of renal function (creatinine 7.31 mg/dL) and hypercalcemia (calcium 17.1 mg/dL) (Figure 1). The patient was hospitalized for management of hypercalcemia, receiving vigorous intravenous hydration, and having suspended calcium carbonate and calcitriol. During hospitalization, alternative causes for loss of renal function were evaluated, ruling out primary or secondary glomerular damage; there was also no evidence of direct tubular damage. The finding of bicarbonate (alkaline reserve) at the upper limit of normal was noteworthy despite the loss of renal function. The patient evolved with progressively lower calcium levels and was discharged with a calcium of 10.7 mg/dL (Figure 1) and creatinine of 5.9 mg/dL after four days of hospitalization, with an indication for follow-up investigation on the etiology of hypercalcemia on an outpatient basis.\nThe etiologic investigation included serum protein electrophoresis and urine light-chain investigation, which ruled out paraproteinemia as a cause of hypercalcemia. In addition, imaging excluded solid neoplasms: (a) chest tomography showed no tumescent lesions; (b) abdomen tomography identified nephrolithiasis on the left kidney and a nodular image in the left adrenal measuring 1.2 cm of indeterminate nature; (c) upper digestive endoscopy had no alteration, and (d) colonoscopy identified a tubular adenoma with low-grade dysplasia.\nBone scintigraphy and whole-body PET-CT were also performed, with no image suggestive of neoplasia. The dosage of PTH-related protein (PTHrp) was less than 1.02 pg/mL.\nThe adrenal nodule was associated with excessive aldosterone production, reduced renin secretion, and elevated aldosterone/plasma renin activity ratio (Table 1). It was decided not to perform a suppression test because the patient still had compromised renal function, low volume tolerance, and adequate blood pressure control with current medications.\nAfter 30 days of the acute condition, the patient remained with controlled calcemia (Figure 1) without additional intervention. The diagnosis of the calcium-alkali syndrome was based on loss of renal function, alkalosis even with a severe reduction in glomerular filtration rate (Table 1), unmonitored use of calcium carbonate and vitamin D in the setting of diuretic usage, and investigations ruling out other secondary causes of hypercalcemia. At last, the favorable evolution of hypercalcemia also reinforces this diagnosis.\nHydrochlorothiazide usage and primary hyperaldosteronism are events peculiar to this case and contributors to alkalosis and hypercalcemia. Finally, six months after admission for hypercalcemia, the patient had symptomatic hypocalcemia (positive Trousseau maneuver), reinforcing the diagnosis. In this context, calcitriol 0.5 mcg was restarted to resolve symptoms and control calcemia without additional calcium carbonate supplementation.",
"gender": "Male"
}
] |
PMC10890900
|
[
{
"age": 31,
"case_id": "PMC10846666_01",
"case_text": "We present a male patient, 31 years old, white, born and residing in Portugal, working in a car parts sales factory. The patient is a smoker with an estimated smoking history of 13 pack years. He denied using chronic medication. He was electively admitted to an internal medicine service to study bimalleolar edema with four weeks of evolution. He reported having a fever (mainly at night, maximum temperature measured at 39oC in the axilla) and night sweats. A physical examination highlighted edema in both lower limbs, with palpation of subcutaneous nodules.\nThe blood test analysis evidenced high inflammatory parameters, namely, a C-reactive protein (CRP) of 11 mg/dl and a sedimentation rate of 75 mm/h. From the urinary study, the absence of proteinuria stood out, which ruled out nephrotic syndrome. Of the remaining studies, HIV, hepatitis B and C, and syphilis serology were negative, autoimmunity and angiotensin-converting enzyme (ACE) were unchanged, and interferon-gamma release assay (IGRA) was negative.\nOn the chest X-ray, the patient showed perihilar reinforcement, mainly in the right hilum, which is why a contrast-enhanced computerized axial tomography (CECT) scan was then carried out (Figures 1, 2), which revealed perihilar and mediastinal lymphadenopathy, with no parenchymal involvement.\nAs it was imperative to exclude lymphoproliferative disease, positron emission tomography (PET) was performed (Figure 3), which revealed anomalous hypermetabolism in the bilateral perihilar pulmonary and mediastinal lymph nodes.\nTherefore, a mediastinoscopy was performed, which showed, surprisingly, that the pathological anatomy demonstrated non-necrotizing granulomas, with a negative mycobacteria (Mycobacterium tuberculosis) CB-NAAT (cartridge-based nucleic acid amplification test).\nDuring the diagnostic process, the symptoms spontaneously reversed without medication; therefore, the diagnosis of Lofgren syndrome was made. The patient is currently undergoing follow-up consultations in rheumatology, internal medicine, and pulmonology, and he is asymptomatic.",
"gender": "Male"
}
] |
PMC10846666
|
[
{
"age": 44,
"case_id": "PMC11371678_01",
"case_text": "A previously healthy 44-year-old female of German origin, living in UAE for more than 8 years, was referred to our care by an internist. She presented at Fakeeh University Hospital in Dubai, United Arab Emirates, in November 2021 with a chronic cough and purulent sputum lasting for 1 year. Earlier in mid-2020, she developed a persistent dry cough and sought medical attention from a general practitioner. Following an allergy test that revealed her sensitivity to pollen, she was prescribed Antihistamines, which were ineffective in alleviating her symptoms.\nIn May 2021, she was inaccurately treated in a local clinic for a bacterial infection with Ampicillin, which unfortunately triggered an allergic reaction. In September 2021, she returned to the local clinic with new onset yellowish sputum and was prescribed another course of antibiotics that the patient does not recall. In November 2021, she experienced a recurrence of the same symptoms, which drove her to Fakeeh University Hospital for medical advice. However, she did not exhibit any significant weight loss, night sweats, fever, or hemoptysis. Her past medical and family history is insignificant. She is a nonsmoker, a married housewife who lives at home with her family, none of whom are experiencing similar symptoms. Additionally, she stated having not had contact with TB patients and stated that there are no pets at home. It is also worth mentioning that she has never received the Bacille Calmette-Guerin (BCG) vaccine and travels annually to her homeland during the holidays.\nGenerally, she appeared alert, oriented, well-nourished, and not in distress. The physical examination showed no cervical lymphadenopathy. Auscultation of the chest revealed normal bilateral vesicular breathing, with a bronchial breathing pattern noted in the right upper lung. Sputum samples were collected for further investigations. In addition, a chest x-ray was done, revealing a pulmonary cavity as shown in Figure 1. The sputum culture, conducted over a 6-week period, reported growth of Mycobacterium riyadhense in December 2021 as seen in Table 1, with drug sensitivity tested and showed susceptibility to all first- and second-line anti-TB medications. Consequently, a 6-month course of anti-TB medications was initiated, consisting of 2 months of Isoniazid, Rifampin, Pyrazinamide, and Ethambutol, followed by 4 months of Isoniazid and Rifampin. Additionally, vitamin B6 supplements were given, along with a battery of serial investigations to detect any possible medication side effects. These side effects include: visual field assessment; uric acid levels; and liver function tests were monitored monthly and were all nearly normal. After completing the anti-TB regimen, symptoms subsided with radiological images showing improvement.\nOn July 27, 2022, the patient experienced a relapse characterized by fever and productive cough, NTM was confirmed again by PCR, but drug sensitivity was not retested at this point. Consequently, she was restarted on the same anti-TB medications, effectively alleviating the symptoms. An immunodeficiency workup was conducted in August 2022, and the findings are presented in Table 1. Additionally, a chest computed tomography (CT) scan was ordered to accurately evaluate the progression of her disease. The scan revealed a pulmonary cavity in the right lung (Figure 2A) and a \"tree-in-bud\" pattern, indicating the presence of mucus and pus causing the normally invisible peripheral airway to become visible (Figure 3A). 1 month later, a bronchoscopy with biopsy was performed to potentially identify other granulomatous diseases that resemble tuberculosis, given the patient's recent relapse. Biopsy results showed necrotizing granuloma in the submucosa of the right upper lung. For more details, refer to Table 1.\nIn early January 2023, just 1 month before completing her second anti-TB course (2 months of Isoniazid, Rifampin, Pyrazinamide, and Ethambutol, followed by 4 months of Isoniazid and Rifampin), she relapsed again for a week, presenting with night sweats, fever, productive cough, and pain in the upper right chest. Subsequently, M. riyadhense was detected by sputum acid-fast bacilli (AFB) stain and culture, showing sensitivity to all four anti-TB medications (Table 1). Following a multidisciplinary team discussion to modify her medications, a decision was made to start Ethambutol and Pyrazinamide, along with Linezolid 600 mg and Moxifloxacin 400 mg. We also included biweekly electrocardiograms to monitor QTc for possible side effects. However, she did not opt for the new regimen, stating that she is feeling better. In addition, a consultation with a thoracic surgeon was planned to discuss the possibility of segmentectomy vs. right upper lobectomy. This consideration arises as the cavity likely functioned as a bacterial reservoir, contributing to her frequent relapses. Despite controversial radiologic findings with worsening pulmonary cavity seen in Figure 2B and regressing \"tree-in-bud\" pattern seen in Figure 3B, the patient appeared reluctant to undergo the latter procedure. After thorough discussion, the patient decided to wait and to get back to the hospital whenever she is ready to resume treatment.\nIn February 2024, the patient contacted the thoracic surgeon to proceed with right upper lung lobectomy, which was uneventful with good lung expansion and no pleural effusion. One week after discharge, she presented with fever, profuse night sweats, and productive cough, which was diagnosed as moderate right-sided pleural effusion for which she was admitted for 4 days. Ultrasound-guided thoracentesis (with pleural sampling) was performed, and the pleural fluid analysis showed lymphocytic exudate and a negative AFB stain, highly suggestive of mycobacterial pleural effusion. The previously suggested modified regimen was initiated, which includes Ethambutol 1,200 mg OD, Pyrazinamide 1,500 mg OD, Moxifloxacin 400 OD, and Linezolid 600 OD (+ Pyridoxine 10 mg OD). In March 2024, Moxifloxacin caused severe tendinitis, which was replaced by Rifampin with the rest of the regimen unchanged.\nIn April 2024, after the latest drug sensitivity results were received, the patient's treatment plan was modified to Isoniazid 300 mg OD, Rifampin 600 mg OD, Ethambutol 1,200 mg OD, Pyrazinamide 1,500 mg OD, and Clarithromycin 500 mg BID. After the final treatment plan, during the subsequent follow-up visit, the patient stated that her symptoms significantly improved apart from a minimal residual cough that is slowly improving. She expressed satisfaction with the results and the plan of care.",
"gender": "Female"
}
] |
PMC11371678
|
[
{
"age": 50,
"case_id": "PMC10287503_01",
"case_text": "A 50-year-old man presented to an outside hospital with unstable angina after suffering from a non-ST elevation myocardial infarction 1 year prior in Hong Kong. Echocardiography showed decreased EF (45%) with apical hypokinesia but no aortic or mitral valve abnormalities. Further workup included a coronary angiography, which showed a, most likely, ruptured, nonstenosing LAD plaque and cardiac magnetic resonance imaging, which revealed an aneurysm of the base of the anterior ventricular wall (see Fig. 1 ). \n The patient was cannulated in standard bicaval fashion, cardiopulmonary bypass (CPB) was commenced and the heart arrested with cold Bretschneider cardioplegia. The area of the aneurysm, a protrusion in the left ventricular wall between LAD and first diagonal branch with scarred margins, was easily identified by palpation (see Fig. 2A , black arrow). An incision was made and the affected area was resected (see Fig. 2B ), with care taken to avoid injury to the LAD. The atrium and ventricle were not dilated (38 and 50 mm, respectively, on echocardiography) and therefore the ventriculotomy was closed with a 5 x 2cm (visual judgement) bovine pericardial patch with single 3-0 Prolene sutures reinforced by felt strips (see Fig. 2C, D ) without using any glue. We used pericardial patch material based on the general institutional policy preferring bovine material due to anticipated low thrombogenesis and excellent surgical handling qualities. The course of the LAD was carefully dissected to avoid putting stress on the myocardium and causing stenosis (see Fig. 2E , F , black arrow). After weaning from CPB and adequate deairing, transesophageal echocardiography showed unchanged EF but no new wall contraction irregularities and again no aortic or mitral valve insufficiency. \nThe postoperative course proceeded without any complications; the patient stayed on the intensive care unit for 2 and 12 days on the normal ward. A final echo showed only minor reduction in EF; the patient was discharged without any symptoms of angina and was advised to take phenprocoumon for 3 months due to the newly inserted foreign patch material. On 2-month follow-up, the patient presented in good general condition with a normal EF on echocardiography.",
"gender": "Male"
}
] |
PMC10287503
|
[
{
"age": 15,
"case_id": "PMC11165051_01",
"case_text": "A 15-year-old male patient presented to our surgical department with a two-year history of paresthesia and fasciculations of the tongue and difficulty swallowing. He also reported that the fasciculations sometimes resulted in impairments in the tone of his language that were consistent with right hemisphere damage, with consequent problems speaking. The patient also reported tinnitus in the right ear within the past year, with sporadic weekly or monthly episodes lasting a few minutes before spontaneously resolving. A neurological examination showed fasciculations on the right side of the tongue. The patient also reported self-perceived, limited rightward tongue mobility. This was confirmed with the observation of reduced external tongue movements. A slight deviation of the tongue to the left was also observed. A magnetic resonance imaging (MRI) study of the neck using gadolinium was performed according to T1 and T2 multiplanar sequences, with suppression of the adipose tissue signal, T2 fast field echo, diffusion-weighted imaging, and Dixon T1 and T2 before and after endovenous administration of paramagnetic contrast.\nAn oval mass with sharp and regular limits was detected at the most cranial portion of the right carotid adipose space, caudal to the right carotid and lateral foramen. The mass was approximately 45 x 29 x 25 mm and was characterized by inhomogeneous T2 hyperintensity due to some contextual hyperintense areas in T2 ( Figure 1 ). The mass displaced the internal carotid artery anterolaterally and exerted modest compression posterior to the internal jugular vein, with a slight increase in the caliber of the upstream sigmoid sinus. At this point, the differential diagnosis was either a schwannoma of the hypoglossus or a vagus nerve/hypoglossal paraganglioma. The MRI scans of the brain uncovered no pathological findings. Oncologists were consulted, and they recommended testing urinary vanillylmandelic acid and homovanillic acid levels for a complete oncological framing; these showed positive results. Preoperative angio-computed tomography confirmed the hypothesis of an expansive lesion of the nerve sheath. Under general anesthesia, the patient underwent surgical removal of the mass via an oblique incision at the level of the right sternocleidomastoid muscle in the supine position. The portion of the tumor posterior to the internal carotid artery and anterior to the internal jugular vein was adequately identified ( Figure 2 , left). The mass was then isolated by carefully preserving the nerve structures and monitoring them with an evoked potential monitoring system. Excision was macroscopically completed ( Figure 2 , right). Motor potentials were unaffected after surgery. A Redon-type suction drain was placed and then removed after two days, and the patient was discharged on the fifth postoperative day. Antibiotic therapy with ampicillin/sulbactam and steroidal therapy was administered for seven days. This was initially administered intravenously and then orally. A histological examination confirmed the radiological suspicion of a schwannoma, as the morphophysiopathological picture was consistent with a schwannoma originating from the hypoglossal nerve (S100+, calretinin+, SOX10+, D240+, and Ki67 5%) ( Figure 3 ). After removing the mass, the patient no longer complained of lingual discomfort but experienced mild eyelid ptosis, miosis, and paresthesia in the ipsilateral cheek, which steadily improved. Although a six-month follow-up period is relatively short for investigating possible relapse in such a pediatric case, there were no signs of tumor recurrence at a follow-up MRI performed six months after surgery ( Figure 4 ), and the patient was in excellent general condition.\nThe main characteristics of the present case are summarized in Table 1 .",
"gender": "Male"
}
] |
PMC11165051
|
[
{
"age": 25,
"case_id": "PMC10911786_01",
"case_text": "A 25-year-old man was referred to the dermatology department with extensive skin folding on his forehead and face, along with a gyrus-like scalp and depressed nasolabial folds. He also complained of bilateral joint pain, muscle soreness, and hyperhidrosis. These symptoms were first noted at 18 years of age. No other family members had a similar condition, and the patient had no history of trauma or fracture. He had been repeatedly operated on for facial purulent nodules at a local hospital, after which painful and pruritic skin tumors had formed. Informed consent for this evaluation was obtained from the patient.\nOn examination, the patient had different pronouncedly shaped keloids on his forehead and face, among the largest being 7 cm x 2 cm in size located on the forehead (Fig. 1a). In addition, the skin folds in the scalp were gyrus-like (Fig. 1b). The development of the patient's skin folds had been insidious and progressive. Clubbing of his fingers and toes (Fig. 1c-e) was observed. The patient had swollen ankles. Moreover, he had seborrhea and profuse sweating in his axillae, hands, and feet accompanied by muscle soreness.\nExamination of the patient's cardiovascular, respiratory, urinary, and gastrointestinal systems revealed no significant abnormalities. Laboratory analyses of blood routine tests, electrolytes, thyroid function, liver function, renal function, blood sugar, parathyroid hormone, and adrenocorticotrophic hormone were normal. Radiographic investigations were performed to search for skeletal abnormalities. X-rays revealed thickening of the bone, indicating increased cortical bone formation in all four limbs. Moreover, there was a cystic region in the distal left ulna (Fig. 1f-h).\nBased on the existing data from history, examination, and investigation, the patient was diagnosed with complete primary PDP and facial keloid scars. After diagnoses and exclusion of relevant surgical contraindications, the patient underwent skin dermabrasion on his face and forehead. After satisfactory general anesthesia, iodine was applied to disinfect the patient's forehead and face, and sterile drapes were placed. The forehead and the sides of the face were anesthetized via tumescent anesthesia with lidocaine solution containing 1:100,000 epinephrine.\nA 1 cm x 0.5 cm-long fusiform incision was made at the skin junction between the forehead and scalp with a No. 10 circular blade up to the subcutaneous fat layer. Then, we sent the tissue for pathological biopsy, and the wound was closed with intermittent suture using a No. 1 silk tread. A No. 10 bard-parker scalpel blade was used to cut the raised skin lesions on the forehead and on both sides of the face until the wound was covered with normal skin. Subsequently, the bleeding was stopped with electrocoagulation hemostasis.\nThe patient's face was disinfected with povidone iodine a second time and treated with a carbon dioxide lattice laser with a minimum energy of 100 mJ, a coverage rate of 2.89%, and a spot size of 15 mm x 15 mm; this process was repeated 4 times and followed by multipoint injections of a mixture composed of 3 mL 2% lidocaine, 1 mL Diprosan and 1 mL fluorouracil and a mixture containing 10 mL normal saline and 100 units botulinum toxin type A, administered separately with a 1 mL syringe.\nTranilast was taken orally three times a day at a dose of 0.1 g, isotretinoin capsules were taken orally once a day at a dose of 30 mg, and spirolactone was taken two times a day at a dose of 20 mg postoperatively. The patient was satisfied with the postoperative outcome. Subsequently, he was injected with botulinum toxin type A once every 6 months (Fig. 2).\nMicroscopic evaluation of the excised skin revealed hyperkeratosis of the epidermis and neutrophilic abscess. Dermal vasculature, lymphoid tissue cells, plasma cells, neutrophilic leukocytes, and fibrous tissue hyperplasia were observed. Scars had formed. Some blood vessels were perpendicular to the epidermis (Fig. 3).",
"gender": "Male"
}
] |
PMC10911786
|
[
{
"age": 27,
"case_id": "PMC10936715_01",
"case_text": "A 27-year-old primigravida at 39 weeks of gestation, with a history of RHD and prior MVR, presented with leaking per vaginum. She had severe mitral stenosis, moderate mitral regurgitation, mild tricuspid regurgitation, atrial fibrillation, premature ventricular contractions, and severe pulmonary arterial hypertension (PAH). She was on warfarin 3 mg OD and metoprolol 25 mg OD. An emergency cesarean section was performed due to the severity of PAH, resulting in the delivery of a healthy baby boy. However, the patient experienced postoperative complications, including difficulty maintaining blood oxygen saturation, requiring ventilatory support for 24 h. She was started on anticoagulants, digoxin, and metoprolol from the 3rd postoperative day.\nOn postoperative day 8, the patient developed persistent fever, which was initially attributed to an Acinetobacter infection detected through urine culture. Despite appropriate antibiotic treatment, the fever persisted. On postoperative day 12, she developed wound complications, including mild induration, wound discharge, and wound gape. The wound culture was sterile, and management involved daily debridement and dressing.\nOn postoperative day 15, the patient experienced heavy vaginal bleeding, losing approximately 1000 cc of blood. She was managed conservatively with uterotonics and blood transfusion. As ultrasound (USG) pelvis and Doppler were grossly normal, coagulopathy was suspected due to an elevated prothrombin time-international normalized ratio (PT-INR) of 4.33. Anticoagulants were stopped. Ultrasonography showed no abnormal findings. The bleeding was controlled, and anticoagulation was resumed after 72 h. However, on postoperative day 21, she had another severe episode of bleeding, losing approximately 1-1.5 l of blood, despite a normal uterine examination. As this time too, her PT-INR was 4.11, so cause was attributed to coagulopathy Her hemoglobin dropped to 6.3 g/dl. Conservative management with fluid resuscitation and blood products was initiated, but her condition deteriorated, requiring transfer to the high-dependency unit and administration of noradrenaline to stabilize blood pressure. The repeat sonography with Doppler study did not reveal any pathology this time too.\nGiven all the common causes of postpartum hemorrhage had been ruled out, the patient underwent diagnostic hysteroscopy and laparoscopy, which did not reveal any pathology. Further evaluation through computerized tomography (CT) angiography detected a small mass, which showed a dappled contrast filling on the arterial phase arising from the distal end of the left uterine artery [Figure 1a and b]. Bilateral UAE using polyvinyl alcohol particles was performed [Figure 2a]. Postembolization digital subtraction angiography demonstrated complete occlusion of Uterine Pseudoaneurysm [Figure 2b]. The patient showed improvement, and wound healing progressed well.\nFollowing the procedure, the patient's condition was closely monitored for 2 weeks, during which the wound gape healed successfully. Once the target INR was achieved, she was discharged on a medication regimen consisting of warfarin 4 mg OD, metoprolol 25 mg OD, digoxin 0.25 mg OD, and Ecosprin 75 mg OD. On 2-month follow-up, she was completely symptom free.",
"gender": "Male"
}
] |
PMC10936715
|
[
{
"age": 75,
"case_id": "PMC10830924_01",
"case_text": "The patient is 75 years old, a nulliparous woman who, 29 years ago, was diagnosed with right breast cancer and thereafter underwent mastectomy with lymphatic dissection. The pathological diagnosis was papillary ductal carcinoma, 18 mm invasion, v (+), ER (-), PgR (-), and N (0/13). The patient received postoperative adjuvant chemotherapy and radiation therapy.\nDuring her follow-up visit which was 18 years ago, an abdominal ultrasound scan revealed a 70 mm solid-type left ovarian tumor which brought her to the obstetrics and gynecology department of our hospital.\nAs further examinations suggested a malignant ovarian tumor, the patient then underwent a hysterectomy, bilateral salpingo-oophorectomy, and subtotal omentectomy. The pathology was poorly differentiated endometrioid carcinoma, stage IC(b) (FIGO 1988). Five courses of TC therapy were administered after the surgery (T: Paclitaxel 175 mg/m2; C: Carboplatin AUC5). The patient remained recurrence-free for 10 years, and the follow-up was completed.\nAt the time of 18 years after the initial treatment of ovarian cancer, following a fracture of the femoral neck, a CT scan was taken at another hospital. The scan revealed an over 70 mm mass, occupying the spleen (Figure 1). In addition, multiple maximum sizes of 10 mm tumors were seen in liver segment 6. After a liver biopsy was done, the patient was referred to the breast surgery department with a diagnosis of recurrent breast cancer.\nHowever, we were able to locate the pathology slides from 18 years ago. After histological comparison and additional immunostaining, the pathology suggested it more likely originated from the previous ovarian cancer. The specimen obtained from the liver has a histological pattern similar to that of the ovarian cancer 18 years ago. The previous ovarian cancer appeared to be a poorly differentiated endometrioid type with a solid growth pattern whereas the liver biopsy showed the proliferation of atypical cells with lumen formation adjacent to benign liver tissue. Both showed substantial growth and lumen formation (Figures 2-5).\nThe additional immunostaining of the liver biopsy showed the marker for breast cancer, and GCDFP15 was negative. In addition to ER (+) and PAX8 (+), immunostaining results for CK7 (+), CK20 (-), p40 (-), GCDFP15 (-), PgR (-), HER2 (-), and WT1 (+) were obtained, supporting the diagnosis of ovarian cancer recurrence. The comparison results are shown in Table 1.\nWhen the cancer recurrence was confirmed, it could have been either breast or ovarian cancer or a new onset of peritoneal cancer. However, based on the addition of immunostaining to the biopsy of the liver metastasis, the diagnosis was made as a recurrence of ovarian cancer.\nFurthermore, differentiated diagnosis in ovarian cancer histologic type, high-grade serous carcinoma (HGSC), and poorly differentiated endometrioid carcinoma could be challenging from the histological pattern alone. The immunostaining of this recurrent ovarian cancer from the liver shows WT-1 (+), which is a marker commonly seen in HGSC, suggesting that the previous ovarian cancer might have been the HGSC instead of a poorly differentiated endometrioid type.",
"gender": "Female"
}
] |
PMC10830924
|
[
{
"age": 3,
"case_id": "PMC11068241_01",
"case_text": "A 3-year-old female was referred to the accident and emergency department with a complaint of intraoral swelling following trauma from the thin end of a hand fan while playing. The injury occurred within a span of 2 h. The child was conscious and oriented to time, place, and person. There was evidence of oral bleed and the child had no other bodily injuries. The child had Frankl Behavior Rating Scale 3 for clinical evaluation. Hence, the patient was evaluated in semi-supine position on examination chair with parental support. On extraoral examination, a diffuse swelling was present on the right side of the face, which was firm in consistency, tender on palpation, nonfluctuant, and nontranslucent, and the temperature of the overlying skin was slightly raised. Intraoral examination revealed a laceration on the right buccal mucosa, through which a well-defined, pedunculated mass of size around 4 cm x 3 cm, was extravasating opposite to the crown of the upper deciduous first molar. It was pinkish-red in color, soft in consistency, and nontender on palpation. Irrigation revealed a pale-yellow mass in continuity with the Bichat fat pad [Figure 1a]. A provisional diagnosis of BFP herniation from the right buccal mucosa was made.",
"gender": "Female"
},
{
"age": 4,
"case_id": "PMC11068241_02",
"case_text": "A 4-year-old boy presented to the pediatric accident and emergency department, with the parents complaining of a sudden-onset swelling in the right side cheek within the oral cavity after playing. The child was suspected to have a self-inflicted injury with an unknown object approximately 1 h ago. The child was conscious and oriented to time, place, and person, with a Frankl Behavior Rating Scale 3 for clinical evaluation. He was suspected with global development delay with the parents giving a history of delayed developmental milestones such as expressive language. He could speak individual words but was unable to string a sentence together. The parents had not sought any medical evaluation previously for the same.\nGeneral physical evaluation revealed no other bodily injury. Extraoral assessment revealed a diffuse swelling on the right cheek which was tender on palpation, firm in consistency, compressible, nonfluctuant, nontranslucent, and nonreducible. Intraoral examination revealed, a pale-yellow, jelly-like, lobular mass about 4 cm x 3 cm x 2 cm in size, extruding through a laceration on the right buccal mucosa opposite the deciduous second molar of the first quadrant, interfering with occlusion without active bleed [Figure 1b]. It was clinically evidenced as BFP.\nOwing to the short duration of injury and the intact overlying capsule, it was decided to surgically reduce the BFP to its anatomical site without excision. Emergency preanesthetic evaluation and clearance were obtained by the team of anesthesiologists and pediatrician. Nil per os (NPO) of 4 h was followed as per the latest ASA guidelines 2017. General anesthesia backup was kept available if the children could not be managed under sedation. Informed written consent was obtained from the parents. The procedure was carried in the OT under minimal sedation with intravenous midazolam (0.05 mcg/kg body wt.) administered by the pre-anesthetic clearance (PAC) team under constant vitals monitoring.\nStensen's duct was identified and cannulated with a 26 G cannula to check for its patency and integrity. Iatrogenic injury to the duct was avoided throughout the procedure. 3-4 mL of local anesthesia (2% lignocaine with 1:200,000 adrenaline as per 7 mg/kg body weight) was administered. The herniated tissue was rinsed adequately with 1% povidone-iodine and normal saline and repositioned through the existing laceration using Adson's tooth tissue forceps. Hemostasis was achieved and closure was performed in layers with 3-0 polyglactin 910 sutures with a 3/8 round-bodied needle [Figure 2a and b]. The procedure was carried out under aseptic conditions and precautions. Patients were given postoperative antibiotic and analgesic coverage (syrup amoxicillin 125 mg/5 mL at 15-30 mg/kg thrice daily and syrup paracetamol 120 mg/5 mL at 15 mg/kg thrice daily) for 5 days. Mild extraoral swelling on the cheek was observed on the next day. Postoperative recovery was uneventful. The patients were followed up for a period of 1 year with satisfactory, healing no soft-tissue prolapse, and no associated complications. The same approach was followed for both cases.",
"gender": "Male"
}
] |
PMC11068241
|
[
{
"age": 59,
"case_id": "PMC10797860_01",
"case_text": "Approximately a decade prior to the current assessment, a female patient aged 59 was first admitted to our hospital presenting with symptoms of shortness of breath and chest tightness. Her clinical laboratory test results revealed a N-terminal prohormone BNP (NT-proBNP) level of 3,556 pg/ml, significantly above the normal range of 0-125 pg/ml. Transthoracic echocardiography (TTE) depicted an enlargement of the heart (with LVDd 65 mm, LAS 53 mm, RVD 47 mm, RAS 47 mm), a patent ductus arteriosus (PDA), and a normal ejection fraction indicative of healthy left heart function, at 66%. Believing PDA to be the potential cause of the patient's heart failure symptoms, we decided to proceed toward its occlusion. In the course of the surgery, a palpable thrill was identified under the right inguinal ligament. A review of the patient's medical history revealed a traumatic incident involving a fire spear at the age of seven, which caused an injury in the right groin. This palpable thrill could potentially be attributed to the development of an arteriovenous fistula, to which the patient had previously declined treatment. Consequently, successful occlusion of the PDA was carried out via puncturing the left femoral artery. Following the surgical procedure, we observed a gradual improvement in the patient's initial symptoms, with a noted decrease in the levels of NT-proBNP to 1,115 pg/ml:significantly lower than the pre-surgery levels. Although we suggested consulting with the Vascular Surgery Unit to treat the femoral arteriovenous fistula, the patient didn't heed our advice. Post-surgery, the patient appeared to perform physical activities without difficulty. Upon discharge, we assessed her heart function as New York Heart Association class I.",
"gender": "Female"
},
{
"age": null,
"case_id": "PMC10797860_02",
"case_text": "Ten years post-PDA occlusion, the patient was readmitted to our hospital due to a year-long exacerbation of breathlessness. The physical examination revealed swelling and elevated skin temperature in the right leg, along with an audible murmur in the right inguinal region. Laboratory tests indicated an N-terminal prohormone BNP level of 9,120 pg/ml (reference: 0-125 pg/ml) and a high-sensitivity troponin T level of 10 pg/ml (reference range: 0-100 pg/ml), while blood routine, liver function, renal function, and electrolyte tests were normal. TTE illustrated expanded heart chambers (LVDd 88 mm, LAS 53 mm, RVD 39 mm, RAS 48 mm), diffused ventricular wall motion weakness, and reduced left heart function (ejection fraction: 30%). This suggested a 36% reduction in left ventricular ejection fraction and progressive heart dilation compared to the state a decade ago, indicating deteriorating heart failure. An ultrasound of his lower extremity vasculature identified a 3.9 mm fistula between the right deep femoral artery and the right femoral vein with high-velocity color flow. Subsequently, a CT angiography scan revealed severe dilation from the inferior vena cava to the right femoral vein and aneurysms in the dilated right common iliac artery, internal iliac artery, and external iliac arteries (Figures 1, 2). Given these results, open surgical repair was deemed unfeasible due to heart function deterioration. The deployment of a covered stent was dismissed as overly risky given it would obstruct numerous deep femoral artery branches. The patient's blood vessels are severely dilated and distorted, further complicating matters, as it renders the stents unfixable. Instead, a novel approach to fistula closure using ventricular septal occlude was ventured under local anesthesia with fluoroscopic and ultrasound guidance. The left femoral artery was percutaneously accessed under vascular ultrasound guidance. Intravenous heparin (50 IU/kg) and antibiotic prophylaxis were administered. A 4-Fr angiographic catheter (VER135 , Cordis, Corporation, Miami, FL, USA) was introduced into the abdominal aorta and right common iliac artery with a noodle wire (AGA Medical, Golden Valley, MN, USA), detecting the AVF. Angiographies performed with the VER135 catheter visibly showed the abdominal aorta, dilated right iliac artery, and early enhancement of the inferior vena cava. Femoral AVF was confirmed on angiogram at the beginning of the deep femoral artery with an large aneurysm connecting with the common femoral vein (Figure 3). Thereafter, the VER135 catheter was introduced into the deep femoral vein across the AVF with a 260-cm long noodle wire (AGA Medical, Golden Valley, MN, USA). The left femoral vein was percutaneously accessed, and the noodle wire was snared and pulled out with an Amplatz gooseneck snare (Microvena, White Bear Lake, MN, USA) introduced from the femoral vein, establishing a stable arterial-venous wire loop through the fistula. A Lifetech delivery sheath was introduced over the wire from the femoral vein through the AVF to the femoral artery. Under fluoroscopic guidance, an 8 mm (3-5 mm larger than the size of the fistula) VSD occluder (Lifetech, HeartR, XJFVJ08) with its corresponding delivery cable was inserted through the sheath and the device was deployed in the AVF. Aortography was done again to confirm fistula closure, with a small residual shunt remaining (Figure 4). On the first postoperative day, the patient exhibited reduced respiratory distress, the pulsation of the right dorsalis pedis artery normalized, and the ankle brachial index (ABI) measured 1.29 (compared to a preoperative ABI of 0). Treatment included oral anticoagulants, and by the third postoperative day, the patient was discharged in a stable clinical condition.",
"gender": "Male"
}
] |
PMC10797860
|
[
{
"age": 33,
"case_id": "PMC10867548_01",
"case_text": "A 33-year-old gentleman, married and an active smoker with underlying allergic rhinitis, presented to our center with a complaint of sudden-onset transient loss of consciousness while he was cleaning his house. The symptom was associated with urinary incontinence, chest discomfort, and palpitation. It was his first experience with these symptoms. On further questioning, the symptom started after consuming a local energy and sexual stimulant (Kopi Jantan) with instant premixed coffee for the past two years and increased in amount two months before this clinical presentation. He mainly took this drink for energy and sexual satisfaction. On examination, blood pressure (BP) was 140/80 mmHg, pulse rate was 120 beats per minute, and it was irregularly irregular. Physical examination was unremarkable. His electrocardiography (ECG) showed a typical counter-clockwise atrial flutter (Figure 1). Other blood investigations, including thyroid function tests, were within normal range. His urine toxicology for illicit drugs was negative. Echocardiography revealed a structurally normal heart chamber with preserved left ventricular ejection fraction (LVEF). A diagnosis of symptomatic atrial flutter with rapid ventricular response secondary to an ED was made. He was started on intravenous amiodarone, and synchronized cardioversion with 50 J was performed. The tachycardia terminated with a single synchronized cardioversion (Figure 2). He was admitted to the ward for two days for observation, and no arrhythmias were noted. Because his CHA2DS2VASc was 0, he was not started on an anticoagulant and discharged with tablet verapamil 40 mg TDS to maintain the sinus rhythm with outpatient ambulatory ECG follow-up.\nCase two",
"gender": "Male"
},
{
"age": 27,
"case_id": "PMC10867548_02",
"case_text": "A 27-year-old gentleman, a non-smoker with no traditional risk factors for atherosclerosis, presented with sudden-onset central chest pain, described as heaviness and crushing in nature, with a pain score of 10/10, radiating to the back. It was associated with profuse sweating and vomiting three times since the onset. Otherwise, there was no significant symptom. On further history taking, the patient reported consuming Kopi Jantan stimulant for two years for energy. Additionally, he had recently gotten married and was consuming Kopi Jantan more frequently than previously. Otherwise, there was no high-risk behavior or use of recreational drugs and or other traditional supplements or herbs. There was no history of sudden cardiac death, cardiovascular disease, or cardiomyopathy in the family.\nUpon presentation, his blood pressure was 141/96 mmHg, pulse rate was 92 beats per minute, and he was afebrile. Initial ECG showed ST elevation in leads I, AVL, and V2-V6 (Figure 3). He was successfully thrombolyzed with intravenous (IV) streptokinase 1.5 million units, and ECG showed resolution of ST-segment elevation (Figure 4). His blood investigation showed total white cells at 18.9 x 109/L, hemoglobin at 16.9 g/dL, and platelet at 436 x 109/L. Renal and liver function was within the normal range. His troponin T was 310 pg/L. Other investigations, such as urine toxicology, autoimmune disease, and infective screening, were negative. His echocardiography showed LVEF of 25% with hypokinesia anteroseptal, anterolateral, and lateral of the left ventricular wall with spontaneous echocardiographic contrast. Subsequently, coronary angiography was done during the same admission, which revealed non-obstructive coronary stenosis at the proximal left anterior descending artery, as shown in Figure 5. Other coronary vessels (left circumflex artery and right coronary artery) were normal (Figures 6, 7). Hence, he was diagnosed with myocardial infarction with non-obstructive coronary arteries (MINOCA) because of no significant obstructive coronary artery disease and acute thrombotic occlusion resolved with thrombolysis. We did not perform intravascular imaging due to financial constraints. He was discharged on dual antiplatelets and remained well on outpatient clinic follow-ups.",
"gender": "Male"
}
] |
PMC10867548
|
[
{
"age": 4,
"case_id": "PMC10753127_01",
"case_text": "A 4-year-old male presented to our emergency department following a road traffic accident. He had been admitted to different hospital prior, where had had a CT scan done. However, the patient was discharged by his parents against medical advice, and they presented to this hospital instead. They requested an assessment for potential traumatic injuries resulting from the crash. This included comprehensive clinical examinations, as well as an abdominal X-ray. An unexpected finding on the abdominal radiograph revealed an aggregation of dense, circular opacities in the mid to lower abdominal region, prompting a differential diagnosis that included foreign body ingestion (Figure 1). Further inquiries into the patient's history from the mother, divulged that magnetic beads purchased 10 months prior, had gone missing for approximately 9 months. She had estimated that they would weigh around 300 g. After thorough consultation and history taking with the patient, he finally admitted that he did indeed swallow the magnets but was scared to admit it. This was done over one sitting, in small quantities in a row. Despite this revelation, the child showed no symptomatic evidence of foreign body ingestion, remaining free from abdominal pain, vomiting, and any gastrointestinal distress both at presentation and in the preceding months. Further comprehensive screening revealed no signs of mental disability, abuse, or maltreatment, affirming the child was well-cared for and in good health aside from the foreign body incident.\nGiven the ambiguous localization of the foreign body and the potential for serious complications associated with magnetic objects, a multidisciplinary approach was imperative. Initially, an ultrasound scan was performed, but this did not provide any benefit. A CT scan was proposed as a means to better localize the beads. However, the parents declined this option, citing concerns about redundancy and a desire to minimize their child's exposure to radiation. They were unable to provide the previous CT report due to their earlier decision to discharge against medical advice. After discussions among the pediatric surgery and gastroenterology teams, a stepwise endoscopic intervention was agreed upon since there was uncertainty regarding the location of the foreign object. The initial endoscopic evaluation would be an upper gastrointestinal endoscopy, followed by a colonoscopy if necessary, and a surgical laparotomy would be reserved as a last recourse. This decision process was determined through evaluating the unlikelihood of the large mass crossing the pyloric sphincter, as well as the weight of the object likely falsifying the impression of a more distal location on the radiograph. The decision was also driven by the team prioritizing minimizing the patient's exposure to sedation. Given that a CT scan would necessitate additional sedation, it was decided to limit sedation to the operative theater. This approach meant that if the endoscopy and colonoscopy did not yield definitive results, the patient could undergo a laparotomy under the same general anesthesia, thereby avoiding multiple sedation events. Opting for a CT scan would have introduced an unnecessary extra sedation episode, especially since the management plan would include endoscopy, colonoscopy, or laparotomy regardless of the scan's findings.",
"gender": "Male"
}
] |
PMC10753127
|
[
{
"age": 55,
"case_id": "PMC11249797_01",
"case_text": "A 55-year-old male presented with a medical history of typhoid fever at the age of 12 years and no surgical history of note. There was no relevant oncological family history. The patient reported occasional alcoholic habits and denied smoking and drug use. His usual medication consisted of vitamin D and B.\nThe patient presented to gastroenterology consultation with rectal bleeding and mucus emission in large quantities and, subsequently, increased frequency of intestinal transit, tape stools, and tenesmus. Anorectal exam was unremarkable, excluding hemorrhoids and anal fissures as a cause of bleeding. Fecal occult blood test was positive, and a colonoscopy was performed, revealing a voluminous vegetating lesion located approximately 8 cm from the anal verge. The histological report showed a moderately differentiated low-grade ADC of the rectum, with MLH1, MSH2, MSH6, and PMS2 expressions. KRAS mutation c.38G>A p.(Gly13Asp) was detected. Laboratory data ruled out anemia. The serum levels of tumor markers carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9) were within normal ranges (CA 19-9 28.6 U/mL; CEA 0.7 ng/mL).\nComputed tomography (CT) demonstrated several pulmonary micronodules, a right epiphrenic adenopathy, multiple necrotic subcutaneous nodules in proximity to the left semilunar line, along the anterior margin of the rectus abdominis and the oblique muscles of the abdominal wall with 33 mm, on the opposite side with 12 mm and adjacent to the right gluteus major muscle with 10 mm. Pelvic magnetic resonance imaging (MRI) depicted a large tumor involving the upper two thirds of the rectum starting 8.7 cm from the anal margin and extending over 6.2 cm. The lesion had an extramural necrotic component invading the mesorectal fascia. In the upper rectal lymphatic chain, at least one adenopathy was observed, measuring 15 x 7 mm. In the inferior mesenteric lymph node chain, small ganglia were identified. A cutaneous implant biopsy was performed and was compatible with NEC Ki-67 90%, positive for CK7 and synaptophysin and negative for CK 20, CDX2 and chromogranin; the scarcity of material did not allow further studies.\nThe patient presented at consultation with ECOG performance status 1 and mentioned 3 to 4 stools per day with decreased caliber and new skin implants for 2 weeks. On observation, three cutaneous implants were denoted: first implant in the left flank with a 3 cm diameter; second implant >1 cm; third implant in the right flank with a 2 cm diameter; no additional findings on physical examination.\nDue to clinical presentation and after multidisciplinary team (MDT) discussion, the assumed diagnosis was 1 tumor with both ADC and NE components, presenting as an ADC of the middle/upper rectum with neuroendocrine differentiation, with Ki-67 of 90%, stage IV, due to cutaneous and probable lung and lymph node metastasis. Positron emission tomography-18F-fluorodeoxyglucose (PET-FDG) revealed hypermetabolism at the level of rectal neoplasia, probable superior right lateral-tracheal and aortic/pre-vertebral adenopathy at D12 level, pulmonary, hepatic and node/implant metastases next to the right psoas muscle and bilateral subcutaneous lesions in the abdominopelvic wall (shown in Fig. 1).\nAfter MDT discussion, first-line chemotherapy (CHT) with cisplatin and etoposide was started. There was a clinical and imaging response with an overall decrease in subcutaneous implants, and a partial response was assumed. Therefore, he proceeded CHT, with hematologic toxicity (Grade 2 Neutropenia, according to Common Terminology Criteria for Adverse Events [CTCAE] v5.0), and was supported with granulocyte-colony stimulating factor. CHT was completed after 8 cycles, with a progression-free survival of a month and a half.\nTwo months after resuming CHT, he presented at an oncology consultation with neuropathic pain radiating from the left hip to the ipsilateral thigh for the last 15 days. A second CT was performed, revealing a new lytic lesion with cortical disruption in the L1 vertebral body, with a soft tissue mass in the left psoas muscle, new lung micronodular opacities, and volumetric reduction of several known lesions. MRI of the neuraxis did not identify an evident intracanal component or adjacent foraminal obliteration. The patient was admitted to a medical ward for pain control with corticotherapy and radiotherapy (total of 29.4 Gy [6 fractions of 4.9 Gy]). Biopsy of a bone lesion was performed to unravel which component was progressing. Metastasis of ADC was confirmed with CK20 and CDX2 expression, compatible with the rectal origin of the neoplasm. FoundationOne Liquid CDx was performed and gene alterations in KRAS G13D (which favored resistance to cetuximab and panitumumab), APC E1306, R554, FBXW7 R465H, RB1 splice site 1420_1421 + 30del32, SMARCA4 R973Q, and TP53 C135F were revealed; Blood Tumor Mutational Burden - 6 Muts/Mb; elevated tumor fraction and MSI-high were not detected.\nThe patient started a second line of CHT with FOLFIRI. He repeated CT which showed rectal lesion progression with stability of other lesions and partial vertebral fractures of L3 and L4. Vertebroplasty was performed. Rectal biopsy was performed again, confirming the diagnosis of MiNEN, consisting of components of moderately differentiated ADC and NEC (synaptophysin + and Ki-67~70%) (shown in Fig. 2, 3, respectively).\nRegarding the pain and rectal bleeding, the patient was submitted to palliative radiotherapy with 36 Gy (1 fraction of 8 Gy followed by 25 Gy: 5 fractions 5 Gy/day). After MDT, a colostomy was made due to a rectovesical fistulous tract. Due to disease progression and worsened performance status (ECOG PS-2), with a platinum-free interval of six and a half months, third-line therapy with weekly carboplatin and paclitaxel was initiated.\nBone pain worsened and disseminated cutaneous lesions appeared in the trunk, upper and lower limbs, some of them painful, as seen in Figure 4. Another neuraxis MRI was done: a recent fracture underlying L1 stood out, as well as new somatic collapses from L5, D8 to D11 and extensive metastasis of anterior and posterior paraspinal soft tissues.\nThe patient underwent another vertebroplasty and pain therapy optimization with palliative care team support. The clinical status deteriorated during hospitalization and he eventually died.",
"gender": "Male"
}
] |
PMC11249797
|
[
{
"age": 90,
"case_id": "PMC10995294_01",
"case_text": "A 90-year-old female presented with new-onset weakness and sensory loss of her right lower extremity. Initial neurological examination revealed right-sided plegia of foot extension and flexion with moderate leg pain as well as loss of the superficial sensory function including hypo- to anesthesia and reduced proprioception in the lateral aspects of the calve up to the dorsum of the right foot, consistent with a complete loss of function of the sciatic nerve. The symptoms had developed over two to three days. There were no other neurological symptoms or signs of neurological dysfunction. Clinical examination revealed no lymphadenopathy or splenomegaly. No signs of fever or increased weight were observed over the last months. The patient's past medical history included hypertension, mild cognitive impairment in the context of confirmed Alzheimer's disease, and diabetes type 2, yet the patient was still able to live independently. The medical history of the patient's family was negative for hematological disorders or other tumors.\nInitially, the primary concern was that of an ischemic or hemorrhagic vascular event, however, a cerebral CT and MRI did not show evidence for an acute neurovascular event. Given that the presented neurological syndrome was consistent with a peripheral nerve injury, further workup included an electromyogram and nerve conduction studies as well as peripheral nerve ultrasound. The electromyogram showed pathological spontaneous activity of the M. tibialis anterior and the M. gastrocnemius, consistent with an axonal injury to the right sciatic nerve ( Figure 1A ). Peripheral nerve ultrasound revealed a large mass at the proximal to middle part of the sciatic nerve with inhomogeneous echogenicity and signs of a central hematoma. Femoral CT and MRI scans confirmed an inhomogeneous contrast-enhancing lesion of 20 cm length and 2 to 3 cm in diameter originating from the sciatic nerve in the thigh and extending downwards to the popliteal fossa with possible attachment to the femoral veins. Discrete perifocal edema was also observed. In total, imaging was suggestive of a malignant process and compatible with a MPNST ( Figure 1B ). The initial CT scan did not show additional contrast-enhancing lesions in particular in the caudal pelvic region and no enlarged lymph nodes ( Figure 1C ). A lumbar puncture was unremarkable with no evidence of malignant cells ( Figure 1A ). Blood tests showed no evidence of leukocytosis or acute inflammation.\nThe case was discussed at our interdisciplinary neuro-oncology tumor board. Given the patient's age but good general condition and the suspected malignancy of the lesion, the options of either radical surgical resection followed by adjuvant therapy, which could provide good local tumor control and possible pain control, or a less invasive approach of palliative local radiotherapy were considered. Following a detailed discussion about the advantages and disadvantages of both approaches, the patient opted to proceed with radical surgical resection. Considering the patient's advanced age with expected slow axonal recovery and the size of the lesion and the already extensive destruction of the sciatic nerve, nerve reconstruction using sural nerve grafts was not offered.\nSurgery was performed in prone position. The tumoral mass was exposed over 30-40 cm and was carefully dissected aided by intraoperative nerve stimulation to preserve the proximal unaffected muscle branches of the hamstrings. The tumor was of hard consistency and infiltrated several smaller nerve branches, including the tibial and peroneal nerves even after the branching of the sciatic nerve and beyond the expected tumor extension based on MRI. Next, the tumor was completely dissected from the femoral veins and the popliteal artery. The sciatic, the tibial and the peroneal nerves were cut in an area considered to be free of tumor and the whole tumor mass was removed en bloc. Following resection, no macroscopical tumor residuals could be identified. Postoperatively, no new sensorimotor deficits were discovered. Pain was initially controlled with peridural anesthesia and later sufficiently treated with oral pain medication. The patient could be continuously mobilized and was mobile on a walker with a food orthesis at the time of discharge from the hospital.\nHistologically, the resected sciatic nerve was diffusely infiltrated by a highly cellular neoplasm composed of medium- to large-sized lymphoid cells with round to slightly convoluted nuclei with open nuclear chromatin, a single to multiple prominent nucleoli, and variable amounts of basophilic cytoplasm ( Figure 2 ). Immunohistochemistry demonstrated strong expression of the B-cell marker CD20 with coexpression of CD10 (weak), BCL6 and MUM1, corresponding to a germinal center B-cell (GCB) phenotype according to the Hans algorithm. The tumor also expressed BCL2 as well as MYC (heterogeneously). The lymphoblast marker TdT and the T-cell marker CD3 were negative. MIB1 staining showed a proliferation rate of more than 90%. Fluorescence in situ hybridization (FISH) of the BCL6, BCL2, MYC and IRF4/DUSP22 loci revealed a rearrangement of BCL6.\nThe final diagnosis was diffuse large B-cell lymphoma, not otherwise specified (DLBCL, NOS) of GCB subtype. Moreover, based on the localization and the lack of other lymphoma manifestations as shown in Figure 1C , the diagnosis corresponding to a primary extranodal manifestation of a DLBCL was made.\nFurther diagnostic procedures included CSF cytology, a second whole-body CT scan and a cerebral MRI scan. As shown in Figure 1D , the second CT scan 17 days after surgery revealed new nodular lymphoma manifestations in the inguinal region as well as in the right-sided frontal femoral compartment in line with a progression to systemic disease(see orange signs in Figure 1D ). Nevertheless, enlarged lymph node or splenomegaly were not observed. CSF cytology revealed no malignant cells. The case was presented in our interdisciplinary lymphoma board. Taking into consideration the extensive systemic involvement and the unfavorable chance of a good recovery, only local palliative tumor control by radiotherapy was recommended. The patient subsequently received radiotherapy totaling 30 Gy in 10 fractions in the region of the upper thigh and groin including the external iliac lymph nodes. Radiotherapy was well tolerated and the patient could be discharged home with the support of a 24h nursing care service. Seven weeks later, a deep vein thrombosis in the right leg was diagnosed and was treated - in accordance with the national guidelines - with compression therapy and oral anticoagulation with apixaban without any further complications.\nNeoplastic lesions affecting peripheral nerves are most often benign and, in experienced surgical hands, well-resectable. However, a minority of nerve sheath tumors reveal high-grade malignancies such as MPNST or rare entities that can diagnostically be difficult to distinguish based on imaging alone.\nIn the reported case, the geriatric patient presented with an acute monoplegia of the right lower extremity. MRI of the thigh and pelvis revealed an ill-defined contrast-enhancing lesion with central hemorrhage and perifocal edema. Due to the fast onset of symptoms, the radiological features, the initial inconspicuous CT scan and the lack of hematological abnormalities, an MPNST was firmly suspected. In consideration of the patient's advanced age, the clinical presentation, and limited therapeutic options, metabolic imaging, such as FDG-PET as recommended by the ESMO guidelines for lymphoma staging, was not performed. We acknowledge, that this may have provided additional information on the dignity of the lesion and treatment response or might have helped to identify small systemic manifestations not visible on standard CT/MRI scan ( Figure 1C, D ). However, FDG uptake kinetics between MPNSTs and aggressive DLBCLs can hardly be distinguish.\nAs shown in a retrospective study of benign peripheral nerve schwannomas of neurofibromatosis type 2 patients treated in our center, microsurgical resection has low complication rates, good functional preservation and offers good pain management. However, in a suspected malignant tumor, radical removal by en bloc resection according to surgical sarcoma criteria is mandatory and given the intraoperative appearance of a nerve destructing tumor compatible with a MPNST, en bloc resection was performed.\nTo our surprise, histopathology revealed an infiltrative destruction of the sciatic nerve by a DLBCL of GCB subtype, corresponding to the rare phenomenon historically known as neurolymphomatosis, i.e. a direct nerve infiltration by lymphoma cells. Nerve infiltration can occur as the primary manifestations - like in the presented case - or secondary to other manifestations, with both occurring at approximately equal frequency in a mono-centric study. In line with this case, the most common lymphoma responsible is DLBCL. Of note, although smaller studies and case reports have also described nerve infiltration by DLBCL of GCB subtype, recent large-scale analyses have revealed that extranodal manifestations like in the presented case more commonly occur in DLBCL with an activated B-cell-like gene expression signature.\nThe clinical presentation of the reported case is also in accordance with a published series of patients with nerve infiltration by lymphoma. A comprehensive diagnostic work-up including MRI and metabolic imaging as well as CSF cytology is recommended. Due to its rarity, there are no established treatment algorithms and conclusive prospective clinical trials evaluating treatment options are missing. Therefore, therapeutic approaches are based on data available for DLBCL or primary central nervous system lymphoma (PCNSL) and individual treatment recommendations should be made based on a discussion in an interdisciplinary tumor board attended by neurooncologists as well as hematooncologists. Retrospective data reveal a tendency towards better long-term survival after including the anti-CD20 antibody Rituximab into treatment regimens. In the presented case, treatment consisted only of local tumor control by radiotherapy, taking the patient's multimorbidity and frailty into consideration. Radiotherapy can offer effective local control in patients with relapsed DLBCL or with reduced life expectancy.",
"gender": "Female"
}
] |
PMC10995294
|
[
{
"age": 79,
"case_id": "PMC10999613_01",
"case_text": "A 79-year-old male German patient (i.e., 73 years old at first presentation) was diagnosed with microsatellite stable mid-rectaladenocarcinoma during a screening colonoscopy without any clinical symptoms in February 2017 (see also Table 1). The patient had no relevant comorbidities and was in good clinical condition. Colonoscopy revealed a semicircular and exophytic tumor with a size of 50 mm in the rectum 8 cm from the anal verge (Figure 1). Pathology of a biopsy specimen revealed moderately differentiated adenocarcinoma of the colorectal type. Abdominopelvic computed tomography (CT; Figure 2) and pelvic magnetic resonance imaging (MRI) showed concentric growing rectal carcinoma with locoregional lymph node metastasis in the mesorectum as well as circumferential wall thickening with perirectal fat infiltration (Figure 3A). No distant metastases were found. Endoscopy revealed a tumor with a maximum thickness of 13 mm in the midrectum that broadly exceeded the muscularis, as well as suspicious regional lymph nodes. The tumor marker carcinoembryonic antigen (CEA) level was within the normal range. The clinical stage was determined to be uT3uN1cM0; stage IIIB according to the Union for International Cancer Control (UICC) staging manual (7th edition).\nThe case was then discussed by our multidisciplinary tumor board, for which nRCT with up to 50.4 Gy radiotherapy and simultaneous chemotherapy with capecitabine 825 mg/m2 twice daily were recommended. Neoadjuvant therapy started in March 2017, and was given for six weeks without interruption or absence of any severe complications. Briefly, the total dose of preoperative radiotherapy was 50.4 Gy, which was given in a fractionated manner over a period of 6 weeks (1.8 Gy x 28 fr over 6 weeks) in the supine position. The clinical target volumes included the gross mural tumor, regional lymph nodes in the mesorectum and presacral space and the internal iliac and distal common iliac lymphatics. The oral concurrent chemotherapy with capecitabine (825 mg/m2) was administered twice daily.\nA reevaluation of the nRCT response and simultaneous planning of the TME and a protective ileostomy were scheduled approximately 8 weeks after nRCT completion. On presentation in June 2017, no tumor mass or stenosis was palpable during a digital rectal examination. A slight bluish venous dilatation with negligible ulceration was evident on rectoscopy. On endosonography no tumor or lymph nodes were observed. A wall thickening of the rectum was described. MRI revealed no definite mass lesion but mucosal thickening of the rectum after nRCT and no evidence of metastatic lymph nodes. These findings were discussed in detail with the patient and his relatives. We explained the extent of surgical therapy with TME and the possibility of protective ileostomy. The patient refused to undergo surgery. Therefore, we proposed a follow-up regimen for the patient, including digital rectal examination combined with rectoscopy (through an experienced colorectal surgeon), CEA measurement, chest radiology, abdominal ultrasound and pelvic MRI every 3 months. The advantages and disadvantages of these methods were discussed in depth. A written informed consent was obtained from the patient.\nAt the end of August 2017, there was no tumor seen during rectoscopy, and the bluish venous dilatation with negligible ulceration had disappeared. A wall thickening was suspected at 8 cm from the anal verge. This was confirmed by endosonography. We opted to carry out a biopsy at the suspected area. The final histological findings showed only a fibrotic mass without tumor cells. All other examinations, including pelvic MRI, abdominal ultrasound and chest radiology, showed no evidence of local or lymph node recurrence or distant tumor manifestation. The tumor marker CEA was also within the normal range. Follow-up evaluations were performed every three months for the first three years until March 2020, and no regrowth or evidence of lymph node recurrence or distant tumor manifestation was observed. No further thickening of the rectum was observed 12 months after the nRCT. Thereafter, we extended the time interval between follow-up appointments to 6 months. To date, after more than 5 years of follow-up, no evidence of regrowth or recurrence has been observed. We recommended an annual follow-up examination as well as a colonoscopy to rule out a second carcinoma.",
"gender": "Male"
}
] |
PMC10999613
|
[
{
"age": 71,
"case_id": "PMC11249609_01",
"case_text": "A 71-year-old woman presented on December 26, 2017, as a referral from a clinic. She had become aware of decreased visual acuity in the right eye 5 days earlier.\nDiabetes for 30 years, dialysis 3 times a week, and a pacemaker fitted.\nVisual acuity was 0.4 in the right eye and 0.9 in the left, and intraocular pressure was 16 mm Hg in both eyes. The crystalline lens in the right eye had been replaced by an intraocular lens, and that in the left eye exhibited an incipient senile cataract. In the fundus, the macular annular reflex had disappeared, and RAM was evident in the upper part of the vascular arcade at a distance of two papillary diameters from the macular area (Fig. 1a).\nNumerous capillary aneurysms were evident, including around the macula. They were considered to be the cause of macular edema. Fluorescein leakage from the aneurysms was evident in the intermediate phase. There was a retinal macroaneurysm which was distinct on the temporal arcade. It was larger than the capillary aneurysm (Fig. 1b). On optical coherence tomography (OCT), intraretinal edema and serous retinal detachment were evident in the macular area. Diabetic macular edema was diagnosed, and the first intravitreal injection of ranibizumab was administered on January 9, 2018. Five injections of ranibizumab and seven injections of aflibercept were administered. Color fundus photograph on January 20, 2020, showed that the RAM seen in the upper part on presentation has disappeared (Fig. 1c). FA at a final follow-up on January 20, 2020, showed some residual macular edema, but the numerous capillary aneurysms that had been evident on initial examination had almost disappeared, along with the RAM (Fig. 1d). The serial OCT after anti-VEGF injection showed decreasing of macula edema and serous retinal detachment (Fig. 1e-h). OCT on December 9, 2019, showed that macular edema had disappeared (Fig. 1h). Visual acuity in the right eye improved to 0.7.",
"gender": "Female"
},
{
"age": 81,
"case_id": "PMC11249609_02",
"case_text": "An 81-year-old woman presented on June 9, 2016, as a referral by a local clinic. She had become aware of decreased visual acuity in the right eye 7 days earlier.\nColon cancer surgery in 2000, gastric cancer surgery in 2005, hypertension, hyperlipidemia, unruptured cerebral aneurysm.\nVisual acuity was 0.03 in the right eye and 0.5X + 2.0 D in the left eye. Intraocular pressure was 14 mm Hg in both eyes, and incipient senile cataracts were evident in the crystalline lenses of both eyes. In the fundus of the right eye, vitreous hemorrhage meant that the optic papilla was only dimly visible and a detailed observation was impossible. This was considered to represent age-related macular degeneration, and intravitreal injection of ranibizumab was administered on June 24, 2016. Seven days later, the fundus was clearly visible. Color fundus photography revealed hemorrhage in the macular area and intraretinal hemorrhage in the upper part of the vascular arcade (Fig. 2a). On FA, in the intermediate phase, the RAM was visible in a vessel in the upper part of the vascular arcade (Fig. 2b). On OCT, fibrin was evident in the macular area below and within the retina (Fig. 2c). Second, third, and fourth intravitreal injections of ranibizumab were administered on July 29, September 7, and November 8, 2016, respectively. Subsequently, the macular hemorrhage disappeared and visual acuity improved to 0.2. Color fundus photography on June 7, 2017, showed that the macular area was normal, with RAM in vascular arcade. The retinal hemorrhage in the upper macular area had also disappeared (Fig. 2d). On fundus FA, the RAM that had been visible on July 1, 2016, appeared to have been obliterated (Fig. 2e).",
"gender": "Female"
}
] |
PMC11249609
|
[
{
"age": 7,
"case_id": "PMC11178394_01",
"case_text": "A nine-year and 7-month-old male patient presented with his guardian, requesting a second opinion for orthodontic treatment.\nThe patient's height and weight were age appropriate, with unremarkable medical history, and the patient appeared to be socially well adjusted. A detailed family history was recorded with no previous reports of trauma, impacted teeth, or family members having orthodontic treatment.\nClinical examination revealed a mixed dentition malocclusion with slight excess overjet, deep overbite, moderate arch length discrepancies, and a palatally blocked out maxillary left second premolar. A screening panoramic radiograph (Planmeca Promax 6114 Helsinki, Finland) (Figure 1) was captured to evaluate the dentition and to determine if further diagnostic images are necessary. The image revealed that all permanent dentition was present and at an age appropriate stage of development. The maxillary left second premolar was palatally blocked out due to the premature loss of deciduous second molar J and mesial drifting of #14 with subsequent loss of arch length. Deciduous tooth #A presented with two minor occlusal restorations and minimal evidence of remaining root structure. Of particular interest was the lack of eruption to the occlusal plane of primary tooth #A, in addition to the apically positioned succedaneous tooth #4. Primary tooth #T presented with a stainless steel crown, without pulpotomy. A lateral cephalometric radiograph reveals a Class I skeletal pattern with good growth potential. There was ideal symmetry, smile line, and profile.\nA first phase of orthodontic treatment was proposed to recapture adequate arch length for #13 as well as space maintenance for future eruption of #4. Orthodontic records were reviewed with the guardian and patient. Treatment options were proposed including the option of extraction of #4 and #13 with the possibility of incomplete space closure. The guardian and patient opted for recovering space for #13 and maintaining arch length for #4.\nPrior to starting orthodontic treatment, all routine orthodontic risks, including root resorption, bone loss, tooth loss, and the need for future phase II orthodontic treatment, were described. Discussions also included the possible need for surgical exposure with bracket and chain of unerupted teeth. Informed consent was read and signed by the guardian of the patient.\nMaxillary orthodontic appliances (Unitek Victory series, slot size 0.022 x 0.028 bonded with Unitek Transbond XT) were placed without incident, and attention was initially directed to regaining space for #13. A final leveling arch wire 0.018 x 0.025 NiTi was used as space was eventually created for #13. After repeated failure by the patient to exfoliate tooth #A, a progress panoramic radiograph (Figure 2) was captured. At that time, it was deemed necessary to extract #A as soon as possible. Atraumatic removal of primary tooth #A, at fourteen months of treatment, allowed adequate space for eruption of #4. After an additional twelve months of failure to naturally erupt, a second progress panoramic radiograph (Figure 3) was captured to determine the etiology. The panoramic radiograph revealed possible root dilaceration of #4. Root dilacerations can complicate eruption of permanent teeth. This finding was reviewed with the guardian and patient. Treatment options were discussed including extraction with possible incomplete space closure or surgical exposure with bracket and chain to assist in orthodontic eruption. The guardian and patient were not interested in extraction, and the decision was made to pursue surgical exposure with bracket and chain. At twenty-seven months of treatment, a CBCT scan (Figure 4) (J Morita 3D Accuitomo system at 90.0 kVp, 8.0 mA, 17.5 seconds, resolution 0.08 mm, and field of view 40.2 mm x 40.2 mm x 24.8 mm) was captured for ideal surgical orientation and identification of anatomical structures. The CBCT analysis report, by a board-certified Oral and Maxillofacial Radiologist, describes unerupted #4 with \"the root half formed and curves slightly to the distal; an irregularly shaped radiolucency was also noted at the mesiopalatal aspect, highly suggestive of resorption.\" An endodontic consultation by a board-certified Endodontist determined that the radiolucency was most likely external cervical resorption (ECR). These findings were reviewed with the guardian and patient. The risk of further root resorption and the possible need for endodontic treatment in addition to potential loss of the tooth were discussed. In its current unerupted apical position, no endodontic treatment could be attempted. The guardian made the decision to proceed with surgical exposure with bracket and chain to assist in bringing #4 into the arch. Eruption of #4, near the occlusal plane, was uneventful. At six months postsurgery, a periapical radiograph (Figure 5) (Progeny 60kv, 7 mA, 0.125 s) revealed evidence of ECR progression. At eight months postsurgery, a follow-up CBCT (same settings as previous CBCT) (Figure 6) and endodontic consultation were repeated. The CBCT revealed continued aggressive progression of ECR on #4. Since the tooth was finally accessible intraorally, pulp vitality testing was performed using electric pulp test (EPT) and Endo Ice. The tooth responded at 46/80 on the EPT and positive short duration to Endo Ice indicating no inflammatory changes within the pulp. Progression of ECR is evident in the progress CBCT (Figure 6). Treatment options including endodontic therapy and repairing the resorptive defect were discussed. Due to the advanced resorption, prognosis with endodontic treatment was deemed poor, and the decision was made to extract the tooth. At thirty-seven months of treatment and in consideration of poor oral hygiene, extensive appliance breakage, and the final treatment decision to extract #4, the orthodontic appliances were immediately removed. A Hawley retainer was placed to maintain alignment and hold the existing arch length. Uneventful extraction of the second premolar and granulation tissue was completed after appliance removal. The guardian was made aware that all facial growth must be completed prior to implant replacement of #4. The patient presented for only two retainer follow-up appointments at four and 8 weeks postorthodontic treatment. Compliance was poor with his retainer, and loss of arch length was noted. The patient is no longer available for continued monitoring.",
"gender": "Male"
}
] |
PMC11178394
|
[
{
"age": 76,
"case_id": "PMC10725247_01",
"case_text": "A 76-year-old Japanese man under treatment of PD-1 inhibitor (nivolumab) and CTLA-4 inhibitor (ipilimumab) for lung cancer, for 3 months, presented with casual blood glucose 574 mg/dL and HbA1c 7.7%. The patient had no history of diabetes, and this marked the initial onset of hyperglycemia. His primary cancer, situated in the left mediastinum, as well as his supraclavicular lymph node metastasis, exhibited signs of regression due to the therapeutic intervention. However, multiple metastatic cancers were observed in both lungs. No hepatic or adrenal metastasis was observed. No ascites or pleural effusion was noted.\nThe anti-GAD antibody was negative. RBC count was 427 x 104/muL, creatinine level was 1.12 mg/dL, eGFR was 49 mL/min/1.73m2, and potassium level was 5.2 mmoL/L. Other laboratory data are provided in Table 1.\nThe patient was diagnosed with fulminant type 1 diabetes provoked by the CPIs. His pre-prandial blood glucose levels ranged between 358 and 544 mg/dL, and insulin glargine before bed (0-0-0-6 U) plus insulin (Humulin R) sliding scale therapy was initiated. By the second day of hospitalization, insulin glargine was increased to 8 units (0-0-0-8 U) while the sliding scale therapy was continued, yet there was no significant improvement in pre-prandial blood glucose levels compared to day 1.\nBy day 3, the sliding scale was discontinued, and regular pre-prandial injection of insulin aspart commenced at a dose of 12-8-10 U, along with an increase in insulin glargine to 12 units (0-0-0-12 U).\nOn day 4, the dosage of insulin aspart was modified to 12-6-6 U, and insulin glargine was further increased to 16 units (0-0-0-16 U), yet the patient's pre-prandial glucose levels persisted high (331-435 mg/dL).\nInsulin aspart was then increased to 12-6-10 U at day 5 and then to 12-8-12 U at day 6. At day 6, insulin glargine was also increased to 18 units (0-0-0-18 U). However, the patient's glucose level remained high and was difficult to control (pre-prandial glucose levels being 212-269 mg/dL). Despite the possibility of increasing the basal insulin injection, the patient expressed reservations about dose escalation, and therefore, after checking that the urine ketone bodies were negative, SGLT2 inhibitor, dapagliflozin (5 mg), was added on top of the regular insulin therapy. Following the addition of dapagliflozin, the patient's blood glucose level stabilized, maintaining pre-prandial blood glucose levels around 135 mg/dL.\nAlthough HbA1c level was recorded at 8.6% upon discharge, it demonstrated gradual improvement over time. Dapagliflozin was continued, and in the 2-month follow-up after discharge, the HbA1c level was 8.3%. The dosage of insulin glargine was reduced to 16 units (0-0-0-16), while the insulin aspart dosage was increased to 18-12-14 U, based on self-monitoring blood glucose (SMBG) results. At the 4-month follow-up, the HbA1c level further decreased to 8.2% with insulin glargine reduced to 10 units (0-0-0-10 U) and insulin aspart reduced to 10-4-8 U. By the 6-month mark, the HbA1c level stabilized at 7.6% with the continued administration of dapagliflozin, insulin aspart (10-8-8 U), and insulin glargine (0-0-0-8 U).",
"gender": "Male"
}
] |
PMC10725247
|
[
{
"age": 76,
"case_id": "PMC11300108_01",
"case_text": "A 76-year-old male patient presented to our hospital with right knee joint pain. He was a horse trainer and had a history of two femoral fractures and one tibial fracture. Femoral and tibial shaft fractures were treated operatively; however, femoral supracondylar fracture was conservatively treated with cast. Femorotibial OA was radiographically classified as Kellgren-Lawrence Grade IV. Due to postfracture malunion, the overall alignment of the lower limb revealed a hip-knee-ankle angle of 21.7 varus, the femoral deformity was 7 varus in the coronal plane/25 antecurvatum in the sagittal plane, and tibial deformity was 7 valgus in the coronal plane/7 recurvatum in the sagittal plane (Figure 1).\nPreoperative planning was performed using a 3D digital template (ZedKnee, LEXI, Tokyo, Japan). Femoral varus and tibial valgus/recurvatum deformity could be corrected by intra-articular corrective osteotomy, in which the articular surfaces of both femur and tibia were osteotomized perpendicular to the mechanical axis. Regarding the sagittal alignment of femoral component, when the femoral implant was placed in line with the distal femoral axis in the sagittal plane, an extension deficit of 25 could develop (Figure 2(a)). When the femoral implant was placed in line with the femoral mechanical axis in the sagittal plane, a notch was observed (Figure 2(b)). From these simulations of the operative procedure, we considered that extra-articular corrective osteotomy was necessary for the femoral antecurvatum deformity. We planned a one-stage TKA with extra-articular corrective osteotomy by 25 extension at the deformity apex of femur.\nWe performed TKA using the Attune knee system (DePuy, Warsaw, Indiana, United States) using CT-free navigation (Kolibri, BrainLAB). The tibial valgus and recurvatum deformity were corrected by intra-articular osteotomy (i.e., navigation-assisted standard TKA), aiming for a neutral position of the varus/valgus and 0 posterior slope. Navigation was also applied for the femoral extra-articular corrective osteotomy. The femoral tracker was placed proximal to the osteotomy site so that navigation could be used for both TKA and extra-articular corrective osteotomies. During the registration process of the navigation system, we registered the distal femoral reference point as the distal endpoint of the expected mechanical axis in the sagittal plane after corrective osteotomy to enable navigation use after corrective osteotomy (Figure 3). First, navigation-assisted distal femur osteotomy was performed with the aim of achieving a neutral position of the varus/valgus and 25 of flexion (Figure 3, Line 1). Subsequently, a 25 navigation-assisted closed-wedge extension corrective osteotomy was performed at the apex of deformity. We used navigation to decide the coronal and sagittal alignment of the osteotomy line in EAD. The coronal alignment was aimed perpendicular to the mechanical axis, the sagittal alignment of the first osteotomy line was aimed at 25 flexion, and that of the second osteotomy line was aimed perpendicular to the mechanical axis. The amount of bone resection was determined by the point at which the two osteotomy lines were crossed, just at the posterior cortex of femur (Figure 3, Lines 2 and 3). The Stryker Precision Oscillating Tip Saw (Stryker, New Jersey, United States) was mounted with the tracker of navigation (Figure 4), and the osteotomy was performed without a cutting guide. We corrected the rotational deformity of the femur by temporarily fixing the osteotomy site with a stemmed femoral osteotomy guide and rotating the distal fragment freely depending on the surrounding soft tissue. The rotational alignment of the femoral implant was determined using the gap balancing technique, while that of the tibial implant was determined by the range-of-motion technique. The femoral osteotomy site was fixed with the cemented stem and the metaphyseal sleeve. Postoperatively, the patient was immobilized with a knee brace for 1 week, and partial weight-bearing was started at 4 weeks; full weight-bearing was allowed at 8 weeks.\nThe postoperative hip-knee-ankle angle was 1 varus, the femoral implant was implanted at 0.5 varus/0.5 flexion, and the tibial implant was implanted at 0.5 varus/0 posterior slope (Figure 5). Two years after surgery, the range of motion improved from 15 -95 to 0 -110 , the Knee Society Score improved from 39 to 92 points, and the functional score improved from 35 to 100 points.",
"gender": "Male"
}
] |
PMC11300108
|
[
{
"age": 66,
"case_id": "PMC10601694_01",
"case_text": "The patient was a 66-year-old Japanese man who referred to our department for itchy erythema on the trunk, which had appeared 1 year ago, exacerbated by the development of blisters and erosions. He had been receiving oral vitamins K2 and D3 for myelodysplastic syndrome (MDS) for 5 years and had no history of medications that could induce autoimmune bullous diseases, nor a family history of gastrointestinal polyposis or colorectal cancer. He had not undergone routine cancer screenings in the past.\nPhysical examination revealed multiple erythemas with tense blisters and erosions on their periphery, as well as pigmentation of the trunk and extremities (Fig. 1a). No mucosal lesions were observed. Although laboratory tests revealed abnormalities related to MDS (leukocytes, 3,740/microL; hemoglobin, 8.1 g/dL; platelet count, 19.4 x 104/microL; and reticulocyte count, 12.6 x 104/microL), blasts, markers of leukemia transition, anti-desmoglein 1/3, and anti-BP180 antibodies were absent. Tests for HLA-DQA1 and HLA-DQB1 allelic variations and IgA anti-epidermal transglutaminase antibodies, disease markers for celiac disease, yielded negative results. Histopathological examination of a skin biopsy specimen from a bullous erythematous lesion on the back revealed subepidermal blisters and infiltration of neutrophils, eosinophils, and lymphocytes into the blisters and superficial dermis (Fig. 1b).\nDirect immunofluorescence revealed a linear deposition of IgA and punctate deposition of C3 in the BMZ (Fig. 1c, d), while indirect immunofluorescence using normal human skin tissue revealed IgA anti-BMZ antibodies at a 10x dilution (Fig. 1e). Additionally, indirect immunofluorescence performed using 1M NaCl-split-skin showed IgA reactivity on the epidermal side (Fig. 1f). Finally, immunoblotting using a concentrated culture supernatant of HaCaT cells as substrate revealed strong IgA reactivity with the 120-kDa LAD-1 in the patient serum (Fig. 1g), which was consistent with the diagnosis of LL-type LAD.\nThe patient underwent concurrent examination for bullous disease and malignant tumors. Furthermore, upper gastrointestinal endoscopy was performed and revealed no abnormalities. Colonoscopy revealed >100 pedunculated polyps, <20 mm in size, in the colorectum (Fig. 1h, i). Subsequent histopathological examination of the biopsy specimens confirmed the diagnosis of tubular adenoma, two of which were rectal adenocarcinomas (Tis, N0, and M0). Suspecting familial adenomatous polyposis, MUTYH-associated polyposis, and other hereditary polyposis diseases, we performed a multigene panel test consisting of 59 genes to detect intestinal polyposis and hereditary colorectal cancer. Although no pathogenic genetic alterations in the germline were found that could explain the development of multiple colorectal polyps, we identified a missense variation, ATM (NM_000051.3): c.107A>G/p.Asp36Gly (dbSNP:rs1488019755), Chr11:108,098,537 (on Assembly GRCh37), which corresponded to an ATM variant of uncertain significance (Fig. 1j). This variant is not registered at the Genome Aggregation Database (gnomAD) (PM2). Multiple in silico analyses predicted deleterious effects of the missense variant on the ATM protein, including PolyPhen-2, probably managing; PROVEAN, deleterious; and UMD-Predictor, pathogenic (PP3). Based on the ACMG/AMP guidelines, the variant was classified as uncertain significance. In addition, this variant was registered in the Clin Var database as a pathogenicity of uncertain significance, with a review status of two stars.\nFor approximately 1 month, the patient did not respond to initial treatment with oral antihistamines and topical corticosteroids (as shown in Fig. 1k). Thus, 1 month following the first visit, after confirming of LAD, treatment with oral diaphenylsulfone (DDS; 50 mg/day), antihistamines, and topical steroids was initiated. Additionally, 1 month prior to LAD diagnosis, the diagnosis of colorectal cancer was confirmed during the initial endoscopic mucosal resection. Thereafter, endoscopic mucosal resection for multiple colorectal polyps was performed several times after treatment initiation with DDS. Within 3 months, the bullous erythematous skin lesions rapidly resolved (Fig. 1l), and no recurrence was observed during the 2 years of follow-up (Fig. 1m).",
"gender": "Male"
}
] |
PMC10601694
|
[
{
"age": 33,
"case_id": "PMC11330204_01",
"case_text": "A 33-year-old woman sought fertility treatment at Aria Fertility in London in May 2021, following four years of attempting to conceive. Written consent from the patient was obtained for this report. The couple experienced a series of recurrent miscarriages (n=6), most of which occurred within 4-5 weeks of gestation, with the most recent one dated February 2022. A product of conception (POC) analysis was performed via karyotyping, revealing an abnormal chromosome complement (der(14;14) (q10;q10)). Consequently, the couple underwent karyotyping of peripheral blood lymphocytes, which yielded normal results twice. The genetic laboratory determined that the RT detected in the recent miscarriage was most likely to have occurred de novo, rather than resulting from missegregation of a parental rearrangement (Figure 1). For this reason, the risk of recurrence was predicted to be low.\nFertility investigations disclosed an anti-Mullerian hormone (AMH) level of 2.6 pmol/L in 2021 and 3.86 pmol/L in 2022, which were both outside the normal range (4.1-58 pmol/L). In 2023, the semen analysis conducted for the male partner indicated normal values, including a sperm count of 102 M/ml, 71% progressive sperm, and 7% normal forms. Sperm DNA fragmentation testing done in 2020 showed a DNA fragmentation index of 9.4% (normal).\nDuring treatment at the patient's initial clinic in April 2022, a total of 7 mature oocytes were obtained. Among them, 5 successfully fertilized, leading to the transfer of a single blastocyst, while two additional embryos were vitrified. Unfortunately, both the initial cycle and a subsequent frozen single embryo transfer yielded negative results on urine pregnancy tests. Endometrial receptivity analysis (ERA; Igenomix, UK) indicated normal receptivity, and hysteroscopy and dilation and curettage (D&C) procedures showed normal findings. The remaining embryo was transferred to Aria Fertility Laboratories.\nIn April 2023, the patient underwent another cycle of IVF at Aria Fertility including PGT-A. The PGT-A method employed was PGTseq (Juno Genetics, USA), which is a custom targeted amplification-based approach. This method is widely recognized as one of the most validated and accurate techniques for PGT-A currently available. The IVF cycle resulted in 5 oocytes, all of which fertilized successfully, with 3 embryos reaching the blastocyst stage. The three blastocysts from the fresh cycle and the cryopreserved embryo from the previous cycle underwent trophectoderm biopsy, involving approximately 5 cells, followed by PGT-A analysis. The results showed that two of the blastocysts were monosomic for chromosome 14, one was trisomic for the same chromosome, and the remaining embryo exhibited trisomy 14 along with a mosaic loss of chromosome 15 (Supplementary Figure I).\nSperm aneuploidy test (ERA; Igenomix, UK) was performed to determine if the elevated aneuploidy rate for chromosome 14 could have a paternal origin. SAT is a cytogenetic test used to assess male infertility by measuring the percentage of spermatozoa with specific abnormalities involving loss or gain of the tested chromosome(s). SAT employs fluorescence in situ hybridization (FISH) and can be applied to ejaculated, epididymal, and testicular sperm. The details on the probes used are as follows: triple FISH includes a centromeric probe for chromosome 18p11.1-q11.1 (D18Z1) in blue, a centromeric probe for chromosome Xp11.1-q11.1 (DXZ1) in green, and a centromeric probe for chromosome Yp11.1-q11.1 (DYZ3) in orange (Cytocell Ltd., UK). Dual FISH involves a locus-specific probe for chromosome 13q14.2 in green and a locus-specific probe for chromosome 21q22.13 in orange (Cytocell Ltd., UK). Dual FISH utilizes a locus-specific probe for chromosome 14q32.33 in green and a locus-specific probe for chromosome 18q21.33 in red (Cytocell Ltd., UK). A normal SAT result is considered when the sample shows similar percentage of abnormal sperm compared to an internal control population of 44 fertile males with normal sperm parameters (evaluated using a Chi-square test or Fisher exact test; p<0.05). A total of 6175 sperm were analyzed, resulting in a normal SAT outcome for the analyzed chromosomes (13, 14, 18, 21, and sex chromosomes). The percentage of disomy for chromosome 14 was 0.10, compared to 0.13 in the control group. This outcome indicated that there was no elevated risk of sperm chromosomal abnormalities and therefore chromosome 14 aneuploidies observed in the embryos were unlikely to have had a paternal origin.\nIn order to determine the parental origin of chromosome 14 aneuploidies in the embryo biopsies, a genotype analysis was conducted using DNA samples obtained from the maternal and paternal blood samples. Juno Genetics employs PGTseq platform for their regular PGT-A procedures, incorporating chromosomal copy number analysis alongside a genotyping method that encompasses roughly 5,000 single nucleotide polymorphisms (SNPs) distributed across the entire genome. The SNPs located on chromosome 14 were analyzed in the parental samples as well as the embryos tested by PGT-A to investigate the parental origin of aneuploidy. The analysis confirmed that all the four chromosome 14 abnormalities detected in embryos were associated with errors of maternal (oocyte) origin.",
"gender": "Female"
}
] |
PMC11330204
|
[
{
"age": 49,
"case_id": "PMC10889877_01",
"case_text": "The distribution of independent categorical variables across pregnancy termination statuses is presented in Table 2. The overall percentage of women who have ever had a pregnancy that ended in a miscarriage, abortion, or stillbirth accounted for 16.14% in the study sample. The majority of the 16,323 eve-married women in the sample lived in rural areas (78.75%). Of the women, 66.55% had education up to secondary level and more than half (57.72%) was between 35 and 49 years old. The majority of women (66.53%) was between 15 and 24 years old when they first unionized with a male. More than one-third of the women had a parity of two (36.78%) and 45.9% reported a normal Body Mass Index (BMI). Regarding marital status, 90.67% of women was married and most reported not experiencing any domestic violence from their husband or partner. Of the women, 67.85% was unemployed. The majority of women was from the Western Province (19.46%) and lived in households with a low wealth index quintile (23.41%). Moreover, according to the recorded data, 84.41% of women lived in households where smoking indoors was not allowed.\nThe mean VIF was 1.25, indicating the absence of high multicollinearity between the explanatory variables. Table 3 presents the results of the fitted binary logistic random intercept multilevel models. The goodness of fit of the models was evaluated using the Likelihood Ratio (LR) test. The interpretation of the fixed effects was based on the model with the lowest -2 Log Likelihood, which was Model 3.\nThe complete model including both individual and community-level factors was found in Model 3 in Table 3. Individual factors such as woman's age, BMI, parity, contraceptive use, marital status, employment status, exposure to domestic violence, and smoking status inside the house were found significant. Some levels of region and locality were also significant among the community-level factors.",
"gender": "Male"
},
{
"age": 49,
"case_id": "PMC10889877_02",
"case_text": "The odds of pregnancy termination increased significantly with the increasing age of women. Women aged 35-49 years old [AOR = 2.64, 95% CI = (2.10, 3.31)] had approximately three times higher odds of pregnancy termination compared to those women aged 15-24 years old. Overweight [AOR = 1.14, 95% CI = (1.04, 1.26)] and obese [AOR = 1.36, 95% CI = (1.20, 1.55)] women had 14% and 36% higher odds of pregnancy termination, respectively, compared to women with normal weight. The odds of pregnancy termination decreased with the increasing number of children a woman had. Women with three or more children [AOR = 0.62, 95% CI = (0.50, 0.76)] had 38% lower odds of pregnancy termination compared to women with zero parity. Women who used contraceptives [AOR = 1.24, 95% CI = (1.07, 1.45)] had 24% higher odds of pregnancy termination compared to otherwise. Cohabiting women [AOR = 1.57, 95% CI = (1.16, 2.13)] had 57% higher odds of pregnancy termination compared to separated, divorced, or widowed women. Working women [AOR = 1.15, 95% CI = (1.05, 1.27)] had 15% higher odds of pregnancy termination compared to unemployed women. Women who faced domestic violence [AOR = 1.14, 95% CI = (1.02, 1.28)] had 14% higher odds of pregnancy termination compared to otherwise. Women from the Northern [AOR = 0.60, 95% CI = (0.50, 0.73)], Eastern [AOR = 0.80, 95% CI = (0.67, 0.97)], and North Central [AOR = 0.78, 95% CI = (0.64, 0.95)] provinces had a lesser likelihood of pregnancy termination compared to women from the Western province. Women in the estate sector [AOR = 0.70, 95% CI = (0.53, 0.92)] had 30% lower odds of pregnancy termination compared to women in the urban sector. Women who resided in houses where smoking was permitted indoors [AOR = 1.13, 95% CI = (1.01, 1.28)] had 13% higher odds of pregnancy termination compared to those who did not.\nModel 1, the empty model, indicated a statistically significant variability in the odds of pregnancy terminations with a cluster variance of 13%. Further, the ICC of the empty model shows that 4% of the total variability in the pregnancy terminations in Sri Lanka was attributed to differences between clusters, leaving 96% of the variability to be accounted for by other unknown factors. Model 3, the full model, adjusted for individual and community-level factors, reduced the cluster variance to 0.08 (Standard Error (SE) = 0.04) which remained significant. This shows that 2% of the total variance of pregnancy terminations was attributed to clusters. In a multilevel study, an ICC equal to or greater than 2% indicates significant group-level variance and is considered a minimum precondition.",
"gender": "Female"
}
] |
PMC10889877
|
[
{
"age": 28,
"case_id": "PMC11269142_01",
"case_text": "Our patient was a 39 + 6-week male newborn with a birth weight of 2,940 g (13th percentile, -1 SD). As background, his parents were from Morocco. The mother was 28 years old and had six gestations and four miscarriages in the first trimester. She had a healthy 2-year-old son.\nThe pregnancy serologies were negative, except for rubella, which was indeterminate, and cytomegalovirus, which was IgG-positive and IgM-negative. The cervical exudate culture for Streptococcus agalactiae was negative.\nThe pregnancy was monitored at a high-risk gynecology center due to gestational diabetes treated with diet, persistent elevation of resistance in uterine arteries, single umbilical artery, a persistent right umbilical vein in its intrahepatic variant, and mild to moderate polyhydramnios diagnosed in the third-trimester ultrasound. There were no other structural anomalies, and the parents did not desire a genetic study. The water bag broke four and a half hours before delivery, with clear fluid, without fever or other infectious symptoms.\nThe birth took place by vaginal delivery. The newborn did not show effective respiratory effort, prompting vigorous stimulation and ventilation with intermittent positive pressure. Despite this, he continued without respiratory effort and with a heart rate below 100 beats per minute; then, orotracheal intubation was performed with a 3.5-cm Endotracheal tube (ETT), which was mistakenly positioned at 12 cm from the commissure, a distance longer than the standard depth for the patient's size. Following these maneuvers, the heart rate increased above 100 lpm, and the preductal peripheral oxygen saturation (SaO2) achieved 90%. He was transferred to the neonatal intensive care unit (NICU) requiring 100% oxygen without any incidence.\nOn physical examination, no dysmorphism or dyschromia were found. The lip, palate, and clavicles appeared intact, and the anus was permeable and normally positioned. Lung auscultation revealed symmetrical ventilation with abundant respiratory secretion noises. In the NICU, the patient became increasingly vigorous, so we decided to extubate him on non-invasive ventilation. Immediately, he developed severe respiratory distress characterized by generalized cyanosis, absence of audible crying, and severe hypoventilation on venous gasometer analysis. Reintubation was performed by the neonatology team under sedation, during which the supraglottis and glottis were visualized as normal, and the ETT passed through the vocal cords. Nevertheless, despite five attempts by expert neonatologists, the ETT could not be passed beyond the vocal cords. In this context, we requested help from the anesthesiology team, who attempted it six more times, but intubation could not be attempted. Throughout this process, we alerted the pediatric surgical team, who performed a fibrobronchoscopy and confirmed the diagnosis.\nFibrobronchoscopy (see Supplementary Video S1) revealed a normal supraglottis and glottis but with an obstruction at the subglottic level. Initially, it was interpreted as a probable congenital subglottic membrane or stenosis, so an emergency tracheostomy was performed. In this procedure, we observed a lack of airway continuity beyond the cricoid cartilage. We performed immediate esophagoscopy and visualized a fistula that ended in a primitive and non-functional structure resembling a tracheal carina (see Supplementary Video S2). As with other complementary tests, chest x-rays showed the absence of the tracheal pattern, poorly expanded lungs, and an apparently normal digestive system. X-rays of the spine and extremities were normal. The urgent echocardiogram showed an aberrant right aortic arch, a left subclavian artery, and an open ductus arteriosus with a bidirectional shunt. Blood tests including complete blood count and liver and kidney function were normal. We found persistent respiratory acidosis in the blood gases. According to the general parental visitation policy of our NICU, the father was allowed continued presence. Every step of the diagnostic process and the findings were communicated progressively to him. The clinical relevance and severity of the pathology were emphasized, as well as the probability of death. Because of the language barrier, we used diagrams and images to improve comprehension.",
"gender": "Male"
}
] |
PMC11269142
|
[
{
"age": 71,
"case_id": "PMC11101673_01",
"case_text": "A 71-year-old male with past medical history significant for obstructive sleep apnea underwent implantation of an Inspire hypoglossal nerve stimulator. The post-operative course was uncomplicated until postop day #14 when the patient noted increased serous drainage from his chest surgical incision. The patient was promptly seen in Otorhinolaryngology outpatient clinic, where a superficial abscess was found and ~ 10 ccs of serosanguinous fluid were expressed from the device pocket. Patient was prescribed a 7-day course of Trimethoprim/Sulfamethoxazole (TMP/SMX); however, purulent discharge from the chest wall surgical site persisted on postop day #17. Drainage from the device was cultured after 3 days of TMP/SMX use. This wound culture grew gram-variable rods. VITEK mass spectrometry identified this organism as T. otitidis. Patient then presented to the emergency department on postop day #21 with complaints of drainage from not only the device pocket, but also from his neck incision. On exam, patient was afebrile and hemodynamically stable with no leukocytosis. On exam, there was noted to be induration with purulent drainage from both the device pocket and right lateral neck incisions. Both were packed with gauze, and blood and wound cultures were sent from both neck and chest wall surgical sites. Patient was admitted and started on empiric IV antibiotic therapy with vancomycin and piperacillin-tazobactam. Neck surgical site and device pocket cultures on admission also grew T. otitidis. Blood cultures drawn on hospital admission were negative. Computed Tomography Scan of neck soft tissue and thorax with contrast was notable for soft tissue thickening and stranding around implanted chest device as well as associated pockets of subcutaneous gas and enlarged cervical lymph nodes (Fig. 1). On postop day #22, patient underwent surgical removal of the hypoglossal implant plus incision and drainage of chest and neck surgical sites with Jackson-Pratt drain placement. Intraoperatively, wound cultures were taken from both neck and chest wall surgical sites. Intraoperative cultures taken from neck and chest wall sites grew normal skin flora with no isolation of anaerobes. Patient was deescalated to vancomycin alone once blood cultures and operative wound cultures showed no gram-negative growth. Patient was then discharged three days after device explantation with six days of amoxicillin/clavulanic acid for total 10-day antibiotic course. Patient was evaluated in outpatient Infectious Disease clinic one week after hospital discharge. Patient had completed oral antibiotic course. Patient reported persistent clear drainage from chest wall surgical wound, which had been present but decreased since hospital discharge. Patient denied any systemic signs of infection or increased pain, purulent drainage, swelling, or erythema around surgical sites. Patient was instructed to continue to monitor surgical incision sites and discharged from clinic with no further antibiotics. On telephone follow up, patient had denied any recurrence of drainage three months after discharge.",
"gender": "Male"
}
] |
PMC11101673
|
[
{
"age": 33,
"case_id": "PMC10866627_01",
"case_text": "A 33-year-old man presented to the emergency department (ED), complaining of worsening fever, dyspnea, vomiting, and productive cough for 5 days, and an acute onset desaturation. The patient suffers from schizophrenia and has been treated for more than 20 years by using several neuroleptic drugs. From about 6 months ago, his psychiatric condition was not well controlled by medication, and he started weight loss due to low food intake.\nHis vital signs were as follows: temperature of 39.6 , heart rate of 147 beats per minute, blood pressure of 100/50 mmHg, and oxygen saturation of 80% on room air. His body mass index (BMI) was 14.5 kg/m2 (6 months ago, it was about 19.42 kg/m2). Physical examination on admission showed a conscious, noncooperant cachectic and dyspneic patient, with tachycardia but no murmurs. Pulmonary auscultation showed bilateral wheezing and bronchial congestion. Abdominal examination revealed epigastric tenderness, and no urinary symptoms were mentioned.\nBlood tests showed elevated white blood cell count (13,300/mm3) and a protein C level at 26 mg/l. The alkaline reserve was 12.1 mmol/l. Creatinine, liver function tests, sodium, potassium, and chloride levels were within normal limits. A computed tomography (CT) of the chest, abdomen, and pelvis with intravenous contrast material was ordered and revealed bilateral multifocal parenchymal condensations with multiple ground-glass opacities predominant in the lower lobes, suggestive of aspiration pneumonia (Figure 1).\nIn addition, there was an extremely important distension of the esophagus, stomach, and proximal duodenum (Figure 2), that is, an upstream of an abrupt transition zone involving a decompressed caliber in the third part of the duodenum at the level of its crossing in the mesenteric clamp. The rest of the bowel loops were of normal appearance. No intraabdominal collection, parietal pneumatosis, or pneumoperitoneum were noted. The angle between the proximal SMA and the AA, also known as the aortomesenteric angle, was narrow, at 12.3 (Figure 3) and the aortomesenteric distance was 3.5 mm (Figure 4), suggestive of a SMAS. Also, the left renal vein was distended before its course in the mesenteric clamp.\nInitial management included hydration, nasal oxygen, bronchodilators, nasogastric tube insertion, antipyretics, steroids, and hypercaloric total parenteral nutrition (2500 kilocalories per day). Empiric intravenous antibiotics (levofloxacin 500 mg daily and piperacillin/tazobactam 4.5 g QID) were started after blood and urine cultures. Evolution showed severe rapid clinical degradation that resulted in a cardiac arrest and death.\nThe diagnosis of a severe septic shock due to aspiration pneumonia secondary to SMAS was made.",
"gender": "Male"
}
] |
PMC10866627
|
[
{
"age": 71,
"case_id": "PMC11006962_01",
"case_text": "A 71-year-old Chinese woman was admitted to Bishan Hospital of Chongqing Medical University, complaining of Swallowing obstruction, heartburn, regurgitation of gastric acid for more than 2 months.\nThe patient presented with swallowing obstruction, gastroesophageal reflux symptoms including heartburn and regurgitation of gastric acid. She denied any respiratory symptoms such as cough, sputum production, hemoptysis, or fever. Additionally, she had no history of chest or back pain and did not report any other comorbidities.\nThe patient had no prior medical history.\nThe patient did not have a cancer-relative family susceptibility.\nPhysical examination revealed that the patient's body temperature was 36.1 C, pulse rate was 70 bpm, blood pressure was 131/82 mmHg, respiratory rate was 18 breaths/min, and performance status score was 1. None of positive signs were found upon physical examinations.\nHis blood count showed a WBC of 4.29 x 109/L, Hb of 129 g/L, and platelet count of 188 x 109/L. The serum level of carcinoembryonic antigen (CEA) was 0.98 ng/mL.\nAn esophageal lesion was found by chest computed tomography (CT) scans in T7 vertebral level (Figure 1). Simultaneously, chest CT showed a 2cmx1cm solitary lesion in the right superior pulmonary (Figure 2). The presence of distant metastases was not detected through imaging examinations including abdominal CT scans, brain magnetic resonance imaging (MRI), and bone scanning at the time of diagnosis of the double primary malignant tumors.\nThe diagnosis by gastroscopic biopsy was squamous cell carcinoma (Figure 3) at the upper thoracic esophagus. Immunohistochemistry indicated EGFR over-expression. Simultaneously, the histological diagnosis by percutaneous lung Biopsy was \"adenocarcinoma\" (Figure 3). Epidermal growth factor receptor (EGFR) gene mutation status was evaluated by Sanger sequencing, and an exon 21 point mutation (L858R) was identified.",
"gender": "Female"
}
] |
PMC11006962
|
[
{
"age": 32,
"case_id": "PMC10583505_01",
"case_text": "We present a case of splenic volvulus of a wandering pelvic spleen in a 32-year-old mother of one child. She was diagnosed with anaemia in her first pregnancy at the age of 26 years. She was detected to have moderately enlarged pelvic spleen at that time. Ultra sound scan abdomen showed a moderately enlarged spleen at this time (17 cm x 8 cm x 6 cm). She has undergone lower segment caesarean section to deliver her baby. She defaulted from the haematology follow-up at the age of 27 years. She presented with intermittent left side colicky pain for 1-week duration associated with anorexia and fever.\nPhysical examination revealed a fever of 38.3 C, a heart rate of 88 beats per minute, a blood pressure of 100/70 mmHg, and an oxygen saturation of 100% on room air. She appeared in moderate distress from pain, and an abdominal examination revealed a mobile pelvic mass. Laboratory investigation was notable for whole blood count (WBC) 13.44 x 103/muL, haemoglobin 6.5 g/dL, platelets 940 x 103/muL, erythrocyte sedimentation rate (ESR) -37 mm/first hour aspartate transaminase test (AST) 51 U/L, alanine transaminase test (ALT) 83 U/L, amylase 83.3, C- reactive protein (CRP) 143, amylase -83, and total bilirubin 16.4 mumol/L. Electrolyte and renal functions were normal. Her pregnancy test was negative. She was transfused with red cell concentrate to optimize her haemoglobin level. She was started on aspirin due to thrombocytosis. A CT of the abdomen and pelvis was performed, which demonstrated findings consistent with wandering spleen with splenic infarction and rotated mesentery, involving the tail of pancreas, splenic vein and superior mesenteric vein, and its branches suggestive of a whirl sign (Figure 1). She was taken to the operating room for exploratory laparotomy and found to have moderately enlarged pelvic spleen with twisted hilum including tail of the pancreas in the infra colic compartment. Spleen appeared dusky in colour (Figure 2). Detorsion and splenectomy were performed, and the viable tail of pancreas was placed in the supra colic compartment. Size of the spleen was 20 cm x 15 cm x 9 cm and the weight was 3.24 kg. Laparoscopic approach was considered but we proceeded with the open method as the spleen was occupying the centre of the abdomen.\nHer postoperative course was uneventful. Aspirin was omitted when the platelet count reached normal range. Post splenic vaccine prophylaxis was arranged. She was discharged from hospital on postoperative day 5.",
"gender": "Female"
}
] |
PMC10583505
|
[
{
"age": 18,
"case_id": "PMC10953507_01",
"case_text": "We evaluated 16,264 CT exams (cardiac and chest) performed between 2015 and 2022 in the heart imaging department of our institution using a dual-source 128-slice CT scanner (SOMATOM Definition Flash, Siemens Healthineers, Forchheim, Germany). We established a retrospective registry of adult patients (> 18 years old) with ALCAPA, which included 7 cases. Subsequently, we collected clinical and echocardiographic data that were assessed retrospectively. The case series is presented with a range of clinical problems, and the initial diagnoses of patients during observation are shown. Short descriptions are provided, emphasising the most significant clinical problems.",
"gender": "Unknown"
},
{
"age": 34,
"case_id": "PMC10953507_02",
"case_text": "A 34-year-old woman was admitted for further diagnosis because ALCAPA was suspected. In the referring hospital, coronary angiography was performed because of unstable angina symptoms. The origin of the LCA was not visualised. Cardiac computed tomography confirmed the diagnosis (Figure 1). Echocardiography showed a preserved left ventricular ejection fraction of 50% and severe mitral regurgitation. The apex and middle segments of the anterior wall were hypokinetic. Cardiac magnetic resonance (CMR) showed a scar of the myocardium of the anterior, anterior-septal and apex of the left ventricle and the anterolateral papillary muscle (Figure 2). The patient was qualified for surgical intervention. An annuloplasty of the mitral valve was performed. The anomalous origin of the LCA was closed via a pulmonary trunk access, and a left internal mammary artery-left anterior descending artery (LIMA-LAD) bypass was implanted. She was discharged home after an uneventful hospital stay a few days later.",
"gender": "Female"
},
{
"age": 41,
"case_id": "PMC10953507_03",
"case_text": "A 41-year-old female patient was admitted because of severe mitral valve regurgitation and thrombus of the mitral annulus diagnosed in an outpatient clinic. She underwent corrective surgery of ALCAPA 6 years before, with implantation of an LIMA-LAD graft and annuloplasty with an Edwards Lifescience home ring. A biological valve (BioIntegral 27) was implanted. A few days later, she was discharged.",
"gender": "Female"
},
{
"age": 34,
"case_id": "PMC10953507_04",
"case_text": "A 34-year-old patient underwent the operation due to ALCAPA at the age of 25 years and has not required hospitalisation since then. Without angina symptoms. NYHA class I. In echocardiography, a normal systolic function of the right and left ventricles. No significant valve pathologies. Managed at the outpatient clinic for routine check-ups.",
"gender": "Unknown"
},
{
"age": 60,
"case_id": "PMC10953507_05",
"case_text": "A 60-year-old patient was admitted to the hospital to plan the treatment of severe tricuspid regurgitation. Besides ALCAPA, he presented with patent ductus arteriosus (PDA), atrial septal defect (ASD) type II, and ventricular septal defect (VSD). He underwent surgical correction of PDA at the age of 21 years and VSD and ASD II one year later. He was presenting symptoms in class NYHA II, without angina. A pacemaker was implanted at the age of 47 years due to sick sinus syndrome. Echocardiography showed an LVEF of 36%. Severe tricuspid regurgitation and residual VSD of 2 mm.",
"gender": "Male"
},
{
"age": 29,
"case_id": "PMC10953507_06",
"case_text": "A 29-year-old male patient with ALCAPA, who underwent the Takeuchi procedure at the age of 4 months, was admitted for testing. At the age of 9 years, he underwent PDA closure with a clip (Figure 3). He has not visited an outpatient clinic for the past 10 years. Now he is complaining of shortness of breath (NYHA II), palpitations, and one episode of angina symptoms during static exercise. The ECG showed atrioventricular block I. The echocardiography showed an LVEF of 53%, small pulmonary stenosis, and moderate regurgitation. Holter-ECG showed 0.5% of premature ventricular contractions. Single-photon emission computed tomography (SPECT) was ordered, which showed partially reversible ischaemia of the apex and segments of the anterior wall (Figure 4). The patient is waiting for a coronary angiography.",
"gender": "Male"
},
{
"age": 33,
"case_id": "PMC10953507_07",
"case_text": "A 33-year-old patient underwent left coronary artery transplantation and mitral valvuloplasty at the age of 6 years. The mitral valve had to be replaced at the age of 13 years (St. Jude 31 mm). At the age of 16 years, a sudden cardiac arrest occurred. A cardiac stimulator and, one year later, an implantable cardiac defibrillator were implanted. Sudden cardiac arrest happened again at the age of 27 years. When the patient was 33 years old, electrical storms occurred twice, the second after a 6-month break. He was admitted for ablation of the ventricular arrhythmia substrate. Echocardiography showed a severely impaired LVEF of 29%, large left ventricle (70/54 mm) and atrium (70 mm, 56 cm2), mechanical mitral valve, and impaired global longitudinal strain (GLS) of -3.1% (Figure 5).",
"gender": "Male"
},
{
"age": 20,
"case_id": "PMC10953507_08",
"case_text": "The currently 20-year-old patient underwent surgical correction of ALCAPA at the age of 16 years. The echocardiogram after the procedure showed an LVEF of 71%. Holter-ECG showed no abnormalities. CMR showed normal chamber size, preserved systolic function of the right and left ventricle, and no signs of ischaemic scarring of the myocardium. In a follow-up exercise test, he reached 13.5 metabolic equivalent (MET).",
"gender": "Male"
}
] |
PMC10953507
|
[
{
"age": null,
"case_id": "PMC11308003_01",
"case_text": "A lean (body mass index = 19) adult male had his first colonoscopy at age 56, with no intestinal polyps detected. A second colonoscopy 7 years later revealed a large 4-5 cm tumor in the cecum. The patient's family history (paternal, maternal, immediate, and extended) had no record of tumors of any kind. The patient reported a healthy lifestyle, including frequent consumption of organic home-grown vegetables, naturally rich in fiber, and no use of drug, tobacco, or alcohol. The only noted lifestyle change between colonoscopies was the initiation of 4 grams of agave inulin powder daily in his morning beverage for the last 2 years of that seven-year period. The consumption of inulin each morning produced noticeable bowel gas by late afternoon, indicating rapid, intense fermentation of the inulin.",
"gender": "Male"
},
{
"age": null,
"case_id": "PMC11308003_02",
"case_text": "The tumor required a right hemicolectomy where the patient lost roughly 12 inches of his colon, including the appendix and ileocecal valve. The tumor was a mucinous (colloid) adenocarcinoma (>50% mucinous component), poorly differentiated, with a size of 3.5 x 4.0 x 2.3 cm. The tumor invaded through the muscularis propria into the pericolorectal tissues but did not extend to the serosal surface. Immunohistochemistry for DNA mismatch repair proteins revealed positive staining for mutL homolog 1, mutS homolog 2, mutS homolog 6, and PMS1 homolog 2 in the tumor. Memorial Sloan Kettering's Integrated Mutation Profiling of Actionable Cancer Targets estimated that the patient's tumor mutation burden was 10.7 mutations per megabase and had identified 13 mutations (Table). One lymph node out of 36 was metastatic, leading to 3 months of chemotherapy with capecitabine and oxaliplatin. The patient was then free of cancer for 1.5 years. During this cancer-free period, the tumor marker carcinoembryonic antigen level was between 1 to 2 ng/mL, indicating no cancer was present. However, during a six-month interval, the cancer returned as metastatic colon cancer (peritoneal metastasis), a terminal cancer with no cure. During this interval, his serum carcinoembryonic antigen level had climbed to 40 ng/mL. He is now being treated with systemic chemotherapy and is exploring options for cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy.",
"gender": "Male"
}
] |
PMC11308003
|
[
{
"age": 79,
"case_id": "PMC10570567_01",
"case_text": "A 79-year-old man consulted his primary care doctor for a 2-week history of fatigue and pain in his right shoulder, right clavicle, and upper back. Chest radiography revealed a right pleural effusion and a right upper lung field mass (Fig. 1A). A malignancy was suspected, and he was referred to our hospital. The patient was a former smoker with a history of osteoporosis and cataracts. He presented at our hospital with a fever of 37.3 C. His peripheral capillary oxygen saturation was 95% on room air, and he exhibited no signs of respiratory failure. Physical examination revealed decreased breath sounds on the right lower lung field. The right shoulder and sternoclavicular joints were swollen, warm, and tender. No abnormalities were observed in the palms or soles. Laboratory testing yielded an elevated C-reactive protein and matrix metalloprotease-3. All tumor markers were negative (Table 1A). A computed tomography scan was performed. The mass, detected on X-ray, was consistent with osteosclerosis of the sternoclavicular joints (Fig. 1B).\nThe cells in the pleural fluid had significantly more lymphocytes, and the ratio of total protein in the pleural fluid to total protein in the blood was 0.55, making it an exudative pleural fluid according to Light's criteria; however, the lactate dehydrogenase level in the pleural fluid was as low as 71 U/dL. Bacteriological examination showed that both general bacteria and acid-fast bacilli in the pleural fluid were culture-negative, and the transcription reverse-transcription concerted reaction was also negative for Mycobacterium tuberculosis DNA. The cytological diagnosis revealed no malignancy (Table 1B). Although there were no typical dermatological findings, SAPHO syndrome was suspected based on the other findings. Moreover, bone scintigraphy exhibited the \"bull's head sign,\" which was consistent with SAPHO syndrome (Fig. 2).\nThe patient was prescribed loxoprofen for pain control prior to diagnosis, so treatment was started with oral prednisolone (PSL) 15 mg/day, with the PSL dose tapered to 2.5 mg every 2 weeks. The pain resolved within a week of starting PSL, and the pleural effusion decreased significantly (Fig. 3). One year after starting PSL, there were no evidence of recurrence.",
"gender": "Male"
}
] |
PMC10570567
|
[
{
"age": 29,
"case_id": "PMC10777889_01",
"case_text": "The maxillofacial department referred a 29-year-old male patient for root canal treatment prior to surgical excision of a large radiolucency around the root apices of the mandibular central incisors teeth. The primary presenting symptoms were localized to the mandibular anterior region extending from the mandibular left lateral incisor to the mandibular right central incisor and it was soft and non-fluctuant with a slight tenderness to palpation, and dull continuous pain associated with the affected area without any aggravating factors that started two months ago. The patient has no known medical history and dental history revealed a trauma 14 years ago (fell on his chin). Upon oral examination, vestibular swelling to his lower anterior teeth was observed. Tooth #31 was non-responsive to cold and electric pulp tests, and pain to percussion leading to a diagnosis of necrosis with symptomatic apical periodontitis. Responses of teeth #32 and #41 to sensibility testing (electric pulp and thermal tests) were found normal.\nThe clinical assessment was conducted, encompassing an evaluation of the soft tissues, tooth mobility, and any signs of inflammation or discomfort. The study documented the patient's self-reported feedback regarding symptoms or changes in oral health, as well as histopathological evaluation. Radiographic images, including periapical or cone-beam computed tomography (CBCT) scans, were acquired during every subsequent examination (Figures 1-4). One endodontist and one maxillofacial surgeon evaluated the images to ascertain any changes in root position, periapical healing, and bone regeneration. Periapical pathology indicators were documented, such as periapical radiolucency or bone loss.\nThe patient was given written informed consent, in accordance with the Helsinki Declaration on the Ethical Principles for Medical Research Involving Human Subjects for the publication of his case report. The procedure was conducted by an endodontic resident utilizing a surgical operating microscope. Anesthesia was given using two carpules of 4% articaine with 1:100,000 epi as buccal infiltration. The rubber dam was applied and access cavity was made using a size 3 mm in diameter round diamond bur (Dentsply Maillefer, Ballaigues, Switzerland) at high-speed underwater spray; determining the working length using a DentaPort ZX apex locator (J. Morita Mfg. Corp., Kyoto, Japan) Reciproc blue (R25/0.08 mm) (VDW GmbH, Munich, Germany) was used for cleaning and shaping to full working length, and irrigation using 15 mL of 3% NaOCl using a 30-gauge side vented irrigating needle (Max-I-Probe, Dentsply Maillefer, Ballaigues, Switzerland). The canal was dried using an absorbent paper point size 25 red color code (Meta Dental Corp., New York, USA), and Cold single-cone technique (hydraulic condensation technique) with (#25/0.08) matching gutta-percha cones and bioceramic sealer were used as an obturation method. Total Fill bio-ceramic sealer (TotalFill BC Sealer) (FKG Dentaire, La Chaux-de-Fonds, Switzerland) was applied. One week later the surgery was scheduled and anesthesia was given using two carpules of 4% articaine with 1:100,000 epi as buccal infiltration and 1 carpule of lidocaine 1:50,000 epi distributed along the mucogingival line from tooth #33-42. A triangular full mucoperiosteal flap was raised with a mesial vertical releasing incision. Lesion enucleation was carried out followed by root resectioning of 3 mm using Lindemann bur and retropreparation using ultrasonic and retrograde filling using MTA. Suturing was done using 5-0 nylon and removed five days later.\nThe patient received postoperative instructions and oral hygiene protocols. Periodic follow-up appointments were arranged for clinical and radiographic assessments at 1, 2, and 3-year intervals which show healing of the periapical lesion except slight widening on the mesial side of the root of tooth number #41. The research complied with ethical guidelines and the principles stated in the Declaration of Helsinki, adopted in 1964.\nHistopathological samples sent for microscopic examination consisted of three fixed pieces of soft tissue, tan-black in color, and measuring aggregate of 2.5x1.3x1.0 cm. The largest was bisected and revealed multiple fragments of granulation tissue infiltrated by a mixed chronic inflammatory cell infiltrate, with hemorrhagic bleeding and trabeculae of vital bone. The diagnosis was periapical granuloma.",
"gender": "Male"
}
] |
PMC10777889
|
[
{
"age": 25,
"case_id": "PMC11093682_01",
"case_text": "LJ, a 25-year-old person (preferring they/them pronouns) transitioning from female to male and receiving GAHT, was brought to hospital by ambulance after their partner noticed new erratic and bizarre behaviour. LJ had a past psychiatric history significant for anxiety, major depressive disorder (MDD), and post-traumatic stress disorder (PTSD). They saw a psychologist regularly in the community and had sequentially trialled duloxetine and sertraline, the latter of which was being weaned prior to admission. They had been receiving topical testosterone 1% as GAHT for approximately 12 months prior to presentation with no recent changes in formulation or dose. They drank alcohol and smoked cannabis socially, with no other drug use prior to admission. A family history of bipolar affective disorder (BPAD) in LJ's maternal uncle and grandfather was recorded.\nDuring initial reviews LJ presented with features of psychosis as well as affective lability, giving an initial impression of bipolar mania with psychosis. Oral olanzapine (20 mg daily total) and lithium sustained release (450 mg twice daily) were commenced. In the days following admission, LJ's condition deteriorated with signs of emerging catatonia with deteriorating oral intake and emerging lithium toxicity. ECT was urgently commenced under the Mental Health Act, with a bifrontal standard stimulus approach utilised and using a MECTA Spectrum 5000Q ECT machine. Treatments were fully modified using suxamethonium and propofol with doses of 40 and 100 mg, respectively.\nDuring planning of treatment, it was noted that the existing titration protocols guide dosing based on binary male or female gender. This posed a question for the service about what protocol should be followed in LJ's case where, although they were of female sex at birth, had been receiving testosterone GAHT for 12 months which we considered may have biological effects impacting neuromodulation treatments. In LJ's case, the threshold was 48 millicoulombs (mC) and they received the treatment dose at 72 mC with a 3 s well-modified motor seizure and 18 s electroencephalogram (EEG) seizure recorded. Following the first treatment, LJ did experience transient tachycardia to a heart rate of 108 beats per minute and was not observed on subsequent treatments. They had a normal electrocardiogram (ECG) during this time. LJ's post-ECT recovery was uneventful with no evidence of postictal confusion. Improvement in mental state was noted following the first treatment, and LJ received seven further treatments over 3 weeks with the treatment dose remaining at 72 mC. Following the fifth treatment, they were assessed to have the capacity to continue ECT under informed consent. Testosterone GAHT was continued during this time. No cognitive changes were noted across serial Montreal Cognitive Assessment testing. Following the final ECT treatment, they were discharged home with community mental health service follow-up to continue treatment with lithium as a mood stabilising agent and olanzapine antipsychotic therapy. In the months following their recovery, they continued to improve and engage with the community mental health team with plans to slowly return to work.",
"gender": "Transgender"
}
] |
PMC11093682
|
[
{
"age": null,
"case_id": "PMC10757234_01",
"case_text": "An Asian male patient in his late 30s with an approximate 5-year history of HIV, currently on dolutegravir-lamivudine with undetectable viral load and CD4 count above 500, presented with pink plaques on the left side of the scrotum and left side of the penile base associated with mild pruritus and burning for at least 1 year (Fig 1). Two punch biopsies from the scrotum were obtained. Pathology showed clusters of epithelioid cells with ample myxoid cytoplasm within the epidermis. Neoplastic cells stained positive for CK7 and negative for CK20, suggestive of primary EMPD. Biopsy from the penile base was performed and was negative for EMPD. The patient was referred for MMS consultation and multidisciplinary cancer screening. During consultation for MMS, 10 additional scouting biopsies were obtained (Fig 2), including a repeat biopsy from a pink patch at the penile base (J). The central specimen (I) was positive for intraepidermal EMPD and the peripheral margin of specimen D was also positive. Remaining biopsies were negative for EMPD.",
"gender": "Male"
},
{
"age": null,
"case_id": "PMC10757234_02",
"case_text": "Because of immunosuppressed status, young age, and patient preference, extensive oncologic work up was performed to rule out secondary EMPD. Urine cytology was negative for high grade urothelial carcinoma. CA 19-9, CEA, PSA, and CA 15-3 were normal. IHC was negative for PD-L1 and progesterone receptor. Mutational burden testing was remarkable for ERBB3 mutation but otherwise showed no mutations requiring change in management or further testing. The patient was referred to urology and gastroenterology to rule out underlying malignancy. Renal ultrasound, scrotal ultrasound, cystoscopy, esophagogastroduodenoscopy, and colonoscopy were unrevealing.",
"gender": "Unknown"
},
{
"age": null,
"case_id": "PMC10757234_03",
"case_text": "The patient was treated with MMS with IHC analysis for CK7. Complete resection was obtained after 3 stages, and intermediate primary repair was performed the following day (Fig 3). The patient's postoperative course was complicated by fever. Given the concern for possible surgical site infection, he was treated with a course of cefadroxil. He subsequently tested positive for COVID-19 and was advised to follow-up with his primary care provider for further evaluation and treatment.",
"gender": "Male"
}
] |
PMC10757234
|
[
{
"age": 27,
"case_id": "PMC11068466_01",
"case_text": "A 27-year-old male presented to the outpatient department with complaints of multiple swelling in the neck for the past 6 months associated with evening rise of temperature, loss of weight, and loss of appetite with no significant past and personal history. On examination of the neck, there were multiple, hard, mobile, discrete, non-tender, cervical lymph nodes of size 2-2.5cm with no active discharge and overlying skin showing signs of healed ulceration. The tuberculin skin test was positive, showing an induration of 20mm. Fine needle aspiration cytology from the lymph node showed caseating granulomatous inflammation suggestive of tuberculosis. A dermatologist's opinion was taken and a biopsy from the overlying skin showed central necrosis with peripheral granuloma formation suggestive of scrofuloderma. The patient was started on anti-tubercular treatment and at one month follow up there was regression of lymph nodes. Scrofuloderma is one of the cutaneous manifestations of tuberculosis, accounting for approximately 2% of extrapulmonary tuberculosis. It is also called tubercular colliquative cutis and occurs from the direct extent of disease from deep structure for example: lymph node, joint, bone, or epididymis. It is mostly seen in the adolescent age group and commonly involves the neck, axilla, and groin. They may be single or multiple. Treatment is therapy with isoniazid, rifampin, ethambutol and pyrazinamide for 9-12 months.",
"gender": "Male"
}
] |
PMC11068466
|
[
{
"age": 33,
"case_id": "PMC11097720_01",
"case_text": "A 33-year-old woman, who had undergone a triple valve replacement for rheumatic valvular disease and was receiving acenocoumarol, presented with a 12-month history of paroxysmal and intermittent left iliac fossa pain, exacerbating during menstruation and accompanied by an estimated weight loss of 10 kg. Physical examination revealed normal findings, except for heightened sensitivity in the left iliac fossa and hypogastrium. The patient exhibited anemia with a hemoglobin level of 9.9 g/dL, a prothrombin time of 40%, and an international normalized ratio (INR) of 1.5. The rest of the blood profile, including tumor markers (carcinoembryonic antigen at 2.21 ng/ml, carbohydrate antigen 19-9 (CA19-9) at 24.3 U/mL, and cancer antigen 125 (CA 125) at 34.4 U/mL), was within normal limits.\nInitially, an abdominopelvic ultrasound was conducted, complemented by an angiographic computed tomography (CT) scan, revealing a well-encapsulated retroperitoneal mass on the right side, clear and lobed outline projecting onto the epigastrium and right hypochondria. The mass measured 118 x 92 x 120 mm and exhibited very low heterogeneous density. It made contact with the pancreas, spleno-mesenteric trunk, and portal trunk anteriorly, while sliding posteriorly between the abdominal aorta and the inferior vena cava (IVC). The mass extended into the right anterior perirenal space, encompassing the homolateral renal artery and contacting the homologous renal vein. It overflowed the midline, enclosing the celiac trunk (CeT) and the superior mesenteric artery (SMA), while making contact with the left adrenal gland, splenic vein, and left renal vein (LRV). Externally, the mass intimately interacted with the liver and gallbladder, pushing the right adrenal gland against the VII segment of the liver. It encased the IVC over 180 of its circumference without compromising its opacification. No intra- or retroperitoneal lymphadenopathy was observed (Figure 1). In the pelvic space, a left ovarian cystic tumor was identified, hypodense with a thin wall, containing discreetly hyperdense sloping material, indicative of an ovarian dermoid cyst classified as O-rads 2 (on ultrasound; Figure 2).\nTo obtain a definitive diagnosis, an upper gastrointestinal echo-endoscopy with biopsy of the retroperitoneal mass was performed. Pathological examination revealed a tumor proliferation characterized by a schwannoma stroma containing fusiform cells with elongated nuclei. Scattered mature ganglionic cells were also present, resembling the histological appearance of ganglioneuroma.\nDespite the apparent difficulty or even impossibility of complete resection based on CT data, surgical abstention was deemed risky due to the potential for wider extension, compression complications, and subsequent riskier resection afterward. Moreover, the presence of the pelvic mass prompted surgical intervention. In light of the patient's significant medical history, requisite preoperative measures were undertaken. These included discontinuation of acenocoumarol, necessitating a transition to enoxaparin sodium at a dosage of 6000 UI administered twice daily, with the cessation of administration 12 h prior to the scheduled procedure to mitigate the risk of bleeding. An INR test was conducted to assess the coagulation status. A comprehensive cardiac assessment was carried out, encompassing an electrocardiogram and a transthoracic ultrasound. Additionally, a thorough hematological evaluation was conducted on the day preceding the surgical intervention. Subsequently, a requisition for packed red blood cells and platelets was made on the day of the surgery to ensure preparedness for potential transfusion requirements. In anticipation of complications, provision was made for the patient to be accommodated in the surgical intensive care unit.\nAbdominal exploration through xyphopubic laparotomy confirmed the CT scan findings, revealing the giant retroperitoneal mass in contact with adjacent organs and enveloping large retroperitoneal vessels. A complete resection necessitated the opening of the tumor in contact with large vessels and a circular dissection of the CeT and the SMA, posing a risk of damaging the surrounding nerve plexus.\nThe exploration further identified a left ovarian cyst, from which brownish fluid was extracted, more suggestive of endometriosis than dermoid cysts, leading to cystectomy. The postoperative course was uneventful, and the patient was discharged on the sixth day with subsequent removal of drains. The final diagnosis was confirmed through histopathological examination of the specimens, revealing a synchronous retroperitoneal ganglioneuroma and a left ovarian endometrioma (Figure 3). The patient was subsequently referred to a gynecologist for endometriosis management. As of 6 months post-surgery, no local recurrence has been reported.",
"gender": "Female"
}
] |
PMC11097720
|
[
{
"age": 61,
"case_id": "PMC11316962_01",
"case_text": "We report the case of a 61-year-old transgender man who developed two typically female cancers simultaneously: invasive breast cancer and locally advanced cervical cancer.\nThe patient denied any family history of cancer, except for prostate cancer. The germline BReast CAncer gene 1 and 2 (BRCA1/2) status was unknown, due to the patient's refusal to undergo testing. Concerning the gynecological history, the patient referred nulliparity and menopause onset at the age of 50 years. He denied smoking behavior. Past medical history included several years of drugs and alcohol abuse, followed by a diagnosis of hepatitis C in 1995, which was treated with an 18-month course of sofosbuvir several years later.\nFrom May 2021 through April 2022, the patient underwent testosterone treatment (testosterone gel, four pump actuations, once daily) to induce masculinization. In March 2022, due to vaginal bleeding, a pelvic ultrasound and a magnetic resonance imaging were performed, showing a cervical mass of more than 3 cm, with right parametrium involvement, and extension to the vagina. In April 2022, a cervical biopsy confirmed the diagnosis of locally advanced grade 3 squamous cervical cancer, HPV+ and p16+.\nSimultaneously, a palpable right-sided breast mass of 3 cm, located in the upper outer quadrant, was discovered through breast ultrasound [Figure 1(a)] and mammography, revealing a heterogeneous background echotexture with a hypoechoic area of 7 mm diameter in the breast without axillary node involvement. The ultrasound-guided breast biopsy revealed an infiltrating ductal carcinoma of grade 2 in the right breast, with estrogen receptor (ER) 90%, progesterone receptor (PgR) 90%, human epidermal growth factor receptor 2 (HER2) 2+, in situ hybridization not amplified, and a Ki 67 index of 28%.\nA positron emission tomography/computed tomography (PET-CT) with fluorodeoxyglucose found no distant metastases, confirming the presence of pathological cervical neoplastic tissue with high metabolic activity, extending to the vagina [Figure 1(b)]. No focal areas of hypermetabolism were detected in the breast.\nFollowing multidisciplinary team consultation, the decision was made to treat the cervical cancer first and to postpone breast cancer treatment.\nIn May to June 2022, the patient underwent concurrent chemoradiation. This included weekly intravenous administrations of cisplatin at a dose of 50 mg/m2, accompanied by radiotherapy. The radiotherapy was delivered using the volumetric modulated arc therapy (VMAT) technique, targeting the pelvic and inguinal nodes. The initial radiotherapy dosage was 45 Gray (Gy) in 25 fractions, followed by a boost, bringing the total radiation dose to 55 Gy. The patient developed significant hematological toxicity, with persistent thrombocytopenia (possibly related to pre-existent liver dysfunction), which led to platinum discontinuation after the second week of treatment. In July 2022, concurrent chemoradiation was followed, by intracavitary brachytherapy. During radiation therapy, the patient also developed severe diarrhea, which only partially resolved after several months, as well as mild leukopenia and persistent thrombocytopenia. A PET-CT, carried out in September 2022, showed a reduction of the cervical mass but persistent parametrial involvement.\nSubsequently, in September 2022, the patient underwent bilateral nipple sparing mastectomy and right axillary dissection, with surgical pathology confirming the diagnosis of grade 3 right-sided breast infiltrating ductal carcinoma, measuring 4 cm in diameter with lymphovascular invasion. Two out of 18 axillary nodes were metastastic with extracapsular extension (pT2pN1a, G3). The immunohistochemical profile confirmed a high expression of ER and PgR, HER2 negative status, 10% expression of the androgen receptor (AR), and a 25% Ki-67 rate.\nIn November 2022, a PET-CT showed a substantial stability of the cervical lesion and the absence of distant metastasis from both cancers. Due to the poor tolerability of previous chemotherapy for cervical cancer, breast adjuvant chemotherapy was excluded from the treatment plan, opting instead for only the adjuvant aromatase inhibitor anastrozole. Initially, there was a plan to administer the cyclin-dependent kinase 4/6 inhibitor (CDK4/6i) abemaciclib, which was ultimately not started due to persistent diarrhea and thrombocytopenia.\nFrom the patient's perspective, he expressed profound disappointment upon being diagnosed with cancers affecting the breast and the cervix, two organs he had long rejected and denied due to gender dysphoria. In fact, he had previously refused to adhere to any cancer screening programs, dismissing the risk of cancer development. The patient had experienced gender dysphoria since childhood but only decided to pursue gender-affirming therapies only several decades later. Throughout his life, he endured severe psychological distress, together with alcohol and drug abuse, and sexual promiscuity. However, after the deciding on gender reassignment, he started psychotherapy together with hormonal treatments. Following the cancer diagnoses, he expressed fear about halting testosterone therapy and its potential impact on his body. Nevertheless, he agreed to temporarily interrupt testosterone administration and to accept a cancer treatment plan specifically tailored to his comorbidities and preferences.\nIn February 2023, due to the rapid onset of abdominal distension, the patient underwent an ultrasound and a subsequent CT scan, which revealed ascites, compensatory collateral circulation, including esophageal varices, a markedly cirrhotic liver, and sloping edemas. Based on the imaging findings and reported symptoms, a diagnosis of severe liver failure was made and the patient was referred to a hepatology center.\nIn May 2023, a PET-CT demonstrated multiple suspicious lung micronodules and an increase in the extent of cervical cancer infiltration into the right parametrium. A chest CT scan with contrast medium followed by a biopsy was recommended to investigate the nature of the lung micronodules.\nUnfortunately, the patient died quickly at home, due to bleeding from esophageal varices. The timeline of cancer history is graphically displayed in Figure 2.",
"gender": "Transgender"
}
] |
PMC11316962
|
[
{
"age": null,
"case_id": "PMC11412331_01",
"case_text": "On August 30, 2019, a female Chital (Figure 1A and 1B) was taken to the Wildlife Studies Center (NEVS) at the University of Western Santa Catarina (UNOESC). It had been rescued by soldiers from the 2nd Platoon of the 2nd Company of the 2nd Battalion of the Environmental Military Police of the State of Santa Catarina after being found in a rural area near the BR-163 highway in the municipality of Sao Jose do Cedro (26 28'S, 053 30'W)), state of Santa Catarina, Southern Brazil.\nFor inspection and physical examination, the individual was sedated using dex-medetomidine 0.01mg/kg as a pre-anesthetic medication followed by Ketamine 7mg/kg + Midazolam 0.3mg/kg, all used intramuscularly in a single application for dissociative anesthesia. The physical examination revealed that the animal had an exposed fracture on the left pelvic limb and signs of acute respiratory failure. Feces were collected rectally, stored in procedure gloves, identified, and refrigerated until the moment of analysis, carried out the following day. Macroscopic examination of the feces demonstrated normal consistency, color, and odor. The samples were processed by two techniques using fresh feces: centrifugal flotation with zinc sulfate, which was used to diagnose parasites of the gastrointestinal system, including protozoa, and), to search for parasitism in the respiratory tract. The first technique revealed the presence of cysts of G. duodenalis (Figure 1C), while the second revealed the absence of parasitic structures. The cysts were identified using a binocular microscope with a 40x objective. Their identification was based on literature records. The animal died on the same day of its arrival due to a cardiorespiratory arrest.",
"gender": "Female"
}
] |
PMC11412331
|
[
{
"age": 70,
"case_id": "PMC10932509_01",
"case_text": "A 70-year-old female with a history of osteoarthritis presented to the Emergency room because of symptomatic thrombocytopenia. Four days prior to admission, she noticed purple spots on her legs. She had been experiencing night sweats and chills for the past six months and had lost about 3 kg during the same time. She had traveled to Peru a year prior to her current condition. She denied usage of any medications or supplements. Her previous blood test six months ago revealed a normal platelet count of 211 K/CMM. Her labs on admission revealed platelets 56 K/CMM, hemoglobin (Hg) 11.5 g/dL, Leucocytes 6K/mm3 with a differential of neutrophils 6k/mm3, lymphocytes 7K/mm3, Monocytes 200/mm3. A peripheral smear revealed to be normal and she underwent a thorough evaluation for thrombocytopenia, including flow cytometry, serum electrophoresis (SPEP), antinuclear antibody (ANA), hepatitis panel, human immunodeficiency virus (HIV), and Lyme's serology. All of these tests came back negative. Immunoglobulins (IgG) for Epstein-Barr virus (EBV) and Cytomegalovirus (CMV) were positive, but IgM levels were normal. An ultrasound (USG) of the abdomen showed no significant abnormalities with the liver or spleen. However, the patient's stool antigen test came back positive for Helicobacter pylori, leading to a discharge at day 5 on outpatient (OP) triple therapy with amoxicillin, proton pump inhibitor (PPI), and Clarithromycin. As there is reported literature on association between Immune Thrombocytopenia Purport (ITP) and H. Pylori, her initial presentation of thrombocytopenia was thought to be secondary to H. Pylori infection. Unfortunately, this treatment did not improve the patient's condition, and subsequent outpatient follow-up labs at 2 weeks revealed a further decrease in platelets to 29 K/CMM.\nIn order to delve into further etiology, we did a CT scan of chest, abdomen and Pelvis with and without contrast in Outpatient setting. It revealed focal colitis of the distal ileum and ascending colon that extended to the inferior edge of the liver. The appendix was dilated, measuring 2.1 cm in diameter. Due to a significant drop in platelets to 9K/CMM at the second outpatient follow-up in 4 weeks from initial discharge, the patient was admitted to the hospital due to the risk of spontaneous hemorrhage. While admitted, An EGD was done due to previous positive H. Pylori stool antigen and unknown cause of dropping platelets which did not reveal any abnormal findings. Gastric biopsies eventually tested positive for H. Pylori. She also underwent a colonoscopy which revealed a partially obstructing, ulcerated mass in the ascending colon (Fig. 1). The biopsy confirmed an abscess of the cecum with no evidence of high-grade dysplasia. Abscess cultures tested positive for polymicrobial infection with predominance of Escherichia coli (E.coli) & Bacteroides fragilis, both susceptible to Levofloxacin. During the hospital stay, the patient was treated with IV Levaquin 750 mg daily for five days, which improved the platelet count from 9 K/CMM to 82 K/CMM. The patient was discharged on Day 6 on triple therapy with Levaquin 750 mg to complete a course of 14 days.\nA month after discharge, the patient returned with worsening abdominal pain. A CT scan of the abdomen showed worsening cecal and ileal wall thickening with associated enlarging 6.5 x 5.5 cm soft tissue component suspicious for a colonic mass (Fig. 2). The scan also revealed increased inflammation in the surrounding fat tissue and several enlarged bowel loops and lymph nodes. The patient underwent a right hemicolectomy after consultation between gastroenterology and colorectal surgery. Pathology results confirmed diffuse large B-cell lymphoma-germinal center origin with CD20 (+), BCL2(+/-), CD10 (+), BCL6(+), MUM1 (-), CD21 (+), C-MYC(-) (Fig. 3). The patient is currently receiving R-CHOP regimen with cyclophosphamide, doxorubicin, prednisone, rituximab, and vincristine as an outpatient and has shown improvement in her platelet counts. PET scans revealed complete resolution in the abdomen and pelvis, and the patient continues to follow up with oncology and colorectal surgery.",
"gender": "Female"
}
] |
PMC10932509
|
[
{
"age": 5,
"case_id": "PMC10461059_01",
"case_text": "A 3.5-year-old intact male Staffordshire terrier crossbreed dog was presented with a 1 week history of progressive paraparesis with fecal and urinary incontinence (defecation and urination at inappropriate times, house soiling). There was no history of trauma and the dog was walked on the leash only prior to onset of signs. General clinical examination was unremarkable aside from worn nails on the digits of the pelvic limbs. The neurological examination revealed ambulatory paraparesis and ataxia with proprioceptive deficits, worse on the left side. Patellar hyperreflexia and a crossed extensor reflex were found in the pelvic limbs. A cutaneous trunci reflex cutoff was present at the level of L1. Some mild paraspinal muscular atrophy was seen at the thoracolumbar junction. Subjectively decreased sensation (or superficial nociception) was noticed in the tail and both pelvic limbs. The bladder was filled with urine and difficult to express manually, consistent with an \"upper motor neuron bladder.\" A T3-L3 myelopathy was suspected based on these findings. Hematology and biochemical blood tests were unremarkable. The dog was anesthetized and positioned in dorsal recumbency for a MRI study of the thoracolumbar spinal cord (1.5T Canon Vantage Elan). The following sequences were performed: T2W sagittal, T1W sagittal, STIR sagittal, STIR dorsal, T2W transverse, T1W transverse, T2* GRE transverse, T1W sagittal post-contrast, T1W transverse post-contrast. A post-scanning subtraction technique was also employed (T1W post-contrast minus T1W pre-contrast).\nThe MRI study revealed a well-defined intramedullary space-occupying lesion centered and extending to the level of the vertebral body of T12 (Figure 1). The mass occupied over 75% of the cross-sectional area of the cord on its midline, with slightly more left-sided involvement. This lesion had an irregular ovoid shape, with a heterogeneous appearance in all sequences. From the T2W and STIR images, the peripheral aspect of the lesion was characterized by a very thin hypointense rim, underlined by a thicker hyperintense rim, while the center was markedly hypointense. The periphery of the lesion was slightly hypo- to isointense in T1W, whereas the center was hyperintense in T1W. This central area corresponded to a signal void in T2* sequence, suggesting the presence of hemorrhage. The lesion did not show contrast enhancement on T1W post-contrast images. The spinal cord was mildly swollen at the site of the lesion, causing obliteration of the subarachnoid space. Cranial to the intramedullary lesion, there was generalized T2W hyperintensity of the white matter, which was T1W isointense and without contrast enhancement, extending from the vertebral body of T12 to T9. Mild dilation of the central canal was also present in this segment. These findings were compatible with a pre-syrinx or spinal cord edema.\nThe differential diagnoses for the intramedullary space-occupying lesion at the level of T12 included a vascular malformation (such as cavernoma or arteriovenous fistula), vascular hamartoma or primary hematoma (hematomyelia). Other differentials include an inflammatory process or granuloma with hemorrhage, intramedullary neoplasia with a hemorrhagic component (such as hemangioblastoma, glioma or hemangiosarcoma) or metastatic intramedullary neoplasia. However, these seemed much less likely given the lack of contrast enhancement and the absence of a solid component. Medical treatment with prednisolone (0.3 mg/kg q12h PO - AST Beheer B.V., Oudewater, Netherlands) was initiated and further treatment options including surgical management were discussed with the owner. Neurological signs progressed over the following days to barely ambulatory paraparesis and ataxia, with increased severity of proprioceptive deficits and fecal and urinary incontinence. Surgery was performed 5 days after presentation.\nThe dog was anesthetized, positioned, and stabilized in sternal recumbency. Perioperative cefazoline (20 mg/kg, q6h IV - Cefazoline Mylan, Mylan B.V., Amstelveen, Netherlands) was administered. A dorsal laminectomy (T12-T13), durotomy, and midline dorsal myelotomy at the level of the dorsal median sulcus were performed with the use of a surgical microscope, and the vascular lesion in the swollen spinal cord segment was identified (Figure 2). Stay-sutures (6-0 PDS) were placed in the dura mater and arachnoid mater overlying a region of grey/blue spinal cord parenchyma and a longitudinal incision was made with an iris scalpel while retaining mild tension on the dura. At the edges of the incision, transverse cuts were performed to give an H-shaped incision and adequate exposure of the T12-T13 segments of the spinal cord after retraction and breaking of the arachnoid trabeculae. Normal vasculature of the spinal cord was visualized (e.g., dorsolaterally positioned dorsal spinal arteries and their branches). The dorsal median sulcus was evident cranially and caudally to the lesion and a midline myelotomy was made along its course. Gentle manipulation with gelatin sponges revealed the lesion. The lesion was blueish with a clear translucent wall and was somewhat adhered to grey matter on its cranial and caudal poles. The delicate wall was breached when manipulating the structure with gelatin spears and blunted nerve hooks. Next, piecemeal removal of the lesion was performed. Multiple samples were placed in buffered formalin and sent for histopathological examination. After the visually complete removal of the lesion, the spinal cord appeared reddish and devoid of some central grey matter. Hemostasis was achieved with repeated placement and removal of gelatin sponges in the cavity where the lesion was situated. Subsequently, the dura mater was closed with interrupted single sutures of absorbable monofilament 5-0. Routine closure of the epaxial musculature, fascia, subcutis and dermis was performed.\nHistopathological examination of surgical samples yielded only fibrinous clots, hemorrhage, hematoidin pigment, and some (normal) neural tissue (neuronal cell bodies and glial cells). Although a vascular wall was visualized at surgery consistent with a vascular malformation, such a structure was however not found histologically, hampering the definitive classification of the lesion. Therefore, a diagnosis of a vascular malformation (not further subclassified), was concluded based on diagnostic imaging findings, surgical findings, and lack of histopathological findings supportive of reactive vascular proliferations, benign neoplasm, hamartoma or neoplasia.\nPost-operative treatment consisted of urinary bladder catheterization, continued prednisolone (0.3 mg/kg q12h per os - AST Beheer B.V., Oudewater, Netherlands), ketamine continuous rate infusion (20-50 microgram/kg/h IV - Alfasan Nederland B.V., Woerden, Netherlands), methadone (0.3-1 mg/kg IV - Eurovet Animal Health BV, Bladel, Netherlands) based on pain score assessments, gabapentin (10 mg/kg q8h per os - Gabapentine Aurobindo, Aurobindo Pharma B.V., Baarn, Netherlands), omeprazole (1 mg/kg q12h per os - Losec MUPS, Cheplapharm Arzneimittel GmbH, Greifswald, Germany) and paracetamol (15 mg/kg q8h IV - Paracetamol Aurobindo, Aurobindo Pharma B.V., Baarn, Netherlands). The dog was paraplegic with intact nociception the day following surgery, with fecal incontinence. Over the next 2 days, the patients showed progressive return of motor function in both pelvic limbs and tail. Urinary bladder catheter was removed. Fecal and urinary continence were regained before discharge 3 days post-surgery. Medication was continued with gabapentin and prednisolone per os. Other analgesic medications were discontinued. Ambulation was recovered within 2 weeks. Some urination in the house was reported, but otherwise no signs of incontinence (fecal or urinary) were apparent. Gabapentin was discontinued at that point. Prednisolone was tapered off over the next 8 weeks (0.15 mg/kg q12h for 4 weeks, 0.15 mg/kg q24 h for 4 weeks). Progressive and complete recovery of neurological function was seen during the next 12 weeks. No recurrence of neurological dysfunction was seen over a 12-month follow-up.",
"gender": "Male"
}
] |
PMC10461059
|
[
{
"age": 76,
"case_id": "PMC10540079_01",
"case_text": "On March 2020, a 76-year-old male with a long history of heavy smoking (about 75 pack-years) started to develop irritating cough, nausea, and paroxysmal chest tightness. These symptoms gradually worsened in the following months. On June 2020, positron emission tomography/computed tomography (PET/CT) scan was performed, revealing a lesion in the apical segment of the upper lobe of the right lung (5.1cmx 3.3 cm), encircling the superior vena cava and right pulmonary artery, with possible mediastinal, and right upper and lower clavicular lymph node metastases. Tumor marker carcinoembryonic antigen (CEA) was 183.4ng/mL. An electrocardiogram was also conducted, suggesting anterior interstitial and anterior wall old myocardial infarction, but the patient has no symptoms. Then, we performed a biopsy of the right supraclavicular lymph nodes, and histopathologic analysis suggested a poorly differentiated carcinoma, with immunohistochemical staining showing CK (+), CK 7(-), CK20 (-), P63 (-), TTF-1 (-), NAPSINA (-), Ki-67 (60%+) ( Figures 1A-D ). Next-generation sequencing (NGS) analysis was performed and identified. The results were obtained: EGFR, ALK, RET, MET, ROS1 without positive driver genes, the tumor proportion score (TPS) of PD-L1 protein expression was less than one percent, microsatellite state was stable (MSS), and tumor mutation burden (TMB) was 22.19 mutations/Mb. The clinical stage was cT4N3M0. Concurrent chemotherapy/radiotherapy was administered from July 24 to August 13, 2020. The radiotherapy target included the lung mass, right hilar, mediastinal, supraclavicular and subclavian lymph nodes and the dose of PGTV was 45Gy/15F. On July 20 and August 12, 2020, two cycles of paclitaxel liposome and carboplatin were performed. There were no obvious side effects during the treatment. One month after chemoradiotherapy, chest CT scan was performed to evaluate efficacy and the tumor regression degree was 31.4%. Then, the treatment was converted to paclitaxel liposome combined with sintilimab immunotherapy on September 17. After three cycles, the lesion was assessed as stable.\nOn November 19, 2020, patient began to develop painful erosion of the lips and the oral mucosa, dark red erythema localized to the chest wall, back, hands and feet. Hands and feet started to be swollen and blistered ( Figure 2 ). On November 24, 2020, the patient was admitted to our dermatology department. TOX IgM, FZ IgM, CMV IgM, DP IgM were all negative. HCMV-DNA, EBV nucleic acid, BK virus nucleic acid, and JC virus nucleic acid were also all negative. After treated with antihistamines and compound glycyrrhizin anti-inflammatory therapy, the symptoms were not relieved and the pain of the lips and oral mucosa was getting worse. A pathological examination of the right forearm was performed on November 26, 2020. It showed epidermal necrosis and subepidermal split ( Figures 3A, B ), consistent with SJS. Immunofluorescence showed granular IGM and linear deposits on the basement membrane zone. Staphylococcus aureus was detected in the pustules. Severe drug rash with infection was considered and intravenous shock treatment was administered with methylprednisolone 50 mg/day (1 mg/kg/day) and infusion of immunoglobulin ( Supplementary Table S1 ). Mupirocin ointment was applied to the infected area. 20 days later, the skin erythema became lighter, and the erosion and desquamation appeared on the chest, back and upper extremities. Some of the toenails became yellow and thickened before falling off. The dose of prednisone was reduced to 40 mg/day orally, until discontinuation on January 11, 2021. However, the dorsum of the left foot and the left external ankle were still erosional, the wound discharge was reviewed without bacterial or fungal growth. A medical wound nursing membrane was applied to promote healing, and the erosion had improved but still persisted. The erosion was somewhat resistant to local corticosteroids. Then we analyzed the patient's right forearm skin biopsy to assess for PD-1 and PD-L1. The results were positive for both PD-1 ( Figure 3C ) and PD-L1 expression (22C3 pharmDx assay, Agilent Technologies), particularly with PD-L1 expression in the basal layer of the skin ( Figure 3D ) and in the glands ( Figure 3E ). PD-L1 expression in tonsil tissue was used as a control to verify antibody specificity ( Supplementary Figure 1 ). We also performed CD4 and CD8 positive T lymphocyte expression assay, and the results showed positive CD4 ( Figure 3F ) and CD8 ( Figure 3G ) positive T lymphocyte infiltration.\nAfter two months, chest CT revealed that the right lung lesion and right supraclavicular lymph nodes were significantly larger than before. We performed a second biopsy of the right supraclavicular lymph node and confirmed a poorly differentiated adenocarcinoma with immunohistochemical staining results showing CK 7(-), TTF-1 (+), NAPSINA (-), P40 (-), P63(-), CK5/6(-), 35BH11(+), CK (+), Ki-67 (70%+) ( Figures 1E-H ). Two cycles of chemotherapy with pemetrexed were administered, however the tumors continued to grow and the patient's physical state was not adequate for further chemotherapy. On July, 2021, chest CT revealed tumor progressed. On August, 2021, the right lung lesion and right supraclavicular lymph node were implanted with radioactive iodine-125 particles. The patient was followed up by telephone in December 2021, and he was in a good condition.\nOn June 2020, the patient was diagnosed with poorly differentiated lung cancer and the clinical stage was cT4N3M0. From July to August 2020, concurrent chemotherapy/radiotherapy was administered. Paclitaxel liposome and sintilimab were administered for three cycles from September 2020. Unfortunately, SJS-induced by sintilimab on November 2020. Then, the treatments for SJS were performed. on March 2021, the right lung lesion and supraclavicular lymph node were significantly larger than before, two cycles of chemotherapy with pemetrexed were administered. On July 2021, the tumor was progression again and the radioactive iodine-125 particles were implanted ( Figure 4 ).\nOn June 28, 2020, the mass in right lung approximately 5.1cm x 3.3 cm. On September 15, 2020, the tumor regression degree was 31.4% after chemoradiotherapy (approximately 3.5 cm x 2.2 cm). On November 2, 2020, the tumor assessment was stability (approximately 3.5 cm x 2.2 cm). On March 9, 2021, the tumor mass of right lung (approximately 4.2 cm x2.8 cm) and right supraclavicular lymph nodes were significantly larger than before. On July 28, 2021, the tumor of right lung was significantly larger than previous detection (approximately 7.2 cm x3.6 cm) ( Figure 4 ).",
"gender": "Male"
}
] |
PMC10540079
|
[
{
"age": 44,
"case_id": "PMC10546301_01",
"case_text": "A 44-year-old woman presented for a pancreatic mass found during the physical examination. Abdominal computed tomography (CT) scan showed: (1) a lesion (38 mmx25 mm) occupying the tail of the pancreas ( Figure 1A ); (2) a lesion occupying the right adrenal gland and suspected as adenoma ( Figure 1B ); (3) small stones in the right kidney. Plain and contrast magnetic resonance imaging (MRI) scans of the pancreas showed: (1) a lesion occupying the tail of the pancreas and suspected as neuroendocrine tumor; (2) the right adrenal adenoma (23 mmx12 mm). The patient received resection of pancreatic body and tail, and the postoperative pathology showed a soft, grayish-yellow mass (4 cmx3cmx2cm) with a clear margin in the tail of the pancreas. Tumor cells in the mass were uniform in size, mildly atypical, and arranged in papillary structure or solid sheets. No tumor cells were found in the resection margin of the tail of the pancreas. Immunohistochemistry results showed AE1/AE3 (+), CgA3 (+), Syn3 (+), Ki67 (about 4%), beta-catenin in the membrane (+), alpha-ACT (+), progesterone receptor (PR, +), and Vimentin (-). G2 neuroendocrine tumor was finally diagnosed based on the pathological and immunohistochemical findings ( Figure 1C ). Serum calcium and parathyroid hormone (PTH) at postoperative 1 month were 2.65 mmol/L and 2847.6 pg/ml, respectively. The patient did not exhibit fatigue, nausea, vomiting, anorexia, abdominal pain, diarrhea, asthma, cough, lower limb pain, thirst, polyuria, constipation, hand and foot convulsions and mental changes during the course of disease.\nThyroid function tests at her age of 28 years were normal. Sex hormone binding globulin serum tests for measuring prolactin level at her age of 30 years were normal. The patient denied the history of medication. She had a healthy son. Her old brother had a medical history of hyperparathyroidism and kidney stones. Physical examinations of the patient showed slight thickening of bilateral toe joints.\nLaboratory testing was performed. (1) blood routine tests: white blood cell count, 6.89x109/L; red blood cell count, 3.67x1012/L; hemoglobin, 112 g/L; platelet count, 1.0x109/L; (2) biochemical tests: alanine aminotransferase, 40.4 U/L; aspartate aminotransferase, 56 U/L; albumin 36.9 g/L; creatine, 46 micromol/L; creatine clearance, 117.4 ml/min/1.73m2; serum sodium, potassium, magnesium and phosphorus levels were normal; (3) urine specific proteins testing: urine alpha1-microglobulin<4 mg/L; urine IgG, 7.98 mg/L; urine transferrin <2 mg/L; Kappa and Lambda light chains of immunoglobulins in serum and urine were normal; Bence-Jones protein (-); 24-h calcium in urine, 5.55 mmol/L; (4) Multiple times of serum calcium and PTH testing showed abnormal increases ( Supplementary Table 1 ).\nAn uneven signal intensity was detected on the plain MRI scan of the pituitary gland, and no abnormal findings were detected on contrast scans ( Figure 1D ). The dual-phase 99mTc-MIBI parathyroid scan revealed a soft-tissue-density nodule behind the inferior pole of the right thyroid lobe, considering a hyperfunctioning parathyroid mass ( Figure 1E ). Prolactin level of 59.2-120.55 ng/ml, as well as basal prolactin of 63.75 ng/ml and peak/baseline prolactin <1.5 detected by the metoclopramide test were suggestive of hyperprolactinemia. The elevated growth hormone (8.12-10.97 ng/ml ) and 1-h glucose tolerance test of 8.05 ng/ml indicated the secretion of high-level growth hormone. The aldosterone blood test showed that the orthostatic plasma aldosterone/renin ratio (ARR) was 0.18; 24-h urine catecholamine, 24-hour urine cortisol and cortisol circadian rhythm were in the normal ranges, suggesting the nonfunctional adrenal adenoma. The gastrin level was 28.43 pg/ml . Painless gastrointestinal endoscopy showed chronic superficial gastritis with erosions and colonic diverticulum. A normal structure of the right accessory on the gynecological ultrasound scan excluded the possibility of ovarian tumors. A moderate-to-strong echo in the right kidney on the urinary system color Doppler ultrasound was suggestive of the hamartoma. Thyroid function tests and ultrasound did not suggest any thyroid disorder. Z-score of the bone mineral density of L1-4 was below -2.0. CT scan of the chest showed micronodules in both lungs. The patient was finally diagnosed as MEN1 by genetic testing ( Supplementary Figure 1 ), revealing a novel mutation c.1520delG>T (p.G507Afs*52) in exon 10 of MEN1 gene. Moreover, genetic testing was performed in the first-degree relatives of the patient, and the MEN1 gene mutation was detected in the patient's father, old brother and nephew ( Figure 2 , Supplementary Figure 1 ).\nThe patient was treated with the surgical resection of the right inferior parathyroid gland in February 2022 in other hospital, and postoperative pathology showed nodular hyperplasia of the parathyroid gland ( Figure 1F ). Serum calcium and PTH were 2.9 mmol/L and 256.5 pg/ml right after surgery, and 2.78 mmol/L and 294.3 pg/ml at 3 months, respectively, suggesting that hyperparathyroidism was not completely relieved. ECT images on the parathyroid glands in June 2022 showed two adjacent radioiodine uptake tissues (hyperparathyroidism tissues) on the dorsal side of the right thyroid lobe, and one suspected radioiodine uptake tissue on the dorsal side of the left upper thyroid lobe ( Figures 3A, B ). Ultrasound scan of parathyroid glands also showed a hypoechoic nodule in the lower posterior part of the right thyroid lobe (3.1 cmx0.9 cm) and a hypoechoic nodule in the left posterior lobe (0.93 cmx0.46 cm), suggesting benign nodules that may originate from the parathyroid gland ( Figures 3C, D ). The 25(OH)D3 level was 10.1 ng/ml , and the Z-scores of BMD in L1-4 were below 2.0.\nThe patient was intervened by MWA for supplementary therapy after being fully informed of therapeutic efficacy and potential risks. The MWA for bilateral parathyroid glands was guided by intraoperative ultrasound, as previously reported. The MWA system (KY-2000) was produced by Canyon Medical Inc. (Nanjing, China). Briefly, a total of 78 ml of normal saline was injected and maintained surrounding the parathyroid adenoma to create a barrier that prevents thermal damage to the trachea, esophagus and recurrent laryngeal nerve. The ablation antenna was inserted into the parathyroid lesion through previously determined path, and MWA was initiated at 35 W output power. The operation was sustained until the entire gland was hyperechoic ( Figures 3E, F ). After the ablation, color Doppler ultrasound and contrast-enhanced ultrasound were performed to confirm that no blood flow in the nodule and remaining lesions ( Figures 3G, H ). The MWA procedure lasted 170 s, and intraoperative heart rate, blood pressure and blood oxygen level were 77 beats/min, 136/79 mmHg and 79%, respectively. The patient only complained of mild pain. PTH level immediately returned to the normal at 10 min postoperatively, and remained normal at 20 min, 4 h, 24 h, 1 month, 2 months, 3 months, 4 months, 7 months and 8 months postoperatively, suggesting the complete remission of hyperparathyroidism ( Figure 4 , Supplementary Table 1 ). The patient developed hypocalcemia at 1 month postoperatively due to the irregular supplement of vitamin D and calcium. Serum calcium and PTH levels both returned to the normal after treatment. Postoperative adverse events like obvious hoarseness and hemorrhage were not reported.",
"gender": "Female"
}
] |
PMC10546301
|
[
{
"age": 18,
"case_id": "PMC11283805_01",
"case_text": "A comprehensive preoperative evaluation was performed first by the surgeon for each patient to ensure that the patient was a suitable candidate for SILK procedure. Patients were required to be at least 18 years old and in good health to participate in the clinical study of the SILK procedure for laser vision correction. Inclusion criteria for eligible eyes included a myopic spherical equivalent (SE) refractive error of <=-12.00 diopters (D) and astigmatism <=-6.00 D, with at least 250 microns residual corneal stromal thickness after lenticule extraction. Additionally, patients were eligible to have uncorrected distance visual acuity (UCDVA) of 20/40 or worse, corrected distance visual acuity (CDVA) of 20/20 or better, and CDVA that is at least 2 lines better than UCDVA. Patients must also exhibit <=0.75 D difference between cycloplegic and manifest refraction spheres, stable refractive error for at least 12 months, and have discontinued rigid contact lens wear for at least 4 weeks or soft contact lens wear for at least 2 weeks prior to surgery. Exclusion criteria for surgical eyes include corneal thickness less than 470 microns at the thinnest point, a history of prior intraocular or corneal surgery, corneal abnormalities, active ophthalmic diseases such as keratoconus, clinically significant dry eye syndrome, and evidence of glaucoma. Pupil size under mesopic lighting conditions was also assessed to evaluate the potential impact of postoperative complications such as halos and glare.\nThis study was part of the Phase II clinical study, which included refractive error range in the surgical eyes between -2.00 D and -6.00 D and astigmatism up to -1.00 D based on manifest refraction at optical infinity. Cyclotorsion correction after docking was available for astigmatism greater than -1. 00 D with SE limited to up to -6.00 D. It included 24 eyes that underwent a corneal refractive lenticule extraction SILK procedure for myopic correction at the Narayana Nethralaya Eye Institute, India. The SILK procedures were performed from April 6, 2021, to September 3, 2021, with preoperative and postoperative eye exams starting on March 27, 2021, and finishing on July 1, 2022.\nELITATM Femtosecond Platform is a new generation of the commercial iFS Advanced Femtosecond Laser (Johnson & Johnson Surgical Vision, Inc). This innovative FS laser platform is designed to conduct both the flap treatment for a LASIK procedure and the lenticule treatment for a LALEX procedure. It utilizes an ultralow energy per laser pulse (laser energy of 40-90 nJ) along with 1.0 microm focused spot size and tight spot spacing (mean spot spacing of 1.0 microm) for corneal tissue cuts. These features allow for the precise creation of corneal incisions with minimal tissue-bridges. For the SILK procedure, this advanced FS laser platform empowers surgeons to perform lenticule extraction procedure for myopic correction, with or without astigmatism, up to a maximum of -12.00 D sphere, and astigmatism correction up to -6.00 D, with the sum of sphere and cylinder between -1.00 D and -12.00 D using minus cylinder convention based on the manifest refraction at optical infinity.\nThe SILK procedure with the ELITA system uses a unique biconvex lenticule shape for myopic correction with or without astigmatism. The diagram in Figure 1 illustrates the cross-section of an applanated biconvex lenticule created by the ELITA system within the corneal stroma. The lenticule cutting procedure starts with the creation of the posterior lenticule surface incision, followed by an angled ring cut, an anterior lenticule surface incision, and finishes with the entry incision. The refractive correction is equally applied to both the anterior surface and posterior surface of the lenticule. Each lenticule is meticulously designed with an optical zone for refractive power correction and a transition zone to mitigate the edge effect generated by the ring cut. To prevent tissue tearing at the lenticule's edge during extraction, a non-refractive flat ranging from 15 to 30 microm thickness is added in the center of the lenticule. The non-refractive flat consists of a layer with a consistent thickness, serving to enhance the mechanical properties of the lenticule. \nThe corneal lenticule extraction with the ELITA system is akin to a SMILE procedure performed with the Zeiss VisuMax500 FS laser, which includes docking, femtosecond laser application, lenticule dissection, and extraction.\nPrior to treating the eye, the treatment parameters were programmed on the FS laser platform, based on the required correction for manifest refractive errors (sphere and cylinder error) as well as the keratometry measurements (K1 and K2). Additionally, this new FS laser supports corneal markings to ensure proper lenticule centration and compensation for cyclotorsion. Corneal marking was performed before placing the suction ring on the surgical eye for docking. If lenticule treatment includes an astigmatism correction, the surgeon first created two peripheral marks with surgical ink on the nasal and temporal cornea. These nasal and temporal marks were aligned with the horizonal axis while the patient was in an upright position. Subsequently, the surgeon placed a central mark with the surgical ink at the pupil's center while the eye was viewing a coaxial fixation target under a surgical microscope when the patient was at supine position on the surgical bed. Once docking was achieved under the ELITA system, the surgeon could align the lenticule treatment center with the central mark and adjust the lenticule axis to compensate for any cyclorotation of the surgical eye.\nEach eye underwent a preoperative eye exam, as well as a postoperative eye exam at 1-day, 1-week, 1-month, 3-month and 9-month after the lenticule extraction by the SILK procedure. During the eye exam, manifest refraction for UCDVA and the best corrected distance visual acuity (BCDVA) were conducted using a phoropter. Wavefront aberrations up to the 6th order Zernike polynomials were measured using a commercial iDESIGN wavefront aberrometer (iDESIGN Refractive Studio, Johnson & Johnson Surgical Vision, Inc). iDESIGN Refractive Studio is a wavefront aberrometer, combined with a corneal topographer, which uses a Hartmann-Shark sensor to measure the whole eye's wavefront aberrations at the pupil plane.\nAll wavefront measurements were conducted on each eye with a natural pupil while the eye was under mesopic light conditions (non-pharmacologically dilated). This study only included 24 eyes for which wavefront data were available with a pupil size equal to or larger than 6 mm at preoperative and postoperative iDesign wavefront measurements at 1-day, 1-week, 1-month, 3-month, and 9-month visits. Each wavefront measurement was then rescaled to a 6 mm pupil size for the analysis of HOAs. HOAs, such as comas, spherical aberration, and wavefront error of all higher-order aberrations (HOAs RMS) were analyzed based on a 6 mm pupil.\nStatistical analyses were conducted using Microsoft Excel 2021 (Microsoft Corporation) to assess the changes of HOAs following SILK procedures in the 24 eyes. The data were analyzed using a paired study control method, where each eye's preoperative HOAs were used as the control group to compare its postoperative HOAs at multiple time points. Student's t-tests were performed to compare preoperative HOAs with postoperative HOAs at 1 day, 1 week, 1 month, 3 months, and 9 months. Differences were considered statistically significant when the p-value was less than 0.05.",
"gender": "Unknown"
}
] |
PMC11283805
|
[
{
"age": 59,
"case_id": "PMC11147783_01",
"case_text": "To our knowledge, there is only one case report of spinal cord ischemia following COVID-19 vaccination. A 59-year-old male in Greece developed acute-onset right lower limb weakness and abdominal pain, which progressed to paraplegia 20 days after receiving the BNT162b2 mRNA COVID-19 vaccine. MRI revealed non-contiguous foci of T2 hyperintensities from the T6 level to the conus medullaris, indicative of spinal cord ischemia. Despite treatment, including antiplatelet therapy, the patient's condition showed limited improvement, with an American Spinal Injury Association (ASIA) impairment scale improvement from grade B to grade C over 8 months.\nLaboratory results for patients with arterial stroke mirrored those with CVST, including thrombocytopenia, elevated D-dimer levels, reduced fibrinogen, and the presence of anti-PF4 IgG antibodies. These similarities suggest a common pathological pathway related to vaccine-induced coagulopathy.\nHowever, some patients do not exhibit these paraclinical findings.\nSeveral studies have demonstrated that endothelial function assessed by flow mediated vasodilation (FMD) staff is a surrogate marker for organ damage and cardiovascular events. In a Japanese study involving a total of 23 vaccinated people, FMD was significantly reduced two weeks after the second dose of the BNT162b2 mRNA COVID-19 vaccine compared to pre-vaccination levels. However, FMD returned to baseline levels six months post-vaccination.\nMoreover, similarly to Sars-cov-2 virus though much rarer Sars-cov2-vaccinations could induce blood-brain barrier and choroid plexus barrier impairments and vascular inflammation in mice, as well as changes in perivascular astrocytes, neurons and microglia, thus impairing the neurovascular unit.\nInterestingly, pro-atherosclerotic risk factors and a history of previous ischemic strokes are common among patients without evidence of coagulopathy.\nAcute ischemic stroke observed after COVID-19 vaccines are commonly due to large artery atherosclerosis (34.9%), as has been reported in Mexico- and Indonesia-based studies. Therefore, it is hypothesized that these events may also be attributed to the underlying conditions of vaccine recipients, such as hypertension, diabetes mellitus, smoking, and dyslipidemia. Nonetheless, it could be assumed that the vaccine administration may have further predisposed these individuals to such outcomes.\nLarge retrospective studies showed that around two-thirds of arterial events occurred in women, with nearly 90% experiencing an anterior circulation stroke, particularly in the middle cerebral artery. Motor deficits were the most prevalent symptom, seen in 75% of cases, followed by language impairments.\nIn patients with suspicion of vaccine-induced immune thrombotic thrombocytopenia (VITT), thrombolysis is usually contraindicated due to low platelet count. Mechanical thrombectomy (MER) should be considered in large vessel occlusion. High-dose IVIG should be administered immediately. Alternative anticoagulation to heparin should be initiated as soon as possible after stroke onset, unless significant hemorrhagic transformation has occurred. Platelet transfusion is contraindicated and should be considered only in cases of severe hemorrhagic complications. Due to the hypercoagulable state in VITT, restenosis or reocclusion of the revascularized artery is possible, making angiographic surveillance after the procedure advisable.\nIn a retrospective analysis of 137 patients with COVID-19 treated with mechanical thrombectomy for acute ischemic stroke at 20 tertiary care centers in Austria and Germany COVID-19 vaccination did not impact angiographic or clinical outcomes for COVID-19-positive patients, with acute ischemic stroke undergoing mechanical thrombectomy. However, the presence of acute COVID-19 infection was associated with worse outcomes.\nAcross diverse populations and vaccine types, the overwhelming evidence suggests that the risk of ischemic stroke post-vaccination is not significantly elevated. While some studies identified minimal increases in risk for specific vaccine doses or types, these findings must be contextualized within the broader benefits of COVID-19 vaccination, including reduced risk of severe disease, hospitalization, neurovascular side effects of COVID, and death. Limitations across these studies, including retrospective designs, potential under-reporting, lack of unvaccinated control groups and exclusion of younger patients in some analyses, necessitate cautious interpretation of results. Nonetheless, the consistent lack of a significant association between COVID-19 vaccination and increased ischemic stroke risk provides strong support for the continued use of these vaccines in public health efforts against the pandemic. While the Self-Controlled Case Series (SCCS) analysis inherently adjusts for constant, individual-specific factors, there is a possibility of potential time-varying covariates such as body weight, lifestyle factors, and COVID-19 infection which increase the risks over time, especially among the oldest participants.\nA series of studies have delved into this issue, providing valuable insights into the incidence of CVST following vaccination with different COVID-19 vaccines. The most important studies are summarised in Table 2. \nA self-controlled case series in England involving over 29 million individuals aged >=16 years vaccinated with either the Oxford-AstraZeneca or Pfizer-BioNTech COVID-19 vaccines found an increased risk of CVST after the first dose of both vaccines. Despite this increased risk, it was significantly lower than the risk associated with SARS-CoV-2 infection itself.\nFurther analysis from another English study assessing risks from 46 million adults indicated increased rates of CVST and thrombocytopenia post-ChAdOx1-S vaccination, particularly in those under 70, albeit these risks were deemed small relative to the vaccine's benefits. This contrasts with the findings for the Pfizer-BioNTech vaccine, where no significant increase in thrombotic events was observed. A pooled analysis across the UK echoed these findings, observing a slight increase in CVST incidence following the AstraZeneca vaccine, a pattern not seen with the Pfizer-BioNTech vaccine. Similarly, a case-crossover study from Scotland evaluating CVT cases post-vaccination supported a causal link between CVST and the AstraZeneca vaccine, with incidence rates suggesting a higher risk following this vaccine compared to Pfizer-BioNTech and Moderna.\nAnother multicenter observational case series study involving 116 patients with CVST identified a substantial proportion (67.2%) who developed thrombosis with thrombocytopenia syndrome (TTS), primarily after receiving the Oxford-AstraZeneca vaccine (97% of CVST-TTS cases). Patients with CVST-TTS often presented with comatose states (24%), had intracerebral hemorrhage (68%), and a high rate of concomitant thromboembolism (36%). The in-hospital mortality rate was significantly high at 47% for the TTS group. The study highlighted a distinct clinical profile and high mortality rate in patients with CVST post-vaccination meeting the criteria for TTS.\nComparative research between middle-income (MIC) and high-income countries (HIC) reported CVST cases post-vaccination, noting a lower in-hospital mortality rate in MICs. This study also pointed out the infrequent testing for anti-PF4 antibodies in MICs, a key diagnostic marker for VITT, suggesting variations in diagnostic and management practices across different settings.\nCommon across these studies is the observation of an increased risk of CVST following vaccination, particularly with the Oxford-AstraZeneca vaccine. This research underscored a unique clinical pattern and a significant mortality risk among patients who developed CVST following vaccination and fulfilled the criteria for TTS. The findings underscore the need for vigilance and prompt recognition of symptoms associated with CVST to mitigate risks effectively.\nLimitations across these studies include potential under-reporting, reliance on coded healthcare data, and the inherent challenges in measuring rare events in large populations. Furthermore, the variation in diagnostic criteria and management practices, especially concerning the testing for anti-PF4 antibodies, highlights the need for standardized approaches in identifying and treating VITT. Despite these challenges, the concerted effort to understand and mitigate vaccine-related adverse events continues to be crucial in navigating the path forward in the COVID-19 pandemic.\nThe development of Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT) following the administration of the ChAdOx1-S vaccine is believed to be associated with the generation of IgG antibodies targeting Platelet Factor 4 (PF4). This mechanism is reminiscent of the pathophysiological process observed in Heparin-Induced Thrombocytopenia (HIT), where PF4 forms complexes with heparin, triggering an immune response in certain individuals. These immune complexes activate platelets via FcgammaRIIa receptors, leading to platelet activation and aggregation, followed by the release of procoagulant substances that ultimately result in thrombosis. VITT presents a similar immune response, wherein antibodies specifically recognize PF4 regions, initiating platelet activation. A \"two-hit\" hypothesis suggests that vaccine components may modify PF4, creating new antigens, while a systemic inflammatory response heightens the production of autoantibodies, particularly with adenoviral vector vaccines.\nA study disclosed that 9.8% of healthy individuals immunized against COVID-19 developed IgG antibodies targeting the PF4 complex within two weeks post-vaccination, without leading to platelet activation, indicating a potential asymptomatic seroconversion. This finding suggests that a minor fraction of vaccinated individuals may produce PF4 complex antibodies, with a smaller subset possibly developing VITT, likely due to genetic predispositions that favor the production of such antibodies and, consequently, VITT.\nRegarding mRNA vaccines, research involving nonhuman primates has shown that they elicit a T helper (Th)1 immune response, characterized by the production of cytokines such as interferon-gamma, tumor necrosis factor (TNF), and interleukin-2 (IL-2). Typically, endothelial cells regulate thrombogenic states, influenced by cytokines. TNF, among others, promotes the expression of tissue factors that initiate coagulation. This implies that the Th1 response induced by mRNA vaccines could be linked to prothrombotic conditions.\nPatients experiencing CVST following vaccination with adenoviral vector vaccines like ChAdOx1-S or Ad26.COV2.S reported a range of neurological symptoms. Initially, some only showed minor signs like headaches, while others exhibited severe neurological effects, including vertigo, vision loss, speech difficulties, seizures, paralysis, behavioral changes, and consciousness alterations. Interestingly, the symptoms of CVST were similar regardless of whether patients received mRNA or adenovirus-based vaccines, with common complaints including persistent headaches, fatigue, vomiting, and motor issues.\nDiagnosing VITT requires the identification of consumptive coagulopathy and is characterized by several key features: thrombocytopenia, elevated D-dimer levels, hypofibrinogenemia, and high-titer anti-PF4 IgG antibodies. The UK Hematology Expert Group has delineated five criteria for a definitive diagnosis, which include the onset of symptoms 5 to 30 days post-vaccination, the presence of thrombosis, confirmation of thrombocytopenia, a positive anti-PF4 antibody test, and significantly increased D-dimer levels. Diagnostic assays for VITT, which are adapted from those used in Heparin-Induced Thrombocytopenia (HIT) tests, primarily utilize ELISA to detect anti-PF4 antibodies, reflecting the similarities in the pathobiology between VITT and HIT.\nA recent study evaluated the effectiveness of competitive anti-PF4 enzyme immunoassays (EIA) in distinguishing VITT from HIT. Using F(ab')2 fragments of monoclonal anti-PF4 antibodies (1E12, 1C12, and 2E1). The researchers assessed their ability to inhibit binding of human VITT and HIT antibodies to PF4. The antibody 1E12 showed strong inhibition of VITT IgG binding (93%) but not HIT antibodies (6%), whereas 1C12 and 2E1 inhibited both VITT and HIT antibodies. Thus, a competitive anti-PF4 EIA with 1E12 can assist in confirming VITT diagnosis and distinguishing it from HIT.\nWhen ELISA results are negative, functional assays, specifically platelet activation assays, serve as alternative diagnostic tests. These assays are notably effective for detecting platelet-activating antibodies and have demonstrated high sensitivity and specificity for VITT. A positive outcome from a heparin-free platelet activation test, coupled with reduced activation in a test with low heparin levels, indicates that platelet activation is mediated through a pathway not involving heparin.\nIn this context, promptly recognizing CVST following vaccination is essential. Healthcare professionals and individuals should be alert to any neurological symptoms, even subtle ones that manifest particularly within 48 hours post-vaccination and they should be aware of the potential for severe neurological adverse events. Thrombocytopenia serves as a critical warning sign, acting as a primary indicator of this condition. Comprehensive blood analysis and imaging are pivotal in differentiating between typical vaccine reactions and significant neurological adverse events. VITT cases often exhibit variable levels of thrombocytopenia, increased D-dimer, and occasionally, prolonged clotting times, requiring continuous and meticulous monitoring. In addition to detailed blood work, targeted imaging studies are vital for diagnosis. Reports have shown that CVST typically affects the sigmoid and transverse sinuses and is associated with hemorrhages in the cerebellum and frontal brain regions. Furthermore, VITT-related thrombosis can extend beyond the cerebral veins to other venous areas, such as the superior ophthalmic vein, and even to arteries, resulting in arterial events.\nFor treating VITT, reports highlight positive outcomes using therapies such as intravenous immunoglobulin (IVIG) and anticoagulation with heparin alternatives. IVIG has shown efficacy in stopping platelet activation and quickly raising platelet counts in conditions like spontaneous HIT, which resembles VITT in its pathophysiology, characterized by autoimmune-activated platelets due to heparin-independent antibodies without heparin exposure. IVIG's action is believed to involve FcgammaRIIa receptor inhibition through IgG. Research showed that platelet activation could be halted by an FcgammaRIIa-blocking antibody and high IgG levels.\nEndovascular treatment (EVT) should be considered, especially for patients with extensive thrombosis or clinical and/or radiological deterioration. In the largest cohort study, 18 out of 136 CVST-VITT cases underwent EVT (92% aspiration and/or stent retrieval, 8% local thrombolysis), which resulted in improved local blood flow in 83% of cases. Survivors largely attained functional independence, showcasing EVT's potential benefits despite a high mortality rate. Moreover, EVT was not linked to an increase in mortality rates.\nA retrospective study conducted in Netherlands from April 2021 to July 2021 examined the outcomes of patients with cerebral venous thrombosis (CVT) due to vaccine-induced immune thrombotic thrombocytopenia (VITT) post-SARS-CoV-2 vaccination. Out of 107 CVT-VITT cases, 43 (40%) died during initial hospitalization. For the 64 survivors, follow-up was available for 60, showing a median age of 40 years, with 75% being women. After a median follow-up of 150 days, functional independence (modified Rankin Scale (mRS) score of 0 to 2) was achieved by 88% of patients, with two deaths reported during follow-up and one major bleeding event, indicating low mortality and new thrombotic events post-discharge.\nIntracerebral hemorrhage (ICH) is a significant health concern, and there have been infrequent reports of ICH following COVID-19 vaccination.\nOne noteworthy study conducted in Hong Kong involved a substantial population of 4,492,167 individuals, representing 65.2% of the eligible population, with 60.1% having received two doses of the COVID-19 vaccines, either Pfizer-BioNTech BNT162b2 or CoronaVac. This is the only self-controlled case series study that identified an increased risk of hemorrhagic events associated with the BNT162b2 vaccine, particularly 14-27 days after the first dose (adjusted IRR of 2.53) and 0-13 days after the second dose (adjusted IRR of 2.69). A limitation highlighted by the study is the Self-Controlled Case Series (SCCS) model's inability to adjust for potential time-varying covariates, such as body weight, lifestyle factors, and COVID-19 infection.\nIn Japan, two cases of ruptured vertebral artery dissecting aneurysm (VADA) in the V4 segment one and seven days following mRNA COVID-19 vaccination were reported. The patients, following vaccination with either the Moderna mRNA-1273 or Pfizer-BioNTech BNT162b2 vaccine experienced good recovery, being discharged with a modified Rankin Scale (mRS) score of 1.\nAdditionally, three cases of intracranial aneurysm rupture within three days post-administration of the Pfizer-BioNTech BNT162b2 vaccine were documented. These cases involved intracranial artery segments (bifurcation of the middle cerebral artery, internal carotid-posterior communicating artery, and anterior communicating artery), with symptoms appearing from 0 to 3 days post-vaccination, leading to severe headaches. Treatment outcomes were favorable, with modified Rankin scale scores ranging from 0 to 2.",
"gender": "Male"
},
{
"age": 56,
"case_id": "PMC11147783_02",
"case_text": "Another reported case involved a 56-year-old woman who suffered an intracerebral hemorrhage in the left temporal lobe extending into the intraventricular space immediately after receiving the Pfizer-BioNTech COVID-19 vaccine. Despite surgical efforts to clip a ruptured aneurysm, the patient unfortunately passed away on the second postoperative day.",
"gender": "Female"
},
{
"age": 80,
"case_id": "PMC11147783_03",
"case_text": "Beyond ICH, there are rare instances of spinal hemorrhage following COVID-19 vaccination. One case describes a spinal epidural hematoma between T10-L1 in an 80-year-old male after the first dose of the Sputnik V COVID-19 vaccine. Despite surgical intervention, there was no clinical improvement one month post-surgery. Another case, involved a 67-year-old female who developed a spontaneous intramedullary hematoma after her first dose of the Sinopharm COVID-19 vaccine extending from the brainstem to T2. Initial treatment including plasmapheresis and high-dose methylprednisolone therapy did not yield significant improvement, but after 18 months, she showed notable neurological recovery with an improved modified Rankin Scale score to 1.\nDespite the global administration of billions of COVID-19 vaccine doses, the literature reveals limited evidence of the risk for hemorrhagic events, typically in patients with pre-existing pathologies and primarily associated with mRNA vaccines. This scarcity of adverse incidents further underscores the safety of vaccination.",
"gender": "Female"
},
{
"age": 9,
"case_id": "PMC11147783_04",
"case_text": "Whereas several cases of PACNS after COVID-19 have been reported, we found only a case of primary angiitis of the central nervous system in a 9-year-old boy following his second dose of the Pfizer-BioNTech COVID-19 vaccine (BNT162b2). Symptoms began one day post-vaccination, including persistent headache and fever. Diagnostic MRI on the sixth day revealed stenosis of the left middle cerebral artery. Treatment with three courses of methylprednisolone pulse therapy with gradually tapering and aspirin as an antiplatelet therapy led to the disappearance of symptoms and improvement in vascular stenosis, with the patient in remission for over a year.",
"gender": "Male"
},
{
"age": 50,
"case_id": "PMC11147783_05",
"case_text": "There are some case reports describing cases of pituitary bleeding and following apoplexy, mostly on the basis of pre-existing adenoms. A 50-year-old man experienced severe headache, vomiting, nausea, and diplopia after receiving his third Moderna COVID-19 vaccine dose treatment included stress dexamethasone for potential adrenal insufficiency and to reduce edema. The patient underwent transsphenoidal resection of the pituitary tumor. Post-surgery, the patient showed significant improvement, with normal pituitary hormone levels and resolution of headache and diplopia at the 4-month follow-up.",
"gender": "Male"
},
{
"age": 45,
"case_id": "PMC11147783_06",
"case_text": "Another case involved a 45-year-old man with a giant pituitary tumor and bitemporal hemianopsia, whose surgery was delayed due to COVID-19. After receiving the second dose of the Pfizer/BioNTech vaccine, he experienced a severe headache and vision loss due to pituitary apoplexy, necessitating emergency surgery.\nA summary of all neurovascular side effects of Sars-Cov2 Vaccination is depicted in Figure 1.",
"gender": "Male"
}
] |
PMC11147783
|
[
{
"age": 67,
"case_id": "PMC10985253_01",
"case_text": "A 67-year-old woman had psoriasis vulgaris for 1 year. She was treated with topical hormone and narrow-band ultraviolet B phototherapy for a prolonged period of time. Neither of the therapies led to a consistent improvement of cutaneous manifestations, and she developed fever and extensive erythema along with pinpoint pustules for 2 weeks prior to our treatment ( Figures 1A, B ). Her medical history included type 2 diabetes, hypertension, cerebral infarction, and stage 4 CKD. Histopathological examination revealed psoriatic hyperplasia of the epidermis with keratosis, along with Kogoj abscesses in the horny layer. Lymphocytic infiltrate was present in the superficial dermal layer along with dilatation of capillary vessels ( Figure 2 ). The patient was diagnosed with acute GPP based on pathological and clinical manifestations.\nPrior to starting systemic treatment, blood tests (blood count, biochemical tests, and inflammatory markers) were performed. We also decided to perform a computer tomography (CT) scan of her chest to exclude an underlying infection, because she had a self-limiting fever episode 2 weeks earlier. The results were unremarkable except for creatinine (247 mumol/L), glomerular filtration (18.3 mL/min/1.73 m2), and D-dimers (13.04 mg/L), and the CT scan revealed pulmonary interstitial fibrosis. Acitretin, methotrexate, and cyclosporine were avoided due to serious renal insufficiency. The patient declined systemic corticosteroids due to type 2 diabetes and cardiovascular disease, and the use of topical emollients and steroids was not efficient. With informed consent, the patient received oral tacrolimus at an initial dose of 3 mg/day (0.05 mg/kg/day). The patient was afebrile, and her lesions were almost completely resolved after 2 weeks ( Figures 3A, B ). Creatinine dropped to 213 mumol/L, the glomerular filtration rate was 22 mL/min/1.73 m2, and the D-dimers dramatically improved (2.99 mg/L). The patient's blood pressure and glycemia were well controlled, and no adverse events such as diarrhea, infection, or paresthesia, were observed. The drug dose was reduced by 1 mg every month, and the entire treatment duration was 3 months. No recurrence was observed after 6 months of follow-up.",
"gender": "Female"
}
] |
PMC10985253
|
[
{
"age": 62,
"case_id": "PMC11075674_01",
"case_text": "A 62-year-old female was referred to our hospital as a case of upper airway obstruction secondary to possible advanced thyroid cancer + Grade 5 dysphagia after five days of stay. She presented with anterior neck swelling of 12 years' duration, which increased in size rapidly over five days with associated fever, shortness of breath, a hoarse voice, difficulty swallowing both solids and a fluid diet, and vomiting of ingested matter. She had long-standing intolerance of heat and irritability, and was easily fatigued, and had experienced unquantified weight loss despite having a good appetite along with anterior neck swelling. Otherwise, she had no history of cough, orthopnea, body swelling, previous neck surgery or trauma, treatment for tuberculosis, or chronic medical illnesses like diabetes, asthma, hypertension, cardiac or renal disease. For the above complaint, she was treated at the referring hospital with oxygen supplementation, ceftriaxone, and dexamethasone for a week but did not show improvement.\nUpon presentation, the patient was acutely sick looking, in severe respiratory distress and had a stridor with oxygen saturation (SPO2) of 77% on a 15-liter per minute face mask. She had a respiratory rate of 40-44 breaths per minute, pulse rate of 118 beats per minute, blood pressure of 145/90 mm Hg, and temperature of 37.8 0C. Examination of the neck revealed a large mass more on the right side of the anterior neck, which was shiny without ulceration or discharge. The mass was non-tender and warm to the touch, with a firm-to-hard consistency. It measured 15x13 centimeters, extending from the sternum to the submental area, but had no retrosternal extension on either palpation or percussion (Figure 1). Upon oropharyngeal assessment, the patient had a Mallampati score of III. Otherwise, there were no oropharyngeal lesions or cervical lymphadenopathy, and no pertinent findings on other systems.\nLaryngoscopic glottis visualization showed complete obstruction of the glottis, class 4 according to the Cormack-Lehane scale, but no visible mucosal infiltration, thickening, or bleeding. With the above history and following physical examination, mixed type 1 and 2 respiratory failure, secondary to upper airway obstruction, anterior neck mass compression, and hospital-acquired pneumonia was considered. With this, a difficult airway was anticipated and prepared for double setup airway management but there was no place for a surgical airway. Adequate preparation was made to increase the success rate of endotracheal intubation with a bronchoscope. A rigid bronchoscope with a size of 7 mm was used to visualize the airway and possible intubation; however, we could not advance the scope beyond the glottis area due to the compression effect of the mass causing resistance. No visible infiltrative mass was noted to the level of the airway evaluated (Figure 2). The patient was then intubated with a 6 mm endotracheal tube secured at a depth of 18 cm and put on a mechanical ventilator: AC/VCV mode, FiO2 of 100%, positive end-expiratory pressure of 5 cm of H2O, SPO2 ranging from 96-98%, tidal volume of 360 mL, and rate of 14.\nOnce the patient was stabilized, she was investigated with a complete blood count showing leucocytosis of 25.47x103, with left-shift and moderate anemia. Her thyroid function test result was within the normal range. Fluid analysis from the aspirate of swelling was chocolate-colored thick pus with a cell count of 108,000/mm3, a neutrophil of 85%, and a low glucose level (Table 1). Gram stain from aspirate revealed gram-positive cocci in pairs; however, culture and sensitivity tests were not done due to their unavailability in our setup. Cytology results from the aspirate demonstrated intense suppurative inflammation along with necrotic material, which raised suspicion of malignancy. Neck ultrasound showed a homogenously hypoechoic avascular midline ovoid mass more on the right, with posterior acoustic enhancement measuring 13x10.7 cm, and a significant mass effect on the cervical esophagus and trachea (Figure 3). Head and neck computed tomography (CT) performed two days prior to her presentation revealed a well-defined lesion, with water attenuation at the right neck region extending from the clavicle inferiorly to the hyoid bone level, cranially measuring 11x10.5x10.8 cm (craniocaudal, transverse, anterior-posterior). The lesion had enhancing soft tissue foci, likely thyroid tissue. The lesion displaced right-side vascular structures postero-laterally and midline structures (larynx, trachea, and esophagus) on the left lateral side, suggesting a large cystic mass originating from thyroid tissue (Figure 4). \nSubsequently, after stabilization and initial investigation, incision and drainage (I & D) of the thyroid abscess was done, draining a total of 900 mL thin pus with the initial aspirate (Figure 5). Antibiotics were initiated and wound care was done on a daily basis. The patient was extubated after four days of intubation with improvement. Subsequently, the patient had persistent discharge from the wound and neck swelling increased. A right-side thyroid lobectomy with cystic mass excision was then performed, and a 6x6 cm smooth cystic mass on the right thyroid lobe on an elective base was found interoperatively. The patient was discharged in a better condition after 10 days of stay in the hospital. The biopsy result turned out to be follicular nodular disease.",
"gender": "Female"
}
] |
PMC11075674
|
[
{
"age": 69,
"case_id": "PMC11182298_01",
"case_text": "A 69-year-old African-American male presented for baseline ophthalmic examination prior to beginning pemigatinib treatment. His medical history was significant for a tumor mutation burden 3 (TMB-3) metastatic adenocarcinoma of the liver, which was associated with bilateral pulmonary metastases arising from primary cholangiocarcinoma. Other significant medical history characteristics included well-controlled type 2 diabetes mellitus and hypertension. The patient denied having any visual complaints at this stage. The ophthalmic history included stable peripheral drusen, orbital fat prolapse, and mild cataracts in both eyes. The initial ophthalmic examination revealed a non-corrected visual acuity (VA) of 20/40 in the right eye (OD; oculus dexter) and 20/20-2 in the left eye (OS; oculus sinister). The best corrected VA OD was 20/30 at this time. The anterior examination was significant for mild dry eye and mild cataract bilaterally. The complete dilated fundus examination was significant for peripheral drusen. No RPED or SRF was noted on OCT testing. Baseline fundus autofluorescence (FAF) showed multiple areas of hypopigmented lesions consistent with the patient's known temporal macular drusen, as seen in the color fundus photography ( Figure 1 ).\nThe patient began treatment with oral pemigatinib daily and was followed up for an ophthalmic examination during the second treatment cycle approximately 5 weeks into the treatment process. The patient had at this stage received 28 doses of 13.5 mg per day, which was administered in cycles of 14 on-days and 7 off-days, and had no visual or ophthalmic complaints. The non-corrected VA was OD 20/30 + 1 and OS 20/20. The OCT examinations revealed subfoveal SRF bilaterally. The fundus examination was otherwise unremarkable outside the patient's prior documented peripheral drusen. Repeat autofluorescence was overall unchanged, though a slight hypofluorescent ring may be visualized in Figure 2 . The current pemigatinib protocol recommendation for asymptomatic patients suggests no dose modification; however, with worsening presentation or positive symptoms, it is recommended to withhold pemigatinib. After discussion with the patient's oncologist, it was decided to continue the medication at this time. Serial monitoring of the patient's symptoms, vision, and SRF were conducted on specific days during active treatment cycles and days off-cycle to monitor the SRF. Subsequent evaluations demonstrated complete resolution of SRF while off-cycle, and asymptomatic re-accumulation of fluid while on-cycle with varying levels of VA. ( Table 1 ) As we see demonstrated in the table below, in the later stages of the active cycles, such as day 13 of 14 of cycle 2, day 13 of 14 of cycle 3, day 13 of 14 of cycle 4, and day 14 of 14 on cycle 5, the patient's VA showed no correlative changes based on the presence of SRF. The fluctuations in the patient's VA certainly occurred, but were likely to be secondary to surface changes, as certain off-cycle days actually presented with lower acuities than days when the SRF was present on OCT examination.",
"gender": "Male"
}
] |
PMC11182298
|
[
{
"age": 55,
"case_id": "PMC10695438_01",
"case_text": "A 55-year-old female, divorced, who worked as a university teacher sought medical care due to \"difficulty communicating\". Her symptoms began during the previous four years with progressive difficulties in sentence construction, and she reported \"finding it hard to complete a sentence\". After the initial symptoms, language deficits compelled her to quit her job. During the few months before the presentation, her language issues became exacerbated, and she required assistance with writing. Her behavior remained unaltered, but she began to experience difficulty carrying out day-to-day activities due to her language deficits.\nAt the first consultation, in addition to language problems, the patient also reported a depressed mood for the past three months, and she had been prescribed mirtazapine at a dosage of 30 mg/day. She did not have any other psychiatric or neurological disorders, and her clinical and neurological evaluations were normal. The patient had been receiving language therapy for more than six months. Biomarkers and complementary tests needed for a precise diagnosis of PPA were requested and are described below.\nThe neuropsychological evaluation at the moment of her first consultation revealed grammatical, praxis, and verbal fluency deficits, keeping naming and word comprehension ability preserved. The fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed a moderate/marked reduction in glycolytic metabolism in the lateral regions of the temporal lobes and the lower portions of the parietal lobes; there was an asymmetrical pattern due to greater left-side involvement, especially in the lateral portion of the prefrontal cortex, in the posteromedial portions of the parietal lobes and in the posterior gyrus of the cingulate cortex (Figure 1).\nMagnetic resonance imaging (MRI) of the skull revealed gliosis due to atherosclerotic microangiopathy and prominent cisterns, fissures, and cortical grooves; additionally, compensatory ectasia of the lateral ventricles was observed (Figure 2).\nCerebrospinal fluid (CSF) analysis showed an increase in total tau (t-tau) levels (496,9 pg/ml/I.R.: <300 pg/ml (21-50 years); <450 pg/ml (51-70 years); <500 pg/ml (71-93 years) and phosphorylated tau (p-tau) protein (107,2 pg/ml/I.R.: <61 pg/ml), a decrease in beta-amyloid protein Abeta1-42 levels (338,7 pg/ml/I.R.: >500 pg/ml), and a decrease in Abeta1-40 levels (3919 pg/ml/I.R.: 7755-16715 pg/ml). Nonetheless, the Abeta1-42/Abeta1-40 ratio (0,086 pg/ml/I.R.: >0,069 pg/ml) was within the normal range. A genetic panel was performed for several genes, including some already related to neurodegenerative diseases and a pathogenic variant was found: c.6055G>A (p. Gly2019Ser). This variant was identified in leucine-rich repeat kinase 2 (LRRK2). Pathogenic mutations in the LRRK2 gene are associated with Parkinson's disease, and some reports describe preliminary evidence correlating with Corticobasal Syndrome (CBS) and PPA .",
"gender": "Female"
}
] |
PMC10695438
|
[
{
"age": 47,
"case_id": "PMC11017003_01",
"case_text": "A 47-year-old man, with 20-year background of hypertension, had originally presented with unstable angina to the emergency department. He was under treatment of daily tablet losartan 25 mg and 80 mg ASA tablet without any history of surgery or underlying disease. A significant stenosis in the proximal part of the diagonal artery was diagnosed. He underwent a 30-min cardiac catheterization and angiography through the right radial artery with local anesthesia using lidocaine 2%. No sign of stenosis was seen after the procedure.\nThe patient referred to the ophthalmology service with diplopia, which manifested immediately following the procedure. An ocular examination revealed no sign of nystagmus, ptosis, or pupillary involvement, but exotropia of the right eye was seen in primary gaze. The eye movement was normal except a limitation in adduction of the right eye [Figure 1 indicating an incomplete third nerve palsy in its inferior division]. No other neurologic findings: no focal weakness, focal numbness, dysphagia, dysarthria, aphasia, or ataxia was detected. The brain magnetic resonance imaging (MRI) reported abnormal signal intensity (low in apparent diffusion coefficient and high in diffusion-weighted imaging) in the pons (right para-midline) compatible with diffusion restriction due to acute infarction [Figure 2]. One day after the procedure, a computed tomography (CT) angiography of the carotid arteries showed a calcified plaque with mild stenosis at the cavernosal portion of both internal carotid artery (ICA), and the right ICA had retropharyngeal course. In addition, the CT angiography of the circle of Willis demonstrated a calcified plaque with mild stenosis at the distal portion of the both vertebral arteries, that revealed the right posterior cerebral artery caused by the ICA instead of the basilar artery, a common anatomic variation in the circle of Willis, called fetal-type posterior cerebral artery. Furthermore, orbital MRI did not show any lesion, including tumor, infection, or inflammation in the orbit and anterior to the cavernous sinus region. Due to diplopia, an eye patch was applied. In her follow-up appointment, the patient denied recurrent angina symptoms, and her diplopia had resolved. The patient's symptoms improved spontaneously after 2 months of administration of 325 mg daily aspirin tablets.",
"gender": "Male"
}
] |
PMC11017003
|
[
{
"age": 89,
"case_id": "PMC10629296_01",
"case_text": "An 89-year-old Japanese female developed the spontaneous onset of back pain and paraparesis (i.e., motor weakness, hyperreflexia, and sensory loss). Magnetic resonance imaging (MRI) revealed a dorsal epidural hematoma from T4 to L4 [Figure 1].\nWe performed a hemilaminectomy at the T11, T12, and L1 levels and removed/debrided additional intervening hematoma using a flexible neuroendoscope. The flexible neuroendoscope had an outer diameter of 5 mm [Figure 2]. Before insertion into the epidural space, the length that the device could remove the clot was marked on the endoscope. A continuous irrigating system was connected to the endoscope that was used, with intermittent manual aspiration and a rigid syringe, to remove clots/debris. During irrigation, the hematoma was cleared, the dura mater was visible on the lower side of the scope screen, and the epidural fat was visible on the upper side.\nImmediately after surgery, the patient exhibited some neurological recovery. The postoperative MRI showed no residual hematoma [Figure 3]. The drainage was removed 2 days later. Three weeks postoperatively, she showed only mild residual paresis in the left leg. Four months after surgery, the numbness in the left leg persisted, but she was stable enough to walk.",
"gender": "Female"
}
] |
PMC10629296
|
[
{
"age": 65,
"case_id": "PMC10782429_01",
"case_text": "A 65-year-old man presented with limiting Canadian Cardiovascular Society class III stable angina symptoms despite optimal medical therapy. This followed a recent admission to hospital with an unstable angina presentation, which was managed medically.\nHis medical history included hypertension, hyperlipidaemia and gout. In addition, he had established coronary artery disease; 14 years prior, he had undergone coronary artery bypass grafting (CABG) with a left internal mammary artery (LIMA) to the left anterior descending (LAD) artery with triple jump radial artery conduits to the first diagonal with a side to side anastomosis, first obtuse marginal (OM1) with an end to side anastomosis and right posterior descending artery (RPDA) with an end to side anastomosis. A dobutamine stress echocardiogram revealed inducible ischaemia in the inferior and lateral left ventricular walls, so the patient was subsequently listed for a diagnostic coronary angiogram.\nAs the left radial had been harvested and the left ulnar pulse was weak, the procedure was carried out via the right femoral artery initially with a 6 Fr sheath (Cordis). Diagnostic coronary angiography revealed a severe stenosis at the radial artery graft bifurcation site between the continuous radial artery from the LIMA running to the RPDA and the jump radial segment to the OM1. The native right coronary artery (RCA) was a dominant vessel and had a chronic total occlusion (CTO) in the mid vessel with minimal antegrade flow and very little retrograde flow to the distal RCA from the left coronary artery. The LAD was occluded after a large first septal artery and the circumflex (Cx) was a small vessel with a patent distal atrioventricular Cx but occluded obtuse marginal branches (Figure 1).\nIt was felt that percutaneous coronary intervention (PCI) to the native RCA CTO would provide the patient with the best symptomatic relief. As a temporary measure before bringing the patient back for a dual access CTO PCI at a later date when better set up to perform it, it was decided to treat the radial artery graft bifurcation disease with drug-coated balloons at that sitting.\nThe femoral sheath was upsized to a 7 Fr sheath (Cordis), a 90 cm 7 Fr internal mammary guide catheter (Medtronic) was used to engage the LIMA and two Sion blue wires (Asahi Intecc) were placed down each radial artery limb beyond the bifurcation disease. Each limb was pre-dilated with a 2.5 x 12 mm semi-compliant balloon (Boston Scientific). Passage of a 2.5 x 15 mm SeQuent paclitaxel drug-coated balloon (B Braun) was challenging because of the LIMA tortuosity.\nDrug-coated balloon deployment of the RPDA segment of the radial artery graft did not achieve a 'stent-like result', with significant recoil noted, so crossover to placement of a stent was decided upon. Again, passage of a 2.5 x 15 mm Onyx drug-eluting stent (DES; Medtronic) was difficult, but eventually the stent was passed into the RPDA portion of the radial graft across the bifurcation with the OM1 jump and deployed at this site.\nSoon after deployment of this stent, the patient developed chest pain and shortly afterwards sustained VF. He received three stacked shocks at 360 J and 2 minutes of cardiopulmonary resuscitation before return of spontaneous circulation was achieved. Tentative injection via the internal mammary guide catheter with the catheter disengaged into the left subclavian artery revealed iatrogenic dissection of the LIMA with no antegrade flow. The most likely mechanism of dissection was over intubation of the guide catheter during difficult manipulation of the stent through tortuosity, causing catheter-induced dissection.\nAt this juncture, the cardiac surgical team were consulted and were on standby to undertake emergency surgery if the situation could not be rectified percutaneously. The inlet of the suspected dissection site, i.e. the ostium of the LIMA, was secured by placing a 4 x 12 mm Onyx DES but despite this, antegrade flow was not achieved, indicating that the dissection had propagated further into the LIMA beyond the distal edge of the stent (Figure 2).\nUnfortunately, intravascular ultrasound (IVUS) was not available as the portable console was being used in another cath lab for an emergency case. A more distal DES was placed (4 x 12 mm Onyx DES) in what was thought to be beyond the dissection in healthy vessel. To confirm placement of the distal stent and sealing of the outlet, an Export AP thrombus aspiration catheter (Medtronic) was passed into the LIMA and positioned at the distal end of the LIMA. Contrast was then injected via the aspiration port while pulling back slowly on the catheter (Supplementary Video 1). This technique limits the propagation of dissection from hydraulic forces from standard injection via the guide catheter but allows adequate visualisation of the vessel to assess the level of the dissection while also maintaining wire position in the distal vessel.\nA similar procedure can be performed with a dual-lumen microcatheter, which has both rapid exchange and over-the-wire exit ports of which the over-the-wire hub allows the injection of contrast. Such catheters include the Twin-Pass and Twin-Pass Torque (Teleflex), Sasuke (Asahi Intecc) and NHancer RX (IMDS) microcatheters. In emergent situations where neither IVUS nor dual-lumen catheters or their equivalent are available, standard semi-compliant balloons can be inflated ex-vivo using saline then numerous perforations made in the balloon with a micro puncture needle. The balloon is then introduced into the vessel segment of interest and contrast injected via the balloon hub. While this technique has largely been described for the delivery of pharmacological agents in the context of no reflow, the author has also found it helpful as means of localised contrast delivery.\nIn this case, the manoeuvre using the Export thrombus aspiration catheter demonstrated that the more distal stent had sealed the dissection outlet. Such stenting beyond the dissection into normal vessel avoids so called 'tooth-pasting', i.e. propagation of the dissection downstream. The gap in between the inlet and outlet stents was filled to fully seal the dissection and, in total, four DES stents were placed. The stents were post-dilated with a 4 mm non-compliant balloon (Boston Scientific) to 16 atm. A standard injection through the guide catheter then revealed restoration of brisk flow and well-sized stents, with the stent material covering the LIMA ostium and extending around 1 mm back into the left subclavian artery (Figure 3). It was noted that there was loss of flow into the radial jump supplying the OM1 graft, but as the patient was pain free and stable at this point, it was decided to manage this conservatively (Figure 4).\nAt follow-up, the patient reported a significant improvement in his angina and he declined CTO PCI of the RCA.",
"gender": "Male"
}
] |
PMC10782429
|
[
{
"age": 21,
"case_id": "PMC10793715_01",
"case_text": "A 21-year-old man visited the radiation oncology outpatient clinic after undergoing surgical excision of an intradural extramedullary mass in his cervical region. Before his surgery, he had been experiencing neck pain and right-sided body weakness for the past 2 years. His symptoms had gradually worsened over time. He underwent an MRI scan of his spine, which showed the presence of an intradural extramedullary mass in the cervical region outside of the hospital.",
"gender": "Male"
}
] |
PMC10793715
|
[
{
"age": 75,
"case_id": "PMC11350541_01",
"case_text": "A female patient aged 70 to 75 years old who was diagnosed with diabetes several years prior, presented with black stools for 2 months. She was urgently taken to the clinic because of dizziness, profuse sweating, irritability, palpitations, and fainting. The emergency examination results are as follows: blood pressure (BP): 80/44 mmHg, respiratory rate(RR):24 bpm, heart rate (HR): 120 bpm, hemoglobin (HGB): 41 g/L, hematocrit (HCT): 0.178, and fecal occult blood (FOB) test: (+). Based on the patient's symptoms, signs, and examination results, she was diagnosed with hemorrhagic shock. Her HGB increased to 94 g/L after being transfused with 4 units of red blood cells, then, the gastroscopy was performed.\nWe found a 0-Isp type lesion with a size of 22 mm x 20 mm on the posterior wall of the gastric antrum (Figure 1a), at the same time, a fading type 0-IIa lesion in the angular incisure of the stomach was detected. The surface microstructure and microvessels of the 2 lesions were quite different from the surrounding normal mucosa under the observation of magnifying endoscopy combined with narrow-band images (Figure 1b). The submucosa below the lesion located in the gastric antrum was continuous and intact based on endoscopic ultrasonography inspection (Figure 1c). According to the vessel plus surface classification system of EGC endoscopic diagnosis (Kenshi Yao), both lesions were diagnosed as differentiated EGC from the perspective of endoscopic observation. Hematoxylin-eosin staining of the biopsy tissue taken from the 2 lesions were confirmed as high-grade intraepithelial neoplasia (HGIN) by experienced pathologist (Figure 1d). Both the subsequent colonoscopy and capsule endoscopy examination showed no definite bleeding from large intestine and small intestine. We were unable to determine the real cause of hematochezia. Since then, the patient no longer had black stools, so she was discharged with oral proton pump inhibitors (PPI, 40 mg/day) and planned to undergo the endoscopic resection of the EGC in a short period of time after she recovers better.\nTwo weeks after the patient took PPI orally, she was re-admitted to the hospital for endoscopic resection, she developed a small amount of black stool again. Her BP, HR, and HGB at that time was 110/74 mmHg, 98 bpm, and 80 g/L. So the second gastroscopy was performed, and unexpectedly, there was an active outflux of blood at the top of the 0-Isp type lesion located on the gastric antrum surrounded by a large quantity of fresh red blood clots (Figure 2a). It was almost certain that this was the real cause of the patient's recurrent bleeding. An emergency ESD was performed by experienced endoscopist under the conditions of tracheal intubation, general anesthesia and blood transfusion. The patient was placed in the left decubitus position so that the blood could quickly follow along the lesser curvature to the fundus of the stomach. After rapidly peeling the lesion for 10 minutes, it was completely removed and the active outflux of blood was stopped. We also dissected the EGC in the angular incisure of the stomach (Figure 2b). In the isolated specimen from the gastric antrum, the blood vessel stump on the top of the tumor could be clearly distinguished by the naked eye (Figures 2c and d). The pathology images confirmed differentiated adenocarcinoma, and both lesions have achieved to endoscopic curability A (eCuraA) in the 6th Japanese Gastric Cancer Association (JGCA) guidelines. Unusually, thick and abundant blood vessels extending from the inside to the surface of the tumor corresponded accurately to the active bleeding site under the endoscopy (Figure 3a and b). After ESD, the patient recovered well with intravenous infusion of PPI and oral mucosal protectants, and was discharged 5 days later. Oral PPI lasted for 2 months, and during the follow-up period of 2.5 years, there was no further gastrointestinal bleeding.",
"gender": "Female"
}
] |
PMC11350541
|
[
{
"age": 3,
"case_id": "PMC10883445_01",
"case_text": "Three years old female symptomatic for the last 2 years with recurrent episodes of pneumonia. Her antenatal and perinatal period was uneventful. There was no history of recurrent abortions in the mother, sibling deaths, unusual presentations such as non-healing ulcers, skin lesions, recurrent diarrhea, oily stool, recurrent ear discharge, recurrent rhinitis, food allergy, exposure to pigeons, vomiting post feeds or forced feeding in past. Child started eating home cooked food including wheat, rice, and lentils at 9 months of age. She had failure to thrive post-weaning. The mother recalled an increase in her respiratory distress post lentil consumption occasionally. She had a history of multiple hospitalizations as pneumonia, which responded partially to IV antibiotics without complete remission ever. Her CXR was s/o perihilar dense bilateral consolidation with characteristic sparing of lower lobes. CECT chest was s/o peritracheal [Figure 1a], peri-bronchial consolidations in upper and middle lobes bilaterally with sparing of the lower lobe with interstitial thickening [Figure 1b]. Multiplanar reformat images in the axial section were suggestive of perihilar dense consolidation with peripheral sparing [Figure 1c]. Her radionuclide milk scan was positive for gastroesophageal reflux grade 2. In view of characteristic features of hypersensitivity pneumonitis with upper and middle lobe involvement, her IgG levels for suspected lentil hypersensitivity were sent which were high with a level of 76 mgA/L as against a cut-off of <10 mgA/L. Her serum IgE for lentil level was 0.87 kUA/L against a normal cut-off <0.35 kUA/L. Child was diagnosed as a case of lentil hypersensitivity and was treated with oral steroids along with the complete omission of lentils from her diet and anti-GER medication. She was started on alternative sources of protein such as eggs. She became asymptomatic after 15 days.\nFive months, well thriving male was admitted with complaints of fever, cough, and fast breathing of 5 days duration. He was initially managed on supportive care with heated humidified high-flow nasal cannula oxygen as a suspected case of Acute Bronchiolitis. He continued to deteriorate despite supportive care. His hemogram was suggestive of mild anemia with an elevated TLC count of 22,300/mm3 and platelet count of 6.3 lakh/mm3. Sepsis biomarkers, such as Procalcitonin and C-reactive peptide, were negative for bacterial infection. The blood smear did not show any toxic changes or left shift or neutrophilia. CXR was suggestive of bilateral non-homogenous reticulonodular opacities. His systemic examination was unremarkable. His ABG report suggested hypoxemia with - Ph 7.436, PCO2- 41.0, PO2- 54.5, BE -3.1, HCO3- 20.9 meq/L. He was started on IV antibiotics and put on non-invasive ventilation support. However, he continued to worsen clinically. His CECT chest was suggestive of diffuse lung injury with ground glass attenuation in central and peripheral aspects [Figure 2a] with interstitial thickening [Figure 2b] and left lower lobe consolidation with a single cavitatory lesion in the posterior basal segment of left lower lobe [Figure 2c]. In view of this, neonatal interstitial lung disease like surfactant protein deficiency was considered. The patient was unfit for bronchoalveolar lavage. Next-generation sequencing was sent to rule out congenital causes of infantile interstitial lung disease. He was started on IV methylprednisolone pulse @ 10 mg/kg/d in view of moderate to severe interstitial lung disease. However, on day two of pulse steroid therapy, he started having massive pulmonary bleed and succumbed to his illness. Histopathology of the lung specimen was suggestive of minimal features of pneumonitis with the presence of proteinaceous material in the alveoli which showed weak positive staining with Periodic acid shiff which supported the diagnosis of pulmonary alveolar proteinosis. Next-generation sequencing report was suggestive of the presence of X-linked combined immune deficiency with a mutation in exon 2 at gene locus IL2RG with c.157 deletion. The final diagnosis was infantile interstitial lung disease with pulmonary hemorrhage with X-linked combined immunodeficiency due to IL2RG gene mutation.\nSeven years male, vegan, presented with clinical features of persistent pneumonia. He was well nourished and built without any h/o recurrent cough, fever, diarrhea, weight loss, hemoptysis, skin rash, joint pain, exposure to pets/birds, or contact with a case of tuberculosis. He had one episode of undocumented pneumonia at 5 years followed by a second episode at the age of 10 years. Clinically, he had respiratory distress with reduced air entry in the right infra-axillary area. He was hemodynamically stable with normal room air saturations. The child was given IV antibiotics and supportive therapy. However, he continued to deteriorate despite therapy. His CXR was suggestive of consolidation right middle lobe and lower lobe with an air-fluid level. His CECT chest was done which suggested the presence of a large cystic lesion in the right lower lobe posterior basal segment with the presence of air-fluid level [Figure 3a], Bronchiectatic changes adjacent to a cystic lesion in the right lower lobe [Figure 3b] with dense consolidation medial basal segment of right lower lobe [Figure 3c]. Differential diagnoses considered were infected hydatid cyst right lung or congenital cystic pulmonary adenomatoid malformation (CPAM). His Serum IgG for hydatid cyst was sent which was negative. In view of no response to medical management, he underwent a right lower lobe lobectomy. Histopathology of the lung specimen was suggestive of multiple cysts lined by ciliated epithelium with underlying alveolar spaces with sold-appearing areas, foamy intra-alveolar macrophages, lobar pneumonia in resolution phase with peripheral foci of necrosis with dense neutrophilic infiltrates without any atypical or malignant cells. The child recovered completely after the lobectomy. Screening to rule out other associated anomalies was done. The final discharge diagnosis was congenital CPAM type 3.",
"gender": "Female"
}
] |
PMC10883445
|
[
{
"age": 48,
"case_id": "PMC11283270_01",
"case_text": "A healthy 48-year-old male with a non-contributory medical history and no systemic medications presented for evaluation of decreased visual acuity and monocular diplopia in the right eye. His past ocular history was significant for ICL surgery eight years prior in both eyes for high myopia (-8.25 D -2.50 D x 178 OD and -8.00 D -3.25 D x 175 OS). Examination revealed an uncorrected distance visual acuity (UDVA) of 20/60 OD and 20/25 OS and a best-corrected distance visual acuity (BDVA) of 20/30 OD and 20/20 OS. His manifest refraction was 0.00 D -1.00 D x 12 OD and +0.50 D -1.00 x 170 OS. Slit-lamp examination (SLE) revealed a central anterior subcapsular cataract in his right eye. Preoperative biometric indices were axial length of 27.09 mm, K1 of 42.21 D, K2 of 42.66 D, and anterior chamber depth of 3.12 mm. The ICL vault at the time of cataract surgery was 260 microm centrally using anterior segment optical coherence tomography. The decision was made after informed consent to proceed with ICL explantation and concurrent cataract extraction. The IOL selection was performed with the ESCRS IOL Calculator (https://iolcalculator.escrs.org; London, United Kingdom). Of note, as this patient was highly myopic and at high-risk for retinal detachment and other complications, a dilated fundus examination was performed before and after all surgical procedures presented in this case report, including both YAG capsulotomies. No significant retinal findings or complications were observed in any of these examinations.\nAt the time of surgery, a 2.4 mm temporal clear corneal incision was created followed by the injection of a dispersive viscoelastic agent to protect the endothelium and maintain the anterior chamber. A cohesive viscoelastic agent was injected between the ICL and crystalline lens. An O'Gawa instrument was used to carefully lift the proximal end of the ICL away from the crystalline lens to avoid inadvertent damage to the capsular integrity. The two proximal foot plates were brought over the iris in the vicinity of the corneal incision. Subsequently, the ICL was grasped by 0.12 mm-toothed forceps, folded upon itself, and carefully removed from the anterior chamber through the corneal incision. Additional dispersive viscoelastic agent was injected into the anterior chamber through the same incision. A 5.5 mm continuous curvilinear capsulorhexis (CCC) was then successfully created. Using an irrigation cannula, hydrodissection and hydrodelineation were performed. The cataract and cortical lens material were subsequently removed using phacoemulsification and irrigation and aspiration handpieces followed by thorough anterior, posterior, and equatorial capsular polishing using bimanual technique, as well as further capsular polishing utilizing a curved 27-gauge Jensen capsule polisher cannula (Ambler Surgical, Exton, PA, USA). Cohesive viscoelastic agent was then injected into the capsular bag. A one-piece Bausch & Lomb (St. Louis, MO, USA) enVista MX60E 12.0 D IOL was placed inside the capsular bag in such a manner that the entire optic edge was completely covered with the overlying CCC. Any residual viscoelastic agent was then removed. All wounds were confirmed to be self-healing. The surgical procedure was uneventful and well tolerated.\nThe patient was placed on moxifloxacin 0.5% ophthalmic solution, four times daily for one week. Prednisolone acetate 1% ophthalmic suspension drops were used four times daily, which were tapered weekly over one month following surgery. Ketorolac 0.5% ophthalmic solution was used twice daily for six weeks. His postoperative course continued as expected. The patient's 1-month and 1-year postoperative manifest refractions were both -1.00 D sphere OD, UDVA 20/50, and BDVA 20/15.\nTwo years and seven months after cataract surgery, the patient presented with complaints of blurred vision in his right eye for several months. UDVA in the right eye was 20/60 and BDVA was 20/25. SLE showed a fibrous and wrinkled PCO without evidence of Elschnig pearls in the right eye. The decision was made after informed consent to proceed with YAG capsulotomy.\nAfter sufficient dilation, an uneventful YAG capsulotomy was performed with the UltraQ machine (Ellex, Minneapolis, MN, USA). A cruciate pattern was created in single pulse mode at 4.0 mJ power. Brimonidine 0.2% solution was administered following the procedure. The eye pressure was confirmed to be normal at 15 mmHg. He was prescribed prednisolone acetate 1% ophthalmic suspension four times daily for four days. His 1-week postoperative refractive and visual outcomes were -1.00 D sphere OD, UDVA 20/40, and BDVA 20/15.\nThe patient returned eight months later with a gradual decline in vision over several months. SLE revealed a recurrent PCO in his right eye. Elschnig pearls were present on the edge of the original capsulotomy opening, and the area within the original capsulotomy was opacified by a thin fibrous membrane (Figure 1a-c). This was treated by repeat YAG capsulotomy following the same procedure above, using single pulse mode at 3.8 mJ power. At the 1-week and 3-month follow-up visits, the patient remained asymptomatic with no signs of recurrent posterior fibrous membrane formation and subjective and objective improvement in visual acuity.",
"gender": "Male"
}
] |
PMC11283270
|
[
{
"age": 47,
"case_id": "PMC11195031_01",
"case_text": "A 47-year-old Indian male presented with a sudden onset left knee joint pain of one month with inflammatory swelling of knee, antalgic gait, and restricted range of motion particularly flexion. He had no significant past medical or surgical ailments. Middle class working male who travels by train daily without any family history of medical illness or any tuberculosis in the family. No history of trauma to the knee, weight loss, or any chest symptoms were found. He had no nighttime fever or night sweating, and no associated history of tuberculosis contact. Prior to the outpatient visit, the patient was following up with the family physician, who treated it as a superficial skin infection.\nOn examination, the patient had prepatellar swelling with tenderness localised to the prepatellar region without discharging the sinus. There was little erythema and a localised rise in temperature as compared to another knee. \nThe range of motion was terminally painful; otherwise, it was full range. A primary diagnosis of prepatellar bursitis was made, and anti-inflammatory medicines with empirical antibiotic coverage were prescribed. After two weeks of rest, ice application, and medical treatment, there was no significant relief of symptoms. At this moment, a provisional diagnosis of prepatellar bursitis with underlying bacterial osteomyelitis was considered. For the same reason, an X-ray and an MRI were prescribed along with blood work.\nBasic radiological evaluation of knee, on x-ray was suggested erosion of the anterior cortex of patellar margin [Figure1]. MRI was suggestive of focal osteomyelitis of the patella with anterior surface erosion and associated collection extending anteroinferior subcutaneous planes over the patellar tendon [Figure 2]. No intraarticular extension was seen except for some reactionary joint effusion. There was an enlarged popliteal lymph node. Blood work was suggestive of anaemia, with an elevated ESR at 55 and elevated qualitative CRP. X-ray chest evaluation showed an old 5th rib fracture with pleural effusion obscuring the left costophrenic angle [Figure 3]. According to the above-mentioned findings, infective bacterial post-traumatic osteomyelitis with prepatellar bursitis was the provisional diagnosis, and workup was done for surgery of excision biopsy, debridement, and placement of biodegradable calcium granules mixed with antibiotics.\n As a first step in surgery, aspiration of the knee was done, and the synovial fluid was sent for culture and sensitivity with fluid analysis. Intraoperatively, author found that the osteomyelitis showed friable necrotic tissue with caseous necrosis of bone, as shown on the clinical picture [Figure 4]. All of the pathological tissue, along with the prepatellar bursa, was resected and curetted and sent for histopathology, acid-fast bacillus culture, and sensitivity, along with gram culture [Figure 4]. \nThe crater created was almost 5 x 1.5 x 1 cm without breaching the patellar cartilage. As there was a primary suspicion of post-traumatic bacterial osteomyelitis, we placed biodegradable calcium pellets mixed with the empirical antibiotic (colistin) so that sustained release of the antibiotic could control osteomyelitis [Figure 5].\nThe knee was immobilised in extension with the help of a brace for 4 weeks. AFB cultures were negative and the staining was negative for bacilli. Histopathological examination of biopsied soft tissue and bony material showed necrotic areas surrounded by histiocytes, variable lymph plasma cells, neutrophils and occasional multinucleated giant cells without signs of malignancy [Figure 6]. Due to financial constraints patient refused few of molecular testing. Anti-Tuberculosis treatment initiated for a year. Initial two months of four drugs therapy with basic dosage of Isoniazid, Rifampicin, Pyrazinamide and Ethambutol. Subsequent 10 months patient received Rifampicin and Isoniazid only. \nRegularly, patient was evaluated through laboratory tests for any hepatic or renal side effects of the medicines. At a follow-up of 12 months, the knee is free of pain without any recurrent swelling. \nThe surgical wound had complete healing and no scars or discharging sinus. Bony void also showed near total filling with new bone seen on x ray. Short-term results showed not only normalised ESR and CRP levels but also improved knee function. Follow up X-ray demonstrated partial filling of the dead space or bone loss. After 6 years of follow-up, X-rays show complete healing, and the patient remains asymptomatic and without any signs of local recurrence [Figure 7, 8].",
"gender": "Male"
}
] |
PMC11195031
|
[
{
"age": 28,
"case_id": "PMC10800681_01",
"case_text": "A 28-year-old male presented with intermittent right upper quadrant pain exacerbated by fatty foods, suggestive of biliary colic. The patient described episodes of sharp, colicky pain that would radiate to the back and would typically occur after consuming meals high in fat content. The pain would subside spontaneously after a few hours. The patient did not report any associated symptoms such as fever, jaundice, or changes in bowel habits.\nPhysical examination findings were unremarkable. There were no signs of jaundice, abdominal tenderness, or palpable masses upon examination. The patient's vital signs were within normal limits, and there were no specific findings on systemic examination.\nLaboratory tests, including liver function tests, were performed to assess the patient's hepatobiliary function. The results of these tests were within the normal range, indicating no significant abnormalities in liver enzymes (alanine aminotransferase, aspartate aminotransferase), bilirubin levels, alkaline phosphatase, or gamma-glutamyl transferase. The patient's complete blood count and inflammatory markers were also within normal limits, ruling out an acute inflammatory process.\nAn abdominal ultrasound was performed to evaluate the biliary. The ultrasound revealed a septate gallbladder, which refers to the presence of a septum dividing the gallbladder into two chambers. The gallbladder wall thickness was measured at approximately 6 mm, slightly above the upper limit of normal (up to 3 mm). No gallstones or other abnormalities were detected during the ultrasound examination. MRCP has a golden role in detecting biliary structural abnormalities, but it is not available at our facility.\nConservative management was initially attempted, including dietary modifications to reduce fat intake and symptomatic pain management with analgesics. However, due to persistent symptoms and the potential risk of complications associated with a septate gallbladder, the decision was made to proceed with laparoscopic cholecystectomy.\nDuring the surgical procedure, upon exposure to Calot's triangle, a fusiform cystic lesion with a diameter of approximately 1.5 cm was identified arising from the cystic duct (Fig. 1, Fig. 2). The cystic duct cyst and septate gallbladder were dissected and excised intact with a small portion of the CBD that did not affect its continuity without any complications. An intraoperative cholangiogram was not performed because of unavailability at our facility. Postoperative recovery was uneventful, and the patient's symptoms resolved completely.",
"gender": "Male"
}
] |
PMC10800681
|
[
{
"age": 37,
"case_id": "PMC11317288_01",
"case_text": "A 37-year-old woman with a 6-year history of nephrotic syndrome presented to the nephrology department. She had experienced 6 relapses. The diagnosis of nephrotic syndrome was made 6 years ago after the patient developed swelling of both the eyelids and lower extremities. Physical examination revealed normotension and edema of the eyelids and lower extremities. The lung fields were normal. Initial laboratory tests showed a serum albumin level of 23.3 g/L and a urine total protein-to-creatinine ratio (TPCR) of 13.2 g/g ( Figure 1 ). Urinalysis revealed no active urine sediments. The serum cholesterol level was 12.82 mmol/L. Serum urea, creatinine, and electrolytes were within normal limits. Serum phospholipase A2 receptor (PLA2R) antibody was normal. Chest X-ray and renal ultrasound were normal. She had no history of autoimmune diseases, infectious diseases, or tumors and no history of nephrotoxic medication use. No family history of renal disease was reported.\nA renal biopsy was performed to confirm the presence of minimal change disease, as shown in Figure 2 . Due to respiratory tract infection, she decided to postpone glucocorticoid administration. However, starting from month 2, a full dose of prednisone (60 mg) was administered. After an 8-week course of treatment, CR was achieved. Unfortunately, a relapse occurred during the 7th month while the prednisone dosage was gradually reduced. Thus, tacrolimus was initiated during the 9th month to address persistent proteinuria. The trough blood levels of tacrolimus were maintained between 5 and 8 ng/ml. Despite this intervention, three additional relapses occurred during the tapering of both prednisone and tacrolimus. Consequently, the condition was classified as steroid-dependent nephrotic syndrome (NS).\nAfter experiencing a relapse in the 30th month, a treatment plan involving rituximab was initiated. The initial dose was 1g, followed by a second dose of 1g at 34 months. This resulted in achieving CR, which was successfully maintained for 6 months. However, a relapse occurred during the reconstitution of B cells at month 37. To address this, rituximab was re-administered at a total dosage of 2.5g from the 37th to the 51st month. This resulted in another CR accompanied by depletion of B cells, which was maintained for another 6 months until relapse occurred on the 59th month.\nDuring physical examination, the patient exhibited normal blood pressure and lower extremity edema. Laboratory tests revealed an albumin level of 18.3 g/L and a TPCR of 18 g/g. Other serological and immune tests yielded negative results. A dose of 0.5g of rituximab was administered, but proteinuria persisted. On the 64th month, TPCR was measured at 11.38 g/g, and B cells were detected at a count of 75/ul. Despite persistent symptoms, the patient declined repeat renal biopsy and genetic testing. The condition was then categorized as refractory and rituximab-resistant MCD. Due to the patient's desire for fertility, cyclophosphamide treatment was refused.\nSubsequently, obinutuzumab was selected as an alternative treatment. A single 1g dose was administered, and the infusion process was uneventful. This led to the achievement of another CR. B cell reconstitution occurred in the 72nd month. As of the 76th month of follow-up, the patient has remained on CR.",
"gender": "Female"
}
] |
PMC11317288
|
[
{
"age": 75,
"case_id": "PMC11182261_01",
"case_text": "A 75-year-old female presented with a 10-month history of gradual, painless graying discoloration of both sclera, bilateral fingernail beds, and bilateral lower extremities ( Figure 1 ). The patient's medical history was significant for obesity (with a BMI of 39.9 kg/m2), Merkel cell carcinoma of the leg, hypertension, atrial fibrillation, and rheumatoid arthritis. She had no history of liver disease or renal disease and at the time of presentation, she had an estimated glomerular filtration rate of 72 ml/minute/1.73 m2, which is in the normal range. The patient's current medications included HCQ, warfarin, metformin, glipizide, metoprolol, simvastatin, losartan, hydrochlorothiazide, and gabapentin. Of note was that she had no history of tamoxifen use. Importantly, she had a remote history of minocycline-induced hyperpigmentation of the skin of her lower extremities after several months of daily minocycline use for rheumatoid arthritis. After discontinuing the minocycline, the pigment changes faded slowly over months and years. This had been in remission for approximately 5 years prior to starting oral HCQ.\nIn the ophthalmic examination, her best corrected visual acuity was 20/30 both eyes; intraocular pressure, measured by tonometry, was 9 in the right eye and 10 in the left eye; pupils were equal, round, and reactive; and confrontational fields were full in both eyes. The slit lamp was notable for 1+ nuclear sclerosis and pinguecula OU, as well as diffuse graying of the sclera OU without associated scleral thinning or masses ( Figure 1 ). The cornea and dilated fundus examination revealed no hyperpigmentation or other abnormalities, and there was no evidence of HCQ-induced retinopathy. No electrophysiologic testing was performed.\nGiven the patient's history of rheumatoid arthritis, the differential included autoimmune and connective tissue diseases such as scleromalacia perforans and Addison's disease, which can cause a bronze hyperpigmentation of the sclera. However, there were no systemic symptoms to support Addison's disease and there was a lack of scleral thinning such that scleromalacia was less likely. Choroidal or ciliary body melanomas were also considered, but there was no evidence of these lesions in the examination. Furthermore, ochronosis was considered, as excess homogentisic acid in alkaptonuria can lead to scleral hyperpigmentation and associated joint pain. However, the patient had no urinary color changes or other symptoms to support this diagnosis.\nGiven the lack of an organic explanation, we concluded that the oculocutaneous hyperpigmentation was likely drug induced. We considered that this could be a photosensitive exacerbation of more subtle color changes from prior minocycline reactions, but the patient had reported full resolution of symptoms for 5 years after cessation of the drug, and prior eye examinations had all noted normal sclerae. With minocycline unlikely to be responsible, the most likely cause of the hyperpigmentation was determined to be HCQ, as this was the only new medication that she had started within the year prior to presentation, and it has an established role in hyperpigmentation in other tissues of the body. Certain factors have been associated with an increased risk of HCQ retinal toxicity, including obesity and older age, which were both seen in our patient. Higher accumulations of HCQ have been found to accumulate in the ocular tissue of obese patients, which could help explain why this patient was predisposed to scleral discoloration while on the medication. Although older age has been historically considered a risk factor for HCQ-related ocular toxicity, more recent studies have older age, in the absence of other comorbidities, to be a poor predictor of ocular toxicity. Meanwhile, other risk factors for ocular HCQ toxicity include renal or hepatic dysfunction and tamoxifen use, but none of these were in our patient's medical history.\nIn consultation with rheumatology, the decision was made to discontinue the use of the HCQ to see if this would improve the patient's findings on follow-up. Given the cosmetic nature of the side effect, and the benefits of immunosuppressant therapy in rheumatoid arthritis, it would have been reasonable to continue with HCQ and monitor for symptom progression. However, as rheumatology recommended alternative immunosuppressants that could achieve the same effect, we determined that cessation of HCQ was appropriate.\nThe patient was followed up after 10 weeks, and at that time she reported a gradual improvement in the hyperpigmentation of her nails and legs since the cessation of HCQ; however, pigment changes in the sclera persisted. The patient was followed up again 5 months after the initial presentation and the color changes had improved slightly ( Figures 1 , 2 ). This partial reversal of hyperpigmentation on cessation of HCQ further supported it as the causative agent of the systemic hyperpigmentation. However, the lack of substantial improvement in the scleral discoloration suggests a slow-reversal course from months to years.",
"gender": "Female"
}
] |
PMC11182261
|
[
{
"age": 58,
"case_id": "PMC10481634_01",
"case_text": "... people need to be positive always and not allow themselves to be overcome by the fear of getting sick or dying, because if they think that way they will become depressed and feel bad... (Survey 142, female, 58 years old).\nOur quantitative analysis of the surveys is consistent, finding that 81% of respondents used their creativity to solve problems, 74% indicated that they learned to live with the uncertainty brought by the pandemic, and 64% expressed that this experience increased confidence in their ability to solve problems in their personal lives, while 58% said they were able to \"move ahead\" with a more positive attitude. Respondents generally recognized and capitalized on the learning and skills they had developed, discovering and valuing their own capacities to overcome the problems and challenges that the pandemic emergency, and the measures to contain it, were generating.\nMeanwhile, there was widespread use of expressions of religious faith and spirituality that articulate positive feelings, solidarity, optimism towards the future, and the ability to cope with daily life and events beyond one's control. Survey respondents used the expression \"love thy neighbor\" as the basis of solidarity, not only as an act of devotion, but also with a prescriptive character, as a social norm. Pargament, Koenig and Perez (2000) suggest that, in order to face the stressful aspects of life, religious coping uses behaviors such as prayer, confession, the search for spiritual support, and the acceptance of circumstances as representative of the will of God. Studies have shown that spirituality and religion can help people recover from difficult situations, generating relief, hope, meaning, and a sense of value (Alvarado-Diaz, Pagan-Torres, 2021; Van Hook, 2016). From a functionalist perspective, in our analysis, religious faith or spirituality emerges as a resource that allows one to confront, and make sense of, the uncertainty brought on by the pandemic and its control measures, and offers hope for dealing with future challenges. In the region of Northwest Argentina, in general, and the province of Tucuman, in particular, there is a marked influence of religion in everyday life, the cultural landscape, and local history, that allows us to make sense of these sentiments (Ceil, 2019; ). Although there is a wide debate about spirituality or religiosity in circumstances of community crisis or traumatic personal situations, in our analysis these expressions reveal a positive religious coping in relation to the experiences and reflections they describe.",
"gender": "Female"
},
{
"age": 49,
"case_id": "PMC10481634_02",
"case_text": "... I consider myself a gladiator of this moment, reborn from the ashes. Hold on to your closest connections. Live the day-to-day. Hug, kiss, and have conversations about things that happen. The uncertainty of life is constant today, and it will be difficult to adjust to the new economic situation in general. May God and the Virgin help us. Thank you (Survey 145, male, 49 years old).",
"gender": "Male"
},
{
"age": 47,
"case_id": "PMC10481634_03",
"case_text": "The pandemic only strengthened my confidence and faith to cope with every situation that life throws our way. I care for myself, I care for you (Survey 73, female, 47 years old).",
"gender": "Female"
},
{
"age": 59,
"case_id": "PMC10481634_04",
"case_text": "The loss of two people very close to me due to covid taught us that we may be here today, but only God and the Virgin know [what happens] tomorrow (Survey 74, female, 59 years old).",
"gender": "Female"
},
{
"age": 25,
"case_id": "PMC10481634_05",
"case_text": "Hopefully the next pandemic will be one of love for your neighbor (Survey 296, female, 25 years old).\nIn our analysis, people speak eloquently of giving meaning to the pandemic experience and to their own lives, by actively caring for others and seeking to solve problems in their families and communities. In this self-reflection, propositions of responsibility and aid towards others emerged, revealing an ethic of care, especially at the level of intimate ties of affection and trust (toward family, friends, and neighbors). Thus, family and social support networks represent resources that also explain how people have \"moved forward\" in their interaction with others.\nWhen the pandemic began, it obviously produced many mixed feelings, because sometimes it was scary to think about how to move forward, what will happen to us (Community member, Interview).\nSo, there was a lot of fear. But not simple fear, [rather] a terrifying fear, things like, how am I going to support the family, how am I going to repay a debt, how am I going to pay this loan or this credit that I took out, all of this really affected us a lot (Community member, Interview).\nThis ethic of care is also expressed among those who carried out activities that required daily interactions with groups and where the community, to some extent, is perceived as dependent on the activity, or it is understood that ruptures or discontinuities in community work would be detrimental. Such was the case for teachers, managers of soup kitchens, and members of religious communities, among others. People in these circumstances alluded to their ingenuity and their ability to adapt, reinvent workplace dynamics, and maintain activities to fulfill \"their duty\" to others.\nI can tell you that in Education you have no choice but to retrain ... because it's not like you could lock up the Ministry, leave, and wait for this to situation to pass, do you understand? In other words, we had to restructure, it had to be changed, we had to adapt and continue, because we never stopped teaching. Everything was readapted and we carried on (Educational sector representative, Focus Group).\nWe had to readapt ourselves and from the religious aspect, people really need support and space. I think that the demands that people make of us on this point are very strong (Parish priest and community leader, Focus Group).\nAdditionally, the narratives of the pandemic reveal how priorities are identified and redefined, in personal lives and in relationship to others, which leads to the opportunity to give new meaning to one's life and revalue intimate ties, especially with family. Such reflections on the relationship of subjects with their close, everyday surroundings, as well as the introspective view of personal resilience, aligns with what has been reported in studies of crisis situations. For example, a cross-cultural analysis of the production of meaning during the pandemic notes a convergence in discourses that value family and close and intimate ties, and that reflect on developing more connected and meaningful relationships after this health emergency ( ). Likewise, different studies argue that having meaning and purpose in life may mitigate the negative impacts of crises and improve resilience in the face of adversity (Carter, Cordero, 2022; ).\nIn our analysis, solidarity was a recurring theme. It emerges as a way to constructively face the stress of the pandemic, and solidarity is conceptualized from within a discourse that poses it as an unavoidable duty before an external agent \"that we have to face.\" Participation in, or commitment to, solidarity actions represents a behavioral manifestation of community social capital where people are actively and collectively involved in seeking a suitable situation for members of society ( ).\nSocial capital entails the set of resources, real and potential, that are linked to the possession of a lasting network of reciprocal relationships (Aldrich, Meyer, 2015), and usually constitutes a protective factor. Research conducted during the pandemic has reported that communities where people tend to meet and interact frequently have coped better with the situation (Carter, Cordero, 2022; Borkowska, Laurence, 2021). The literature distinguishes types of social capital as: (1) bonding social capital, which refers to close ties - especially between family members and within kinship networks; (2) bridging social capital, that is, those less-close ties that exist between social groups; and (3) linking social capital, which refers to the relationship between dissimilar groups, with more explicit emphasis on verticality and power inequalities (Aldrich, Meyer, 2015). Our qualitative analysis revealed family and neighborhood groups as the main resources for managing ties of solidarity.",
"gender": "Female"
},
{
"age": 30,
"case_id": "PMC10481634_06",
"case_text": "In our experience we gained a better relationship with family and with neighbors, knowing how to support each other in difficult moments (Survey 18, male, 30 years old).\nThis pandemic has also brought out a lot of solidarity among us. We have started seeing the needs of others, and to be more empathetic with others, whereas perhaps before we did not, because such a tremendous thing [as the pandemic] has never happened to us, because before we faced more personal situations. Now it is a more generalized situation, so we begin to put ourselves in the place of the other (Community member, Interview).\nConfirming these sentiments, in our quantitative analysis of surveys, 44.4% (n=311) reported having participated in initiatives to help those most affected by the pandemic. Such initiatives show how bonding social capital is mobilized to carry out acts of solidarity, where work with families (26%) and neighborhood groups (13%), and, to a lesser extent, neighborhood soup kitchens (8%), churches (8%), schools (7%), government bodies such as municipalities and communes (6%), and health centers (4%), were most relevant.\nTo investigate whether participation in solidarity initiatives varied according to people's experience of covid-19 infection, we distinguish three groups: those \"very affected by covid-19,\" that is, those who personally experienced an infection and/or the death of close ties - family and/or friends - (25.1%, n=176) ; \"affected,\" corresponding to the group of participants who reported knowing people who had the disease and/or died as a consequence (32.4%, n=227); and a third group made up of those \"not affected\" by the disease, where none of the aforementioned situations were experienced (42.5%, n=298). Our results indicate that the percentage of people who participated in solidarity activities was similar across these groups, with no significant differences when comparing the groups of people highly affected, affected, or not affected by the experience of covid-19 (X2: 3.682, p: 0.159).\nIn addition, we found that people involved in solidarity initiatives reported more confidence in their ability to solve problems in their own lives, compared to those who did not participate in solidarity initiatives (X2: 58.332, p: 0.001). These results are related to the qualitative analysis, in which those who participated in solidarity initiatives to help those most affected by the pandemic were more likely to express positive feelings, for example:",
"gender": "Male"
},
{
"age": 45,
"case_id": "PMC10481634_07",
"case_text": "It was a very valuable experience to be able to help the indigenous peoples of our province. I received a lot of affection from those people who do not have the possibility of having a more comfortable way of life. I learned from them how valuable the effort and support of the people can be (Survey 3, female, 45 years old).",
"gender": "Female"
},
{
"age": 41,
"case_id": "PMC10481634_08",
"case_text": "In the pandemic, working with and assisting people with covid-19, I realized how fragile and short life is. And I learned to place more value on the moments that one spends with loved ones! Because you don't know when it will be the last time you kiss and hug the one you love! (Survey 8, male, 41 years old).",
"gender": "Male"
},
{
"age": 33,
"case_id": "PMC10481634_09",
"case_text": "The pandemic taught me to value others more and get more involved in political issues, since everything revolves around them and our future depends on those decisions (Survey 21, female, 33 years old).\nConversely, negative feelings were found more frequently among participants who reported low participation in solidarity initiatives, for example:",
"gender": "Female"
},
{
"age": 18,
"case_id": "PMC10481634_10",
"case_text": "Quarantine (not the pandemic) made us worse off socially and economically. Let's not vote for more socialism, we need freedom (Survey 63, male, 18 years old).",
"gender": "Male"
},
{
"age": 20,
"case_id": "PMC10481634_11",
"case_text": "During this pandemic I came to understand that Argentina is far from being a good life project, I want to leave the country, but it is becoming more and more expensive (Survey 2, female, 20 years old).\nOn the other hand, 51.5% (n=361) indicated the presence of social capital at the neighborhood or community level. In our survey, we found that people who perceived this type of social capital were more likely to participate in solidarity initiatives to help those most affected by the pandemic, compared to those who did not perceive social capital in their neighborhoods (X2: 64.560, p: 0.001). Related to these findings, other researchers have pointed out that sharing intense experiences (positive or negative) with members of one's own group or close groups (family, neighbors, work colleagues) increases cohesion within the group and the sense of shared social identity, and even more so in the face of negative, dysphoric, or traumatic experiences ( ).\nDelving into the manifestations of supportive actions, we notice different situations. On the one hand, especially in vulnerable groups with habitual experience dealing with crises, the pandemic has mobilized pre-existing solidarity networks and community strategies in places. In a structural context where infrastructure for basic services such as drinking water and drainage is lacking, where poverty affects 40% of the Tucuman population, including 47% of children and adolescents (Indec, 2010), the coronavirus crisis is experienced as one more challenging contingency to overcome amid structural disadvantages. The needs that emerge are daily nourishment, hygiene, accurate information, psychological and spiritual support, support for small and medium-sized businesses and commerce, and help in access to resources provided by the State. In these areas, the sense of community belonging is marked, and mutual influence or interdependence makes it possible to meet the basic needs of families. Communities have tapped into pre-existing social capital to cope with the pandemic.\nBecause the government or the State gives us a certain amount of merchandise, the basics, and for everything else we make contributions. We put up a certain amount of money per member and that is how we get the cooking done (Community representative, Interview).\nYes, yes, we have all had covid. And well, the community members and neighbors staffed the soup kitchen. And when one would get better, they would come back, and the others who were infected would go (Community representative, Interview).\nOn the other hand, the pandemic has stimulated the development of social capital, that is, the formation of alliances, groups, and associations as a strategy to make needs and collective demands visible to the State, and to achieve public-private agreements at the level of the Emergency Operating Committee (Comite Operativo de Emergencia, COE). For example, in the development of health protocols for the reopening of \"non-essential\" small and medium-sized companies or the management of special aid to independent professionals. We propose that the sense of shared identity is developed and strengthened by a common need or objective, which promotes the generation of bridging and linking social capital. In this sense, we consider it relevant to attend to, and deepen the dynamics of, relations among the State, civil society institutions, and citizens during the pandemic, including affiliations at the community level that help to cope with the crisis.\nThrough the Chamber [of Commerce], agreements were made with the municipalities, or they speak with councilors, in such a way that produce some ordinance [regulation] that allows certain sectors to open up, to maintain structure and avoid closing their businesses permanently ... We look for ways to find solutions for ourselves, as a merchant I am also one of those in that area, so I also have to find my own solutions, just like a large percentage of businesses do. So, it is an everyday job (Businessperson, Interview).\nI am in a WhatsApp group of eighty [business] owners. We have obtained approval from the COE, to be able to continue working with certain protocols ... that protocol is currently canceled (Businessperson, Focus Group).\n...because we understand that if we collaborate so that people comply with all these [sanitary] regulations it is a benefit, both for society and for ourselves, that we will be able to continue working normally (Businessperson, Company leader, Interview).\nIn conclusion, we note a common perception that the solutions to the problems posed by the crisis require collective action, which is activated through pre-existing networks or promotes the generation of groups that share interests and objectives. These statements show that the problems that stem from the pandemic have a community-scale scope, with health, economic, and social impacts. Thus, there is an active search for solutions that consider this multiplicity of effects, with complex and flexible political thinking, clearly overcoming the dichotomy of public health versus the economy. These forms of interpretation and flexible thinking are relevant as they promote the process of learning from experience ( ). The literature explains that, in general, people attribute meanings to their experiences that respond to rigid and polarized ways of thinking, typically organized by oppositions (bad/good, friend/enemy, pleasure/displeasure), while it is less common to find interpretations capable of capturing different kinds of experience and producing differentiated meanings. The latter correspond to more flexible ways of thinking, which then promote learning ( ).\nDuring the first months of 2020, official communication was very frequent, with the increased prominence of the president, aligned with provincial governors and officials from different ministries, especially those in the health field ( ). The policies implemented from within a \"State-centric\" strategy entailed the vertical coordination of measures designed by the central government and coordinated with the provinces (Azerrat, Ratto, Fantozzi, 2021). In our analysis, the State was recognized as the natural leader during the pandemic, taking on the role of arbiter between interests of the public and private sectors.\nThe participants in our study manifest a complex view of the role of the State in the management of the pandemic. They identify resource and infrastructure limitations that condition the actions of the different sectors that make up the state apparatus. In this sense, during the pandemic and related control measures, they make differentiated assessments of the organisms that make up the State, according to the repercussions on their daily lives.\nThere is a positive view of health professionals, as 68% of those surveyed agreed that they did a good job during the pandemic. Survey results are linked to the discourses analyzed qualitatively, which emphasize the vocation of service and the humanity of health professionals, while respondents point to the lack of resources and infrastructure as the causes of failure in the sector during the pandemic.",
"gender": "Female"
},
{
"age": 35,
"case_id": "PMC10481634_12",
"case_text": "... despite their abandonment by the government, health personnel were able to face an invisible and deadly enemy, and this also had repercussions on a personal level for every employee, since we had to sacrifice many things so that our families could count on us to provide for them every day (Survey 71, male, 35 years old).",
"gender": "Male"
},
{
"age": 23,
"case_id": "PMC10481634_13",
"case_text": "Social media often spread misinformation, [and] the government does not educate the public correctly in the face of a health crisis. Health personnel receive the worst possible labor treatment, while the public expects government support to live on, paid for by those of us who contribute to society. The Education sector suffers many limitations and academic resources were very limited in the face of this challenge that teachers faced with their students (Survey 79, female, 23 years old).",
"gender": "Female"
},
{
"age": 37,
"case_id": "PMC10481634_14",
"case_text": "The health sector is very neglected, when it is supposed to be the best prepared in terms of resources, during the pandemic there was a notable lack of empathy towards the [health] professional and the patient on the part of the government, the Ministry of Health, and those in charge (Survey 159, female, 37 years old).",
"gender": "Female"
},
{
"age": 23,
"case_id": "PMC10481634_15",
"case_text": "My opinion is that this context [the pandemic] allowed us to see the shortcomings of the health system, it came to light how poorly prepared the health system is in terms of infrastructure, material resources, or supplies. However, it is worth noting the impeccable performance of human resources (doctors, nurses, etc.). It is important to remember the human losses, in order to improve the conditions of the health system in the future (Survey 202, female, 23 years old).\nRegarding the education sector, 37% of survey respondents approved of its performance during the pandemic: the situation of educational institutions being closed during the first year of the pandemic, and even during the first half of 2021, was described as problematic. At the same time, our informants emphasized the attitude of teachers who confronted a lack of resources in schools and the demands generated by virtual learning. Interviewees also recognized the challenge of the digital divide. These concerns are well-founded, since half of the households in the San Miguel de Tucuman metro area withstood the challenge of virtual learning without having a computer, and 84% of households accessed the Internet via cell phones (Indec, 2020).",
"gender": "Female"
},
{
"age": 43,
"case_id": "PMC10481634_16",
"case_text": "They should also aim to improve education, teachers in the pandemic did their job as best they could, but they are also poorly paid and do not have the necessary resources to offer virtual classes, and in many student homes there is no possibility of connecting [online] to learn (Survey 135, female, 43 years old).",
"gender": "Female"
},
{
"age": 56,
"case_id": "PMC10481634_17",
"case_text": "The pandemic tested the creativity of teachers and parents to help children, but unfortunately, there were also inequalities in the right to receive an education. Only those who had a cell phone could learn ... (Survey 201, female, 56 years old).\nFinally, there was a low level of approval for political leaders, as only 22% (n=156) of survey respondents agreed that they were capable of leading and managing during the pandemic.\nIn sum, with the evolution of the pandemic and control measures, people made differentiated judgments about the sectors that comprise the State. Their evaluations show flexible ways of thinking and interpretation, identifying different determinants of State performance depending on the sector. The health sector - especially its human resources - was rated the highest, and political leadership, the lowest.\nDuring the first months of the pandemic, there was wide recognition of the State's leadership role, and the level of citizen satisfaction with the president and the national government was high; this positive perception of Argentine politics was evident in the high level of agreement and compliance with public health measures (Rodriguez Varela, Carbonetti, 2021; ). Employing paternalistic metaphors, political leaders represented the capacity needed to guarantee safety, establish the law, and enforce it ( ). This manifestation of trust and support for government measures is consistent with what has happened in many democratic societies, as the pandemic situation triggered feelings of national unity or solidarity (Hegewald, Schraff, 2022; ). Many studies indicate that specific events, involving threats or disasters on an international scale, lead to increased support for political leaders by citizens (Hegewald, Schraff, 2022).\nBy the time our study was carried out, the perception of political legitimacy had changed. As discussed in the previous section, in our quantitative analysis we found that only 22% of survey participants had a positive opinion of the government management of the pandemic.\nTo examine this outcome more closely, we compare attitudes between those who expressed support for the government's management and those who indicated indifference or dissatisfaction. As indicated in Figure 1 , there are significant differences between groups, and we found that those who objected to the government's actions were more likely to report adverse experiences during the pandemic, compared to people who supported the government. For example, more than 80% of the participants with a negative view of the government's management agreed with the statement, \"social and economic crises in Argentina affect me and do not allow me to make progress.\" Likewise, this group was significantly less likely to observe solidarity behaviors to help the most affected in their community, as compared to those who supported the government's actions. As far as collective perceptions, those who had negative views of the government expressed themselves negatively towards the statements \"the Argentine people are used to dealing with social and economic crises\" and \"in this pandemic situation, the Argentine people are moving forward.\"\nNext, we analyze the open-ended response to the survey related to lessons learned from the pandemic. As shown in Figure 2 , these statements were classified as expressing negative, neutral, or positive experiences or feelings. It is significant that 18% (n=71) of the people who expressed negative feelings alluded to politics, while among those who expressed positive feelings, politics was only barely mentioned, by only one person (2%). Statements with positive sentiments tended to mention family. In other words, those who shared positive aspects of the pandemic experience highlighted the formation or consolidation of ties with family members and with their social milieu (neighbors, friends, colleagues, etc.), while statements that express discontent are more likely to mention politics.\nAs the pandemic situation became normalized, this negative evaluation of the government is somewhat expected, given that citizens could develop more careful assessments of the government's performance as a mediator of interests and as decision-maker (Hegewald, Schraff, 2022). In the context of deep structural inequalities in our study area, government action generated a wide range of challenges - which include the restriction of social contact, the closure of businesses, the loss of income and/or employment, even the impossibility of guaranteeing food security and sustaining livelihoods - placing the concrete and direct personal costs of public health measures in tension with the more abstract and long-term notion of the public good.\nMoreover, participants in our study describe negative feelings of disappointment and distrust in response to well-publicized events in Argentina, in which officials violated regulations or allowed preferential access to vaccines. Among these situations, the celebration of the birthday of the First Lady in the Presidential Residence located in the town of Olivos (Buenos Aires province) during the first months of the Aspo (known as the \"Fiesta de Olivos\") and the \"vaccinations for VIPs\" - when officials and associates of politicians were given early access to vaccines, despite not being members of the prioritized groups - were repeatedly mentioned.\nOur interviewees mentioned the apathy of political leaders and the abandonment by the State. It is worth noting that these negative discourses on politics evoke feelings of mistrust and disappointment, as well as questions about policy decisions.",
"gender": "Female"
},
{
"age": 32,
"case_id": "PMC10481634_18",
"case_text": "For a long time and with the succession of different governments, we live in constant uncertainty, mainly [we are] talking about economic policies that affect our pocketbook. The pandemic exposes the lack of clarity of public, social, economic, health, cultural, education policies, etc., of this government. It leaves us with greater uncertainty than we are used to and feeling that it is increasingly difficult to believe, grow, and undertake projects in Argentina. As an entrepreneur and someone who is passionate about politics, I feel totally excluded from policies that would help independent people/entrepreneurs who do not receive any kind of benefits [from the state] (Survey 17, female, 32 years old).",
"gender": "Female"
},
{
"age": 29,
"case_id": "PMC10481634_19",
"case_text": "It seems to me that the government did not make appropriate decisions about [pandemic] restrictions. Because they made restrictions, on the one hand, but, nevertheless, today in political acts there were no restrictive measures in place ... in a political act they did not even consider the pandemic (Survey 12, female, 29 years old).",
"gender": "Female"
},
{
"age": 54,
"case_id": "PMC10481634_20",
"case_text": "The antipathy shown by political leaders, such as the party in Olivos and the vaccinations for VIPs, was very sad (Survey 56, female, 54 years old).",
"gender": "Female"
},
{
"age": 20,
"case_id": "PMC10481634_21",
"case_text": "I learned that the State only helps slackers ( vagos ) and politicians. And I learned that even though I may love Argentina, I have to leave as soon as possible (Survey 39, male, 20 years old).\nI could tell you how sad it was to go through those stages [of the pandemic] with the total abandonment by the State, people did not offer work and did not allow you to enter their homes for fear of contagion, on some occasions I STOLE to feed my children (Survey 90, male, 57 years; emphasis in the original).",
"gender": "Male"
},
{
"age": 47,
"case_id": "PMC10481634_22",
"case_text": "The worst experience was seeing how the current government sneered at us by stealing the vaccines, and at the same time they [political leaders] did everything that the people were forbidden to do... (Survey 199, male, 47 years old).\nAt that point in the pandemic, the idea of \"the public\" had become divided, politicians were no longer united with the people, and a general feeling of disappointment ensued in the face of violated trust. As suggest, breaking public trust has rapid consequences and is difficult to restore, as confirmed by similar events that occurred in other countries during the pandemic, revealing weak legitimacy in the exercise of a high-ranking positions in the management of public policy ( ). In this regard, analyzed the moral standards and civil norms that govern society in times of pandemic, and observed a shift from an individualized sense of compliance with the norms, towards loyalty and respect towards the community. While norms are determinants of social behavior, the transgression of the regulations in force during the pandemic by political leaders themselves, not only violated fundamental notions of care, but also showed disrespect towards the community. Our respondents show a deep ethic of social justice that calls into question the existence of different rules for citizens and political leaders.\nLike any other disease, cholera has in itself no meaning: it is only a microorganism. It acquires meaning and significance from its human context, from the ways in which it infiltrates the lives of the people, from the reactions it provokes, and from the manner in which it gives expression to cultural and political values ( , p.151).\nAs we proposed at the beginning of this article, the covid-19 crisis is a highly dynamic phenomenon that transcends framing as a public health crisis, as it has affected economic and social aspects of the daily life of individuals and communities. Through a grounded theory approach, this article has made it possible to elucidate feelings, experiences, practices, and actions that underlie the meanings attributed to the covid-19 pandemic in Tucuman (Argentina) during 2020-2021. This study provides testimonies and articulates interpretations on the role of the different actors that make up a community, articulating symbolic universes during the covid-19 pandemic.\nOur analysis, using mixed methods, explores and describes the way that individuals and communities have signified a particular period, when the pandemic had not ended but had somehow been integrated into daily life. In this sense, the results reveal a transition from an exceptional type of crisis (the pandemic) to a crisis - which we could describe as more typical in Argentina - of a political and economic nature.\nThe historiography of epidemics reveals ideas and ways of thinking particular to societies of a given historical moment, which configure specific symbolic frames. The intellectual and social responses to, and explanations of, epidemics take different forms in different social, cultural, and political contexts (Ranger, Slack, 1995).\nFrom this perspective, we propose an interesting dichotomy for analytical purposes, resulting from the analysis of the perspectives of participants in our study: we argue that two main symbolic frames organize meanings that our informants use to interpret the pandemic experience.\nOn the one hand, a \"personal\" symbolic frame, by which people, through deep reflection, have faced the crisis, finding meaning and managing to signify it through the assessment of their own lives, intimate ties, and the imperative to care for others. From this personal frame of introspection, people have discovered their resilience to face the pandemic: they have put their ingenuity, their ability to adapt, into play; they have actively sought to solve their own problems and collective ones, displaying a genuine willingness to help others and a collective outlook in the search for solutions to the problems and challenges posed by the pandemic.\nIn this search for meaning, religiosity or spirituality is theme that emerges from our discourse analysis, a topic that few studies on the social response to the pandemic in the Latin American context cover, and one that deserves future research.\nIn contrast, those who went through the pandemic with a \"political\" lens expressed negative feelings more frequently. They recognize the leading role of the State as a mediator of interests, but well-publicized events transpired in which politicians undermined the public trust. There is a strong ethic of social justice underlying this perspective, as people question the notion that rights and obligations of citizens are different from those who exercise political power, as exemplified by the so-called \"Vacunagate\" incident in Peru ( ) and the \"vaccinations for VIPs\" in Argentina.\nIn this regard, we suggest that those who expressed feelings of distrust or disappointment are more likely to apply this political framing to the lessons learned from the pandemic. In contrast, those who signified their experience from a personal frame tend to report better experiences of the pandemic.\nHowever, this analysis has certain limitations that are worthy of mention. On the one hand, our results correspond to a specific moment of the pandemic, which may be different from other stages of the pandemic. On the other hand, although we surveyed a mostly representative sample of participants, it is important to consider that digital resources and Internet service are less accessible for sectors with lower socioeconomic and educational levels. This could produce an underrepresentation of the most vulnerable groups in our data collection methodology carried out during the pandemic.\nStill, this study constitutes an original contribution that, through the grounded theory approach, makes visible discourses, perspectives, and subjectivities of social actors, an approach focused on the capacities and resources (material, emotional, affective, spiritual, social) put into action by people and communities to cope with the covid-19 pandemic. Likewise, we highlight as a scientific contribution the solid articulation of theoretical and empirical dialogues that shows experiences of the pandemic beyond a \"public health\" framing, in a transition stage from the acute phase towards what many viewed, at that moment, as a shift towards a \"new normal.\" In our opinion, the task of capturing the reflections and experiences of communities, that is, citizens aware of their duties and rights within a community in a pandemic emergency, constitutes an exercise that contributes to progress towards \"new emancipatory horizons\" for society ( ).",
"gender": "Male"
}
] |
PMC10481634
|
[
{
"age": 11,
"case_id": "PMC10905052_01",
"case_text": "An 11-year-old female presented for a follow-up of surgical repair of bilateral slipped capital femoral epiphysis done in an outside facility and was found to have a limited range of motion of her bilateral upper extremities on examination. The physical exam was otherwise unremarkable. Plain film imaging of the shoulders revealed skeletal abnormalities suggestive of a high parathyroid hormone (PTH) effect on the bones. Radiographs showed subchondral resorption of the ends of the clavicles and ribs and band lucencies of the proximal humeral metaphyses with secondary vara deformity and inferior subluxation of humeral heads (Figure 1). Radiographs did not demonstrate osteosclerosis or subperiosteal bone resorption, as would be expected in primary hyperparathyroidism. There was also no evidence of the Rugger-Jersey spine, which appears as alternating bands of lucency and sclerosis that give the spine a striped appearance, as seen in secondary hyperparathyroidism. Radiographic appearance favored the diagnosis of pseudohypoparathyroidism. The diagnosis was confirmed by hypocalcemia (8.9 mg/dL), hyperphosphatemia (7.1 mg/dL), and elevated intact PTH (860 pg/mL), as seen in Table 1. The patient was placed on a regimen of calcitriol, calcium acetate, and magnesium oxide to normalize the laboratory values prior to any surgical corrective intervention and to prevent further complications such as pathologic fracture, avascular necrosis, and secondary permanent limb deformities.",
"gender": "Female"
}
] |
PMC10905052
|
[
{
"age": 58,
"case_id": "PMC10742366_01",
"case_text": "A 58-year-old healthy male, with no prior medical history, underwent a routine preventive medical examination. A 12-lead electrocardiogram (ECG) was obtained and is shown in the Figure 1. He is an active recreational athlete, engaging in table tennis approximately three times a week for 90 min each session. He reported no symptoms or limitations in his daily activities before and at the time of the examination. The patient has a moderate risk of cardiovascular disease (CVD), with a 3-4% SCORE2 risk on the chart for countries at high CVD risk. His body mass index is within the normal range at 22 kg/m2, he is a non-smoker, and he has a negative family medical history regarding CVD.",
"gender": "Male"
}
] |
PMC10742366
|
[
{
"age": 48,
"case_id": "PMC10800761_01",
"case_text": "We present a case involving a 48-year-old man, with no past medical history of proctology problems, admitted to the Emergency Department with a painful protruding mass through the anal canal. The patient reported a sudden and spontaneous protrusion of this mass (Fig. 1) approximately six hours before seeking medical consultation. He had a history of constipation and had manually reduced several episodes of RP in the past. Physical examination revealed no abdominal distension, peritonitis, or other physical abnormalities. A proctology examination identified a strangulated RP with oedema and mucosal ulcerations measuring 20 cm in length and 8 cm in width. Despite attempts at external manual reduction and the application of salts, necrosis developed, prompting the decision to perform emergency surgery. The biological data results were normal. During the operation, the rectum was transected 1.5 cm above the dentate line with careful hemostasis (Fig. 2). Mesorectal and mesocolic vessels were ligated and divided using an energy device. The rectal wall and mesorectum were completely divided (Fig. 3). The colon was disinvaginated (Fig. 4) and transected, with approximately 30 cm of the sigmoid colon resected. A hand-sewn colo-anal anastomosis was performed using interrupted sutures (Fig. 5). Additionally, a protective ileostomy was created. The postoperative follow-up was uneventful, and the pathological examination of the operative specimen showed no abnormalities. The ileostomy was closed after six weeks, and the anal function was well established. No recurrence was observed after 8 months of follow-up.",
"gender": "Male"
}
] |
PMC10800761
|
[
{
"age": 40,
"case_id": "PMC11307018_01",
"case_text": "The patient was a 40-year-old woman. She became aware of a left breast mass in the last 8 months and consulted a breast surgeon. Mammography showed a dense, oval, finely serrated marginal mass with microcalcification in the left M-O segment (Fig. 1a). Ultra-sonography showed a 2.4 cm lobe-shaped tumor on the left C area (Fig. 1b), and swollen axillary lymph nodes measuring 13 mm and 11 mm were found in the left axilla (Fig. 1c). She underwent a core needle biopsy, which indicated the presence of invasive ductal carcinoma. Immunohistochemistry results indicated that she was estrogen receptor (ER)-positive, progesterone receptor (PgR)-positive, and human epidermal growth factor receptor 2 (HER2)-positive. Positron emission tomography-computed tomography (PET-CT) indicated left axillary lymph node metastasis (Fig. 1d). She was diagnosed with left breast cancer (C, T2N1M0, stage IIB). Neoadjuvant chemotherapy (NAC) with TCbHP (docetaxel + carboplatin + trastuzumab + pertuzumab) commenced. After one course, grade 2 stomatitis, general fatigue, and decreased appetite were observed. Moreover, following four courses, there was an aggravation of adverse events, notably headache, fever, recurrent oral aphthae, facial erythema, dysarthria, disturbance of consciousness, and left hemiplegia. Blood biochemistry revealed very high levels of C-reactive protein, but there were no other significant abnormalities (Table 1). She was thus hospitalized urgently for detailed examination and treatment. Fluid-attenuated inversion recovery MRI showed high intensity in the basal ganglia and marked compression of both ventricles (Fig. 2a). Although the cerebrospinal fluid (CSF) pressure and the CSF sugar/blood sugar ratio showed no abnormalities, mononuclear cell-dominant cell increase and elevated levels of protein and interleukin-6 were observed in the CSF (Table 2).\nShe was diagnosed with BD at 32 years of age and has been taking colchicine 1.0 mg/day since then with good control.\nShe has also been using prophylactic medication for asthma since childhood.\nMammography: A dense, oval, finely serrated marginal mass with microcalcification was found in the left M-O segment (Fig. 1a).\nUltra-sonography: A 1.5 x 1.6 x 2.4-cm lobe-shaped tumor shadow with an unclear border was observed on the left C area (Fig. 1b). Swollen axillary lymph nodes measuring 13 mm and 11 mm were found in the left axilla (Fig. 1c).\nPET-CT: Hyper-uptake, consistent with the mass in the left breast and left axillary lymph node (left breast: maximum standardized uptake value (SUV)max, 15.2, left axillary lymph node: SUVmax, 9.5). No obvious distant metastases were observed (Fig. 1d).\nHistopathological examination: Immunostaining revealed ER-positive (Allred score = 5 + 2), PgR-positive (Allred score = 4 + 3), and HER2-positive (with fluorescent in situ hybridization amplification) status, and Ki-67 index = 50%, indicating invasive ductal carcinoma.\nGlasgow Coma Scale: E3V1M6\nManual Muscle Test upper extremity: right 4/left 2; lower extremity: right 4/left 2.\nBlood biochemistry: C-reactive protein, 10.2 mg/dL (Table 1).\nFluid-attenuated inversion recovery MRI showed high intensity in the basal ganglia and marked compression of both ventricles (Fig. 2a).\nThe leukocyte count in the cerebrospinal fluid was 44.3/mm3, and mononuclear cell-dominant cell increase and elevated levels of protein and interleukin-6 were observed (Table 2).\nFrom the time of admission, steroid pulse therapy (SoluMedrol at 1000 mg/day administered as a drip for three days) was started. The stomatitis improved quickly after the start of the treatment. Next, the steroid was tapered off gradually, and the patient was able to communicate and walk. Two weeks after the start of the treatment, the brain MRI showed a reduction in the high-density areas of the bilateral basal ganglia and a reduction in the compression of the bilateral ventricles (Fig. 2b). A head MRI performed 3 months after the start of the treatment showed a further reduction in the high-density areas in the bilateral basal ganglia (Fig. 2c). Prednisolone 10 mg/day was administered perioperatively. One month after discharge, she underwent a left partial mastectomy and axillary lymph node dissection. A pathological examination of the resected specimens revealed the presence of residual invasive ductal carcinoma, but none of the resected axillary lymph nodes showed the presence of metastasis (n = 0/8). The therapeutic effect of preoperative chemotherapy was Grade 2b. Postoperative therapy with trastuzumab, pertuzumab, and tamoxifen was continued for 8 months. At the 2-year postoperative follow-up, there was no recurrence of breast cancer or NBD.",
"gender": "Female"
}
] |
PMC11307018
|
[
{
"age": 75,
"case_id": "PMC11002799_01",
"case_text": "A 75-year-old man with no prior medical history arrived at our emergency department, complaining of persistent pain in the right upper abdomen and fever for the past ten days. He reported no nausea, vomiting, or jaundice. Physical examination revealed stable vital signs, a body temperature of 40 C, and tenderness in the right upper abdomen. Laboratory tests indicated a white blood cell count of 29600/mm3, a C-reactive protein level of 182 mg/dL, and functional kidney insufficiency. An abdominal computed tomography (CT) scan revealed a low-density, multiloculated mass in the liver measuring over 15 cm at its largest point (Fig. 1, Fig. 2). Notably, a hyperdense linear structure, 3 cm in length, was observed adjacent to the upper part of the duodenum. The diagnosis was a hepatic abscess arising from duodenal perforation due to a foreign body that had been ingested and migrated to the liver. The patient received antibiotic treatment and underwent a median laparotomy procedure. The surgical intervention involved draining the abscess, extracting a foreign object resembling a fishbone, and suturing the perforation in the duodenum (Fig. 3), followed by extensive drainage in the affected area. The postoperative follow-up was uneventful. The patient was discharged from the hospital after eight days. He was seen at the postoperative clinic after three months and there was no recurrence. A post-operative CT scan was performed with no abnormalities.",
"gender": "Male"
}
] |
PMC11002799
|
[
{
"age": 78,
"case_id": "PMC11416986_01",
"case_text": "A 78-year-old man presented to our hospital with sudden onset chest and back pain. A CTA examination revealed a TBAD with multiple entry tears at zone 3 (Figures 1A,B). Both the true and false lumens were supplying blood to the superior mesenteric artery (Figure 1C). The left renal artery was supplied by the false lumen, while the right renal artery was supplied by the true lumen (Figure 1D). The patient had a history of hypertension and was regularly taking telmisartan for blood pressure control, although specific measurements were not recorded. Due to persistent chest pain, TEVAR was indicated.\nDuring the operation, the patient was placed in the supine position, and general anesthesia was administered. Access was obtained through the left femoral artery, and angiography confirmed the correct positioning of the guidewire in the \"true lumen\" of the aortic, with the intimal tear located 8 mm below the origin of the left subclavian artery (Figure 2A). A 36-28 200 mm Ankura II aortic stent-graft (Lifetech Scientific Co, Ltd, Shenzhen, China) was then deployed. However, subsequent angiography showed satisfactory blood flow in the arch arteries but a decrease in flow beyond the stent, with no visibility of the visceral arteries (Figure 2B). An intimal tear was observed at the T12 vertebra level (Figure 2C), suggesting possible misplacement of the stent graft into the false lumen.\nDue to the risk of false lumen rupture, an additional endograft was required to redirect blood flow to the true lumen. The right femoral artery was punctured, and a guidewire and a 6F guiding catheter were introduced. Angiography confirmed the position of the true lumen and visualized the left renal artery (Figure 2D). After multiple attempts, the guidewire was successfully navigated through the stent graft into the ascending aorta. A second 30-26 200 mm Ankura II aortic stent-graft was then implanted, with its distal end placed at the T12 vertebra level (Figure 2E). Follow-up angiography demonstrated restored flow in the true lumen, with the celiac trunk, superior mesenteric artery, and both renal arteries clearly visualized (Figure 2F). Postoperatively, the patient recovered successfully, with no reports of chest pain, renal failure, or paralysis, and was discharged in good health. A CTA at the one-month postoperative follow-up showed no endoleak or false lumen expansion, with satisfactory perfusion of the abdominal organs (Figure 3). Written informed consent was obtained for the publication of patient information and images.",
"gender": "Male"
}
] |
PMC11416986
|
[
{
"age": 84,
"case_id": "PMC10623418_01",
"case_text": "A 84-year-old woman was admitted for effort dyspnea (NYHA class II-III) in severe aortic stenosis (peak/mean gradient 107/61 mm Hg, aortic valve area 0.5 cm2) with high surgical risk (STS PROM 8%). Pre-operative computed tomography angiography showed the aortic valve and the sinotubular junction severely calcified, multiple protruding calcific nodules of ascending aorta, \"gothic\" aortic arch (AA) and multiple calcific stenosis of both iliac-femoral vessels, severely tortuous (Figures 1, 3-4, Supplementary Figure S1). We planned a transfemoral implantation of a 29 mm self-expandable Evolut R valve (Medtronic, Minneapolis, Minnesota, USA) under complete cerebral protection (CP) with TriGuard system and delivery advancement \"snaring-assisted\" (Figures 2, Supplementary Figures S3-S5). The placement of a CP system has been planned because the patient had a history of previous stroke, due to the presence of severe calcifications of the ascending aorta, of the sino-tubular junction and of the aortic valve (in addition of suspected calcific bridge between the left coronary cusp and the right coronary cusp) (Figures 3, 4). Based on the valve anatomy, the presence of very elliptical aortic annulus and LVOT and the huge calcifications of the sinotubular junction, we considered that the implantation of a self expanding valve was the most correct choice. The snaring procedure of self-expanding THV has been planned to anticipate traumatic contact with the aortic wall calcifications and to easier navigate with THV in the \"gotic\" and calcific AA (Figures 1, 3, Supplementary Figures S3-S5). The procedure required the management of 5 vascular accesses: 1 radial access + 2 femoral accesses + 2 ancillary femoral accesses (Figure 1, panels B-C). In order to guide the advancement of the transcatheter heart valve (THV) through the AA we preventively inserted a 20-mm AndraSnare catheter (Andramed, Reutlingen, Germany) from the contra-lateral femoral artery.\nThe THV was advanced on the snared guidewire, and the tip of the THV was ensnared and then pulled in order to be detached from the calcified wall of the ascending aorta, allowing the valve to be steered (\"Chaperoned\") through them moreover without any interference with the CP system (\"Top Hat\") (Figure 2) (Supplementary Movies S1-S4). There were no complications related to the snaring of THV, conversely the snaring maneuver has facilitated the \"atraumatic\" transit of the THV into the aortic arch. At the macroscopic analysis of cerebral protection device (Triguard) there were also present small debris of calcium (Supplementary Figure S2). Finally no complications related to the vascular accesses occurred. On the basis of our experience the risk-benefit balance of implementing cerebral protection with device (and specifically with Triguard) needs to be deeply evaluated because it requires a great care: (a) to avoid uncontrolled movement of the device once opened, (b) to avoid aggressive contacts with the aortic wall during complex maneuvers (c) the CP system requires a dedicated vascular femoral access (8F). To our knowledge, this is the first case of snaring-assisted TAVR under complete cerebral embolic protection with TriGuard system.",
"gender": "Female"
}
] |
PMC10623418
|
[
{
"age": 0,
"case_id": "PMC10825649_01",
"case_text": "A six-month-old female Japanese patient presented with thelache. Rapid growth acceleration was observed by the age of 2 yr (Fig. 1). At 2 yr and 11 mo, her bone age, determined via the Greulich-Pyle method (GP), was between four years and two months and five years. Using the Tanner-Whitehouse 2 method (TW2), her bone age was 4.8 yr. Her serum gonadotropin and E2 levels remained in the prepubertal (Table 1).\nShe was referred to our institution at the age of 3 yr and 8 mo with suspected precocious puberty. Physical examination revealed Tanner stage III breast, and Tanner stage I pubic hair development. Her height was 103 cm (+ 1.79 SD) and she weighed 15.9 kg (+ 0.93 SD). Her bone age was between 5 yr and 5 yr and 9 mo on GP, and 5.6 yr on TW2. No structural abnormalities were noted on magnetic resonance imaging of the head and pelvic ultrasound. On ECLIA (cobas e411 analyzer and ECLusys E2IV immune assay; Roche Diagnostics K.K., Tokyo, Japan), her serum E2 level was 128 pg/mL (reference interval for females aged 1-4 yr: < 5-21.9 pg/mL), her serum LH level was < 0.1 mIU/mL, and her FSH level was 0.8 mIU/mL. A gonadotropin-releasing hormone stimulation test revealed a pre-pubertal response to gonadotropins (peak LH and FSH levels 9.2 and 24.0 mIU/mL at 60 min after the injection, respectively). On LC-MS/MS, the E2 level of the same serum sample was 3.6 pg/mL. The same sample was retested on the same ECLIA analyzer and reagents, yielding an E2 level of < 5 pg/mL (Table 1). Quality control data were within the normal range, and serum levels of other hormones measured using the same analyzer were normal. The analyzer did not display any error messages. No abnormal substances that could've affected the E2 measurement were detected after wiping the surface of the cobas e411 analyzer.\nThe patient was diagnosed with premature thelarche with accelerated bone age. On follow-up, no further exacerbations of accelerated height or bone maturation were detected (Fig. 1). Her serum E2 level, measured using ECLIA, remained < 5 pg/mL (Table 1).\nOur patient showed high serum E2 level without suppression of serum gonadotropin levels after the GnRH stimulation test. Remeasuring the same serum sample using ECLIA or LC-MS/MS did not recapitulate the high E2 level. We speculate that the initial serum E2 level, measured using ECLIA, at 3 yr and 8 mo was falsely elevated.\nThis study was conducted in accordance with the ethical standards of the institutional and/or national research committee, the 1964 Declaration of Helsinki, and its later amendments or comparable ethical standards. Institutional Review Board approval was not required for this case report. Written informed consent was obtained from the parents of the patient.",
"gender": "Female"
}
] |
PMC10825649
|
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