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Your role is to provide a brief, accurate title of this medical case report
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A 60-year-old morbidly obese gentleman, a chronic smoker and alcohol drinker with a medical history significant for uncontrolled hypertension, type 2 diabetes mellitus with microvascular complications, stroke without residual weakness, and obstructive sleep apnea, presented to the emergency department with a three-day history of progressive severe headache. He described it as the worst headache of his life, involving the whole cranium and associated with mild blurriness of vision but without photophobia or any other focal neurological deficit.\nHe had cervical and lumbar spine decompression surgery and a renal transplant 11 years earlier, as well as stable renal graft function on immunosuppressant medications (prednisolone, tacrolimus, and mycophenolate).\nOn physical examination, the patient was having mild distress in a sitting position but was hemodynamically stable, afebrile with normal blood pressure, a pulse rate of 98/min, and a respiratory rate of 24/min on 3L/min nasal cannula maintaining oxygen saturation of 97%. His body mass index (BMI) was 42 kg/m2. He had mild bilateral pedal edema. We were unable to comment on jugular venous pulsations and heart sounds due to his thick short neck and chest wall, respectively. Neurological examination was unremarkable for any focal motor or sensory deficit and cranial nerve examination was normal. Fundoscopic examination of the optic disk was unremarkable for any papilledema.\nAn urgent computed tomography (CT) scan brain ruled out subarachnoid hemorrhage as shown in Figure . Magnetic resonance imaging (MRI) of the brain with contrast showed generalized volume loss of the brain as shown in Figure . Lumbar puncture was difficult to perform due to the history of metallic fixators in the lumbar spine region.\nAn electrocardiogram (ECG) showed low voltage sinus rhythm and no beat-to-beat variation. Chest x-ray showed mild left pleural effusion and cardiomegaly as seen in Figure . Echocardiography was performed which revealed a large pericardial effusion with features of tamponade that included a large circumferential pericardial effusion with respiratory variation greater than 25% and right ventricular compression during systole and diastole.\nThe patient was taken to the coronary care unit and underwent emergent pericardial drainage as described in Figure . Approximately 800 mL of hemorrhagic pericardial fluid was drained. The fluid analysis showed 750 /uL white blood cells with mainly 74% neutrophilic, 1% lymphocytes and 50,750 RBC/uL concluding it as a hemorrhagic pericardial effusion. Acid-fast bacilli (AFB) smear, tuberculosis (TB) polymerase chain reaction (PCR), fluid culture, and viral markers were negative from the pericardial fluid analysis. Vasculitis screening with antinuclear antibody (ANA) and antineutrophil cytoplasmic antibody (ANCA) was negative as well. The septic screen was also sent for the patient and his blood cultures did not grow any microorganism.\nThe patient’s headache was relieved after pericardiocentesis. His headache did not recur during his remaining length of hospital stay. However, his blood pressure started to shoot up to 180 - 220 mmHg systolic over 90 - 120 mmHg diastolic for which we resumed his home antihypertensive medications and it stabilized.\nA positron emission tomography/computed tomography (PET CT) scan did not detect any malignant focus with enhanced uptake. An MRI scan of the heart showed basal septal mid-wall myocardial enhancement of non-ischemic pattern, likely due to myocarditis or cardiomyopathy as shown in Figure .\nAfter ruling out secondary causes of hemorrhagic pericardial effusion, such as malignancy, autoimmune diseases, and TB, our patient was labeled as idiopathic myocarditis leading to chronic pericardial effusion based on MRI scan of the heart. We observed the patient in the hospital with a regular echocardiogram over 10 days. He was asymptomatic and discharged with regular follow-up in the cardiology clinic. Cardiologist outpatient follow-ups with repeated echocardiogram studies for a further five months did not show any fluid reaccumulation. The patient was followed for one year after discharge where he remained clinically stable.
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Cardiac Tamponade: An Unusual Cause of a Severe Headache with Normal Blood Pressure
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You are required to deliver a compact title of this case report, outlining the significant findings
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A 41-year-old man with Behçet's disease was referred to our outpatient clinic for treatment of CTO of the RCA ostium. He did not have any risk factors such as hypertension, diabetes, hyperlipidemia, and smoking. He had undergone a Bentall procedure for severe aortic regurgitation 10 years ago, and required reoperation on the aortic root replacement with Prima Plus 23 mm (Edwards Lifesciences, Irvine, CA, USA) and an ascending aortic graft insertion with Intergard 24 mm (Maquet, Wayne, NJ, USA) due to infective endocarditis 7 months prior. Two months earlier, he experienced rapidly worsening exertional angina and was evaluated at another hospital. Emergent coronary angiography showed a significant tubular lesion of the left main coronary artery (LMCA) ostium () and total occlusion of the RCA ostium (). Stent implantation in the LMCA was successfully performed, but catheter engagement into the RCA failed due to CTO of the RCA ostium. On admission, electrocardiography revealed abnormal Q waves over the inferior leads (), but cardiac magnetic resonance imaging showed no evidence of delayed enhancement. Echocardiography showed normal left ventricle systolic function and aortic valve function. Coronary angiography showed a patent LMCA stent and no disease in the left sided vasculature; however, the RCA ostium was totally occluded and collateral flow (grade 3) was supplied by the left coronary artery (). We first attempted to use a 6 Fr JR 4 guiding catheter (Cordis, Miami, FL, USA) for an antegrade approach, but were unable to penetrate into the RCA ostium. Subsequently, a 5 Fr XB 3.5 guiding catheter (Cordis, Miami, FL, USA) was used in a retrograde approach via the right radial artery. We chose the left circumflex artery (LCX) for the retrograde approach. A superselective tip injection of contrast using a Finecross™ microcatheter (Terumo, Tokyo, Japan) was performed, and a channel from the LCX to the posterolateral branch of the RCA was confirmed. A Runthrough™ NS (Terumo, Tokyo, Japan) with a microcatheter was retrogradely advanced into the distal RCA, and further advanced into the distal end of the occlusion () before penetrating the CTO lesion (). We then exchanged the Runthrough™ NS guidewire for a Fielder-FC™ 300 cm guidewire (Asahi Intecc, Aichi, Japan), which was subsequently snared into the ascending aorta () and pulled out of the sheath placed in the right femoral artery using a Multi-Snare® (PFM medical, CA, USA) (). The lesion was pre-dilated using a 2.0×20 mm Lacrosse balloon (Goodman, Nagoya, Japan) at 18 atmospheres. A 3.0×28 mm Nobori® stent (Terumo, Tokyo, Japan) was then placed successfully in the CTO lesion at 16 atmospheres. Final angiographic findings showed no residual stenosis or complications (). The medications of the previous hospital were maintained including colchicine 0.6 mg qd, azathioprine 50 mg qd, aspirin 100 mg qd, clopidogrel 75 mg qd, ramipril 5 mg qd, bisoprolol 5 mg qd, and atorvastatin 80 mg qd. He was referred back to the previous hospital.
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A Retrograde Approach to Coronary Ostial Stenosis after a Bentall Procedure in a Patient with Behçet's Disease
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Your role is to extract the core information from this case report
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A 63-year-old female with BMI = 43 Kg/m2 underwent an LRYGBP. Ten days after the operation, she presented a positive methylene blue swallow test, with methylene blue through the drain. She was treated with IV antibiotics with no systemic worsening. After three weeks, a gastrostomy was performed and the patient began enteral intake through the gastrostomy. Patient was discharged with the drain placed after 25 days. After two months, she presented with an epigastric pain and an endoscopy showed an acute ulcer due to eroding effect of the drain that was inside the gastric pouch. Drainage was moved into the abdominal cavity as in the other patient. Fistula debit decreased immediately and closed spontaneously.
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Endoscopic Management of Drain Inclusion in the Gastric Pouch after Gastrojejunal Leakage after Laparoscopic Roux-en-Y Gastric Bypass for the Treatment of Morbid Obesity (LRYGBP)
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You need to condense this case report into a succinct title
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A 54-year-old man presented to hospital with 1-month history of right groin pain, intermittent dysuria, and swelling. No gastrointestinal complaints or hematuria was present. Patient gave history of incomplete bladder evacuation, which relieved on manual compression of the hernia. No significant past or family history was present. On examination, right direct inguinal hernia was present, which reduced on manipulation. Computed tomography (CT) revealed a right inguinal hernia with fluid density lesion continuous with right lateral bladder wall [Figure and ]. Herniation of the bladder and continuity of the lesion with bladder wall was better demonstrated on sagittal and coronal reformatted images []. No bowel/omentum was contained in the hernia. Bilateral kidneys were normal. Diagnosis of right inguinal hernia with bladder as content was made.
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Bladder hernia: Multidetector computed tomography findings
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Please create a concise title of this case report, focusing on critical details
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A 33-year-old man presented with low-grade pain in the dorsal aspect of the right wrist for several months, without a history of trauma. This pain had been recurrent for the past 10 years, usually exacerbated by activities requiring wrist motion, such as racquet sports. Clinical examination demonstrated slight protuberance at the dorsal aspect of the wrist at the region of the dorsal 2nd and 3rd carpometacarpal joints without overlying skin changes. The normal range of motion was preserved. The provisional diagnosis was a dorsal wrist ganglion. Initial radiographs, however, suggested narrowing of the joint spaces at the 2nd and 3rd carpometacarpal joints and the trapezio-capitate joint with subtle sclerosis [], raising the suspicion of arthritis.\nAn MRI (Philips Ingenia 3.0T, The Netherlands) was performed for further assessment, which revealed a dorsal bony process at the quadrangular joint representing an os styloideum variant fused to the base of the 3rd metacarpal []. No ganglion cyst, a common finding in dorsal wrist pain and swelling, was evident. The fused os styloideum shared a non-osseous synchondrosis with the adjacent trapezoid bone at its dorsalulnar aspect [, left image]. It was also interesting to note that there was a partial osseous coalition at the dorsal aspect of the 2nd carpometacarpal joint between the 2nd metacarpal and the trapezoid [, middle image]. Degenerative osteophytic spurs developing at the dorsal aspect of the base of the 3rd metacarpal were observed and, in conjunction with the os styloideum variant at the dorsal aspect of the quadrangular joint, constituted the “carpal boss.” This was best appreciated on the sagittal scans []. The dorsal ligaments between the 2nd metacarpal, 3rd metacarpal, the capitate, and the trapezoid were not identified and soft tissue edema was noted at the dorsal quadrangular joint []. This may be related to deficient dorsal ligaments in association with the partial coalition as described by Alemohammad et al. or due to tears of the dorsal ligaments. There was also evidence of full-thickness cartilage loss at the quadrangular joint with subchondral marrow edema consistent with degenerative osteoarthritis [, right image], and an associated effusion in the midcarpal compartment. This probably accounted for the patient's wrist pain and limitation of wrist motion. Our patient responded to a 2-week trial of conservative therapy, and a follow-up clinic visit in 6 months did not reveal significant complaints or limitation of wrist activities.
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Carpal boss in chronic wrist pain and its association with partial osseous coalition and osteoarthritis - A case report with focus on MRI findings
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Summarize this medical case report, ensuring to cover the initial presentation
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A 74-year-old Ecuadorian man who smoked 3 cigarettes a day for a year but quit 15 years prior presented to the Emergency Department (ED) with four days of a productive cough that did not improve with azithromycin. His medical history included hypertension and cataracts. He worked at a clothing factory for years. The body mass index was 24.9 kg/m2. Physical examination showed a blood pressure of 154/86 mmHg, pulse of 115 beats/minute, respiration rate of 18/min, oxygen saturation of 95% on ambient air, and temperature of 101°F. Pulmonary auscultation on hospital admission revealed decreased bilateral breath sounds in the lower lung fields. A chest radiograph showed a large rounded opacity in the superior segment right lower lobe and bibasilar patchy infiltrate. The results of laboratory studies revealed a white blood cell count of 16,000/μl with 82.7% neutrophils and 8% lymphocytes, hemoglobin of 11.9 g/dl, and platelet count of 250,000/μl. Blood and urine cultures yielded no growth, and his acute symptoms of fever and cough subsided with ceftriaxone plus azithromycin. He was discharged home three days after admission. However, his productive cough recurred. More than a month later, computed tomography (CT) scan of the chest revealed multiple, approximately 16.4–28.6 mm, enlarged nodes in the mediastinum and hila, diffuse septal thickening, and multiple ill-defined patchy ground glass opacities with a lower lobe predominance (). On transthoracic echocardiography, the systolic pressure of the pulmonary artery was 33 mmHg with normal ejection fraction. The rheumatoid factor was negative, and the antinuclear antibody was positive at 1 : 80 with a homogeneous pattern. The patient was readmitted (2 months after the first episode) due to pleuritic chest pain and dyspnea on exertion. Radiography of the chest revealed bilateral prominent lung interstitial markings particularly in the left perihilar areas, and he was empirically covered for hospital-acquired pneumonia with vancomycin and piperacillin/tazobactam. More than a month later, his C-reactive protein (CRP) was <5 mg/l. He was lost to follow-up for five months but returned complaining of xerophthalmia, and artificial tears provided relief. He was again lost to follow-up for another five months and then noted to have weight loss of 25 pounds over 6 months. Follow-up chest CT findings more than a year after his initial admission included worsening septal thickening and ground glass opacities. Transbronchial lung biopsy demonstrated mild thickening of interstitial septae and increased infiltration by lymphocytes, macrophages, and plasma cells () consistent with LIP. No malignant cells were seen.\nThen, he developed bilateral metacarpophalangeal swelling and pain and swelling. To treat LIP, he was started on oral prednisone at a dose of 20 mg/day (0.25 mg/kg). His joint symptoms improved markedly. A laboratory workup was positive for the SSA antibody, and he was diagnosed with Sjögren's syndrome. His CRP was elevated (191 mg/l) and complement levels were low (C3 and C4, 40 mg/dl and 1 mg/dl, respectively). He tested negative for anti-SSB, anti-Jo-1, anti Scl-70, anti-neutrophil cytoplasmic, and anti-double-stranded DNA antibodies. Pulmonary function testing did not show obstructive dysfunction. His postbronchodilator forced expiratory volume in one second (FEV1) was 3 liters (126% predicted), total lung capacity (TLC) was 5.48 liters (104% predicted), and diffusion capacity for carbon monoxide (DLCO) was 17.8 ml/min/mmHg (82% predicted). The patient complained of dry mouth, which improved with pilocarpine. He was lost to follow-up for four months, during which time he discontinued prednisone after five months. Then, he developed anterior uveitis which was treated successfully with topical prednisolone acetate. A follow-up chest CT scan more than a year after oral prednisone was first started showed bibasilar and lingular interstitial fibrotic changes, decreased prominence of associated interlobular septal thickening and ground glass opacity, and a decrease in the size of the lymph nodes. Prednisone 20 mg/day was resumed and slowly tapered over three months. A month after prednisone was tapered to 10 mg, he presented to the ED with oral mucosal bleeding. His vital signs were unremarkable. Physical examination was significant for a bloody oral cavity, bruises on the right arm and legs, and scattered petechiae on the chest and lower legs. Laboratory tests were remarkable for a platelet count of 2000/μl. Peripheral smear did not show schistocytes. CT head was negative for acute hemorrhage. Further labs, including liver function, lactate dehydrogenase, and vitamin B12 levels, were normal. Hepatitis C antibody, hepatitis B surface antigen, and human immunodeficiency virus were negative. No obvious drug-related causes of thrombocytopenia were identified. Blood and urine cultures were negative. A diagnosis of ITP secondary to Sjögren's syndrome was made. A bone marrow biopsy was not done.\nThe patient was started on prednisone at 80 mg/day (1 mg/kg/d) and received a total of 12 units of platelet transfusion. He was given intravenous immunoglobulin (IVIG) at 1 g/kg/d for two days. His platelet count improved to 84,000/μl by the sixth day, and oral bleeding resolved. The patient was discharged home, but he was unable to continue the prednisone because the prescription was accidentally not transmitted to the pharmacy. After five days, he was readmitted with oral mucosal bleeding. The platelet count was found to be 3000/μl. He received IVIG at 1 g/kg/d and IV methylprednisolone 62.5 mg twice a day. By the fifth day, his platelet count was 178,000/μl. He was discharged on prednisone 80 mg/day, and it was uneventfully tapered off over four months. He was also started on hydroxychloroquine for musculoskeletal pain. His latest platelet count around six months after the last admission was 254,000 cells/μl.
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Atypical Sjögrenʼs Syndrome Initially Presenting as Lymphocytic Interstitial Pneumonitis followed by Immune Thrombocytopenia
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Your task is to provide an accurate and brief title of this case report
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In March 2009, a 2-year-old girl was admitted to our hospital with the chief complaint of fever and bloody diarrhea for more than 1 week, growth failure and severe perianal disease since infancy. The pregnancy and delivery were unremarkable, as was the family history. At 4 months of age, the patient developed recurrent perianal abscess, colovaginal fistula and recurrent bacterial enterocolitis, and required multiple surgical interventions. On examination, her weight and height were both below the 3rd percentile. Marked abdominal distention and perineal ulcers with poor-healing and pus-like discharge were noted. In addition, she had multiple oral ulcers and cutaneous folliculitis (Fig. ). Laboratory workup revealed anemia, leukocytosis, hypoalbuminemia, and a high C-reactive protein level. The immune work up showed normal numbers and function of lymphocytes and neutrophil granulocytes. The complements and serum immunoglobulin levels were within normal limits (data not shown). Abdominal X-ray discovered colon distention and her stool was positive for Clostridium difficile glutamate dehydrogenase antigen and toxin. Metronidazole was administered, and a diverting colostomy was performed to treat a presumptive diagnosis of pseudomembranous colitis with toxic megacolon. Pathologic finding revealed nonspecific chronic inflammation. Two weeks after the surgery, an ileostomy was performed to treat an obstruction of the proximal colon.\nIn the next 3 years, multiple attempts to close the ileostomy failed due to recurrent episodes of colitis complicated with perianal ulcerations. Eventually a total colectomy was performed and the histology revealed severe total colitis, basal lympholplasmacytosis without identifiable granuloma and transmural involvement, which were more consistent with ulcerative colitis (UC) (Fig. ). She was initially treated with corticosteroids and mesalazine, and ileal pouch-anal anastomosis was created. However, severe pouchitis, pouch (ano-perineal-vestibular) fistula and enterocutaneous fistula around the ileostomy developed, raising a concern for Crohn's disease (CD). At 8 years of age, the diagnosis of CD was supported based on a combination of imaging, the endoscopy and ileal histopathology (Fig. ). Treatment with adalimumab and azathioprine were initiated, and the patient's symptoms partially improved. She continued to have oral ulcers, but had adequate weight gain, and most of the enterocutaneous fistulas healed. Skin folliculitis also subsided. However, she continued to experience multiple exacerbations of her disease, requiring periodic short-term systemic steroid therapies and escalation of adalimumab maintenance dosage. Whole-exome sequencing (WES) identified a missense mutation in IL-10RA (p.Arg101Trp, c.C301T) in 1 allele, but no mutation could be found in the other allele. Functional testing of IL-10 signaling pathway (credited the laboratory in Milwaukee) revealed abnormal suppression of IL-6 secretion in response to lipopolysaccharide/IL-10 co-stimulated peripheral blood mononuclear cell. The result was consistent with an IL-10 receptor defect.\nThe patient is currently 12 years old, and continues to have poor growth. Her weight and height are 33.6 kg (18th percentile) and 128 cm (< 3rd percentile), respectively. Her disease remains active, evidenced by her recent endoscopic evaluation showing shallow ileal ulcers, indicating ongoing disease without remission. The patient is currently undergoing evaluation for hematopoietic stem cell transplantation (HSCT).
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Importance of early detection of infantile inflammatory bowel disease with defective IL-10 pathway
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As a medical summarizer, your job is to condense this case report into its key points
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A 50-year-old man presented to the ED after sudden onset of bilateral lower extremity weakness. The patient developed lower back pain and tingling in both lower extremities which progressed to complete paralysis within two hours after onset of the symptoms.\nHis medical history was significant for diet-controlled diabetes mellitus, systolic heart failure, hypertension, prior myocardial infarction, stroke, and prostate cancer. His medications included furosemide, digoxin, carvedilol, lisinopril, clopidogrel, and aspirin. He received hormonal therapy for his prostate cancer within the last year. His social history included 1 pack per day of cigarettes and a remote history of intravenous drug abuse.\nAt ED arrival, he was found to have a blood pressure of 127/47 mmHg (mean arterial pressure [MAP] of 74 mmHg). Upon physical exam, the patient was alert and oriented to self, time and place. Strength in lower extremities was 0/5 bilaterally, with no sensation from the distal one third of thigh and below bilaterally. Cardiovascular exam revealed regular rate and rhythm, S1, S2, and no pedal edema. However, femoral, dorsalis pedis and posterior tibialis pulses were absent bilaterally, in addition to poor rectal tone. There was mottling over the knees bilaterally, and they were cool to touch.\nLaboratory work-up revealed moderately elevated blood urea nitrogen (BUN) and creatinine, 50 and 2.5 mg/dL respectively, a creatine phosphokinase of 323 IU/L, a pH of 7.50 and a troponin of 0.7 mg/mL. Because of the physical exam findings of decreased perfusion and new onset renal failure, a serum lactate was ordered and found to be elevated to 5.6 mmol/L.\nThe history of prostate cancer led to the inclusion of acute spinal cord compression in the differential diagnosis. Consequently, contrast computed tomography (CT) of brain, thoracic and lumbar spine were ordered, all of which were unremarkable. Due to the absence of pulses in the lower extremities, additional CT angiogram was ordered, which showed a complete occlusion of the distal aorta below the inferior mesenteric artery, extending to the common iliac bifurcations (). To rule out a cardiac source for the thrombus, an echocardiogram was performed and showed an ejection fraction (EF) of 15 %, indicating severe systolic dysfunction. Clinical and laboratory evidence of global tissue hypoperfusion (shock) led to the conclusion that the patient was in need of intensive or invasive hemodynamic monitoring to guide his resuscitation.\nParalleling vascular surgery consultation, a central venous catheter was placed and a goal-directed hemodynamic optimization was performed before the necessary surgical intervention. This included optimization of preload, afterload and contractility to increase systemic oxygen delivery to meet demands and eradicate global tissue hypoperfusion. This was achieved with the use of the central venous pressure, (CVP), MAP, ScvO2 and clearance of lactate levels. During the 3 hours of ED stay prior to surgical intervention, Dobutamine was started at 2.5 mcg/kg/min and raised to 5 mcg/kg/min by the second hour. During this time, CVP decreased from 28 to12 cmH2O and ScvO2 increased from 48 to 74 %, while lactate levels decreased from 5.2 to 1.0 mmol/L. During this period MAP was maintained between 75–88 mmHg, and the heart rate ranged from 72 to 81 beats per minute. These findings indicated the initial presence of global tissue hypoxia and its resolution during the goal-directed resuscitation. Severe global tissue hypoxia was present with normal vital signs.\nAfter improvement in hemodynamic status, he underwent an open aorto-ilaic embolectomy and bilateral lower extremity 4-compartment fasciotomies to prevent the expected reperfusion injury and compartment syndrome. The patient was transferred to the surgical intensive care unit after the procedure for continued monitoring, resuscitation and systemic anticoagulation with heparin.\nHe continued to improve post-operatively and was discharged on anticoagulation. At follow-up evaluation in the vascular surgery clinic, 13 days after hospital discharge, the patient reported full return of lower extremity sensation and was able to ambulate without assistance.
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“I Can’t Walk!” Acute Thrombosis of Descending Aorta Causing Paraplegia
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As a clinical title specialist, your goal is to synthesize the key elements of this case report
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The fifth case was of a 52-year-old woman who presented with pseudoexfoliation syndrome and capsular contraction during the first month after surgery, in a hypermetropic eye with amblyopia. The contraction pushed back the lens (Lentis LS-313Y®), causing intolerable hypermetropia.
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A new device for intraocular lenses explantation
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Your role is to extract the core information from this case report
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A 40-year-old male was referred to our institution one month after he felt numbness and pain in his right hand. He engaged in hard manual labor for the past five years, which involved loading/unloading of about 500 parcels of 10 kg weight every day. Physical examinations showed hyperesthesia and pain in the median nerve area. On active flexion of the index and middle fingers, a convex shape was observed at the carpal area with snapping, which exaggerated the symptoms. Evident thenar muscle atrophy was not observed. Tinel's sign, Phalen's test, and fist test results were positive. Plain radiographs of the wrist showed no abnormalities. Magnetic resonance imaging revealed edematous lumbrical muscle with synovial proliferation around the flexor tendons (). The median nerve was compressed between the transverse carpal ligament and the edematous muscle and synovial tissue (). Motor nerve conduction studies of the median nerve revealed evident prolonged distal latency. Sensory nerve conduction studies showed prolonged latency and delayed conduction velocity. Needle EMG (electromyography) showed no denervation potentials at rest. On voluntary contraction, there was no positive sharp wave but a few polyphasic motor units were detected. These findings were compatible to moderate neurophysiological CTS grading according to Stevens' classification [].\nThus, open carpal tunnel release was performed under local anesthesia. Synovial proliferation of the flexor tendons was found. The median nerve showed no evident abnormality. On flexing the index and middle fingers, the lumbrical muscle was drawn into the carpal tunnel with a triggering phenomenon at the distal edge of the flexor retinaculum, and the muscle belly occupied the tunnel and compressed the flexor tendons with the medial nerve (). On extending the fingers, the lumbrical muscle moved distally and disappeared from the tunnel (). After completely releasing the transverse carpal ligament proximally and distally, partial synovectomy around the flexor tendons, it was confirmed that the wrist triggering phenomenon did not happen. Then, lumbrical muscle belly was not resected. Histopathologically, the resected synovium mainly consisted of dense reactive inflammatory proliferation of fibrous tissue ().\nThe triggering phenomenon at the wrist and painful numbness disappeared immediately after the operation. The Disabilities of the Arm, Shoulder, and Hand score improved postoperatively (Disability/Symptom, 69.2, work, 100 before operation; Disability/Symptom, 1.67, work, 0 at three months after the operation). There has been no recurrence of the symptoms two years after the operation.
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Carpal Tunnel Syndrome with Wrist Trigger Caused by Hypertrophied Lumbrical Muscle and Tenosynovitis
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Your task is to provide an accurate and brief title of this case report
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We present a male case of a 14 yr old 2016 met at Legal Medicine Bihor County Service, Romania who bought an energy drink and while he was consuming it, he was feeling sick and felt down on the ground. He was resuscitated for about 1 hour, but unfortunately, he was declared dead. After we discussed with his family, he felt ill for two weeks, accusing chest pain, drowsiness, fatigue, productive cough and low-grade fever treated withtylenol and aspirin. He was at attending physician the day before his death and he was given tylenol and aspirin because he was diagnosed as having flu. No complementary examination like complete blood count or imaging exams (computed tomography) was made.\nWe followed the human subjects’ procedure, established by our institution. The research was conducted with the rules of good conduct in scientific research. The identity of the participant in the research is confidential when the results of this study are published. Informed consent was taken from the relatives of the patient.\nExternal exam of the corpse did not reveal any violent lesions neither pathological.\nExamination of the oral cavity showed normal dentition, but the gums corresponding to the teeth 1, 1, 1, 2.1, 3, 2.1, 2.2 were red and swollen, specific for gingivitis. There was no visible sign of illness at the level of head and neck so we could exclude the orocervicofacial form of this disease.\nMacroscopic the lungs were described as pneumonia, emphysema and pulmonary edema; the entire myocardium looked like myocarditis () and on the posterior wall of the left ventricle was an area with cardiosclerosis () which made us think that it could be a scar from a myocardial infarction.\nInside the bronchi from the lungs inflammatory granulomas with A. israelii (not stained periodic acid Schiff-PAS negatively) were visible (). In myocardium bacterial colonies, microabscesses, diffuse cardiosclerosis, myocytes with necrosis and polymorphonuclear cells were visible (). Therefore microscopic exam revealed acute myocardial infarction, heart failure, myocardosclerosis, chronic myocarditis and into the lungs infection with A. israelii.\nCorroborating the clinical features, autopsy findings and complementary examinations it was established that this sudden death was caused by an acute myocardial infarction as a result of chronic myocarditis and pulmonary pneumonia with A. israelii.
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Sudden Death of a Teenager Caused by Actinomyces israelii: A Case Report
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You need to condense this case report into a succinct title
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A 51-year-old female visited our clinics due to bilateral plantar heel pain of visual analogue scale (VAS) 10 and limping gait, which was worse with activity and/or upon arising in the morning. She had no previous medical history including feet infection, pedal ulcerations and peripheral vascular disease except plantar fasciitis. She had been previously treated in many local clinics with steroid injection over 50 times and extracorporeal shock-wave therapy over 20 times with the impression of plantar fasciitis for 3 years prior. On physical examination, she had no systemic symptoms and no cushingoid appearance. She experienced a sensation of mild heat, swelling and tenderness of right medial calcaneal tuberosity () with localized tenderness in the bilateral medial plantar heel area. The calcaneal squeezing test was positive in right calcaneus. Ultrasonography showed thickened plantar fascia of both feet and hypoechoic lesions with fat pad atrophy. The plantar aspect of right calcaneus showed cortical irregularity and hypoechoic swelling with edematous change in the surrounding soft tissues (, ). Subsequent magnetic resonance imaging (MRI) revealed cortical destruction at the right medial calcaneal tuberosity, which presented as diffuse osteomyelitis (, ). Laboratory examination showed a white blood cell count of 6,800/mm3 (69.2% polymorphonuclear leukocytes, 20.9% lymphocytes, and 6.6% monocytes), an erythrocyte sedimentation rate of 20 mm/hr, and C-reactive protein level of 0.33 mg/L. The blood cultures showed no growth and administration of broad-spectrum intravenous antibiotics was initiated. Subsequently, she was referred to the department of orthopedic surgery and required partial calcanectomy. The operation site was packed with geneX bone graft substitute (calcium sulfate absorbable beads impregnated with vancomycin and tobramycin) that was removed 14 days after implantation (). Culture of intra-operative bone specimen showed no bacterial growth. Histology showed granulomatous inflammation with multinucleated giant cells (). Microbiological tissue cultures including pyogenic bacteria and acid-fast bacilli remained negative. Analyses of DNA extracted from tissue specimens were positive for NTM on polymerase chain reaction. However, the chest computed tomography, abdominal-pelvic computed tomography, and endoscopic biopsy were negative for primary tuberculosis. Serology for human immunodeficiency virus (HIV), cellular and humoral immunity showed no evidence of immunodeficiency. Sequence analyses of the interferon-γ receptor (IFNGR) gene indicated no mutation of the INF receptor. The patient was started on 5-drugs (cefoxitin, amikacin, azithromycin, INH, rifampicin) for 1 month followed by azithromycin for the next 11 months. Her gait gradually advanced from toe-touch weight-bearing to weight-bearing as tolerated.\nSix months after surgery, a follow-up MRI showed relative well-marginated osteolytic lesion with thick peripheral rim enhancement of right calcaneus posterior portion, which is suggestive of chronic osteomyelitis with abscess formation (). In consultation with the departments of osteosurgery and infectious diseases, we decided to continue antimicrobial therapy without further surgical intervention, since infection sign was not observed and her plantar heel pain was improved (VAS reductions >80%). In addition, she received comprehensive management including lifestyle modification, and heel cushion for treatment of plantar fasciitis.\nAt the 18-month follow-up, the patient had no pain and the radiograph showed remineralization of bones with sclerosis of joint margins (). She could ambulate normally in regular shoes with full restoration of symptoms. Furthermore, after comprehensive rehabilitation therapy, she could carry out her daily activities without any discomfort.
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Calcaneal Osteomyelitis due to Non-tuberculous Mycobacteria: A Case Report
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Your task is to summarize this medical case report into a title
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A 25-year-old male with a long history of drug abuse attended a gathering of friends. He drank alcohol and smoked e-liquid and K powder at the party. During this period, he suddenly experienced shock, convulsions and tachycardia. This individual was seen by a doctor soon after and recovered without sequelae. The police found a large amount of e-liquid and K powder at the scene. According to the existing method of our forensic toxicology laboratory, the concentration of K powder in the hair was qualitatively and quantitatively determined to be 200 pg/mg (Zhuo et al., ). The concentrations of 5F-MDMB-PICA detected in the 1–3 and 4–6 cm hair sections were 275 and 1,025 pg/mg, respectively. The concentration of metabolite M7 was 2.8 pg/mg in the 1–3 cm hair section, and the concentrations of M2 and M8 were both lower than the LLOQ. In addition, the concentrations of metabolites M2 and M7 were detected in the 4–6 cm hair section at 3.0 and 5.6 pg/mg, respectively, and the concentrations of the remaining metabolites were lower than the LLOQ.
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Detection of a New Tert-Leucinate Synthetic Cannabinoid 5F-MDMB-PICA and Its Metabolites in Human Hair: Application to Authentic Cases
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You are required to deliver a compact title of this case report, outlining the significant findings
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A 29-year-old woman was admitted to the hospital with abdominal pain and bloody diarrhea. She was previously healthy and had no specific past medical history. Stool culture was performed and she received intravenous hydration. On hospital day 2, her urine volume decreased, and generalized edema developed. She was transferred to Chonnam National University Hospital (CNUH). Upon admission her blood pressure was 120/70 mmHg, pulse rate was 72/min, respiration rate was 32/min, and body temperature was 36.6℃. The abdomen was slightly tender but not distended. Laboratory tests showed a serum creatinine of 4.2 mg/dL, blood urea nitrogen of 35.4 mg/dL, hemoglobin 9.2 g/dL, platelet count 19,000/mm3, corrected reticulocyte count 5.4%, lactate dehydrogenase 3150 IU/L, haptoglobin 7.69 mg/dL, total bilirubin 1.31 mg/dL, and direct bilirubin 0.19 mg/dL. Peripheral blood smear showed microangiopathic hemolytic anemia (). A diagnosis of HUS was made based on the occurrence of acute renal failure, hemolytic anemia, and thrombocytopenia. Escherichia coli O104:H4 was identified in the stool culture performed at the hospital where she was first admitted by using polymerase chain reaction for virulence-associated genes of EHEC, but other EHEC related serogroups including Escherichia coli O157:H7 were not found at Chonnam Institute of Health and Environment. She received hemodialysis for four days, and plasma exchange and fresh frozen plasma for two weeks. On hospital day 14, tonic seizure occurred suddenly but was not presented until the following day. The brain computed tomography (CT) and electroencephalogram (EEG) did not show any abnormalities. On hospital day 20, her platelet count rose to 299,000/mm3, hemoglobin rose to 10.6 g/dL, reticulocyte count dropped to 1.5%, lactate dehydrogenase dropped to 507 IU/L, and blood urea nitrogen and serum creatinine fell to 17.5 mg/dL and 1.0 mg/ dL, respectively. Peripheral blood smear did not show evidence of hemolytic anemia. After hospital day 21, two successive stool specimens yielded negative results for Escherichia coli O104:H4. On hospital day 27, she was discharged and received follow-up care as an outpatient.
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A Case of Hemolytic Uremic Syndrome Caused by Escherichia coli O104:H4
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Your objective is to distill this medical case report into a succinct title
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An 87-year-old Caucasian male was referred to our centre by a dermatologist, having undergone punch biopsy of a penile lesion with the initial histology reported as showing Bowen's disease. The patient gave a 6-month history of an enlarging lesion on the shaft of his penis prior to presentation to the dermatologist, which had been treated with topical agents and antibiotics. Nevertheless, the dermatologist was clinically suspicious of an invasive lesion prompting referral for wide excision. The patient had had a similar lesion at the same location 10 years earlier which was excised by his general practitioner but no histology report could be traced. He had no other lumps anywhere in the rest of the body and no family history of similar disease. His co-morbidities included ischaemic heart disease, Alzheimer's disease and venous ulcers.\nExamination revealed a 2.5 cm erythematous, fleshy, exophytic plaque at the base of the shaft of the penis (Figure ). There was a satellite lesion proximal to this. The patient had no palpable inguinal lymphadenopathy. A clinical suspicion of an invasive squamous cell carcinoma was made and the patient underwent a wide local excision of the penile and satellite lesions. Frozen-section examination was not performed. The scrotal skin was advanced and primary closure performed. The foreskin was retracted in order to achieve a tension-free closure.\nThe specimen measured 30 × 50 × 50 mm. Light microscopy showed intraepithelial proliferation of neoplastic; large, pale cells, located predominantly in the basal and parabasal layers of the epithelium (Figure ), with margins apparently clear. Immunohistochemical stains showed specific staining characteristics with strong positivity for epithelial membrane antigen (EMA), the cytokeratin (CK) CK7, CAM 5.6 and HER2 protein over expression. CK20 staining was negative. These immunohistochemical appearances supported the histological diagnosis of EMPD (Figure ). Immunohistochemical staining also revealed that there were occasional cells in proximity to the margins.\nThis patient's histology was discussed at our weekly multi-disciplinary cancer meeting and the consensus was not to screen for an underlying non-cutaneous malignancy in view of the patient's age and co-morbidities. Furthermore, a decision was made not to attempt wider excision. At 6-months follow-up, our patient had no local recurrence or palpable inguinal lymph nodes.
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Extramammary Paget's disease of the penis: a case report and review of the literature
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Your job is to distill the important information into a title from this case report
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A 63 year old woman presented with a three year history of a painless growing mass in the groin and increasing pain in her left leg during the last year. Magnetic resonance imaging (MRI) showed a lesion measuring 11 × 7 × 7 cm. near the left hip affecting the quadriceps. The lesion was suggestive of a soft tissue sarcoma. Total body scan revealed no distant metastasis. Excisional biopsy was done, resulting in a low-grade fusocellular tumor with hemangiopericytic pattern.\nSurgical treatment was carried out and the whole tumor was submitted for histopathological study. The patient was treated with radiotherapy (63 Gy). Control MRI, six months after radiotherapy, showed no lesions.\nGrossly the tumor appeared as an encapsulated, tan-grey mass measuring 10 × 4 × 3 cm. At cut section the tumor was pseudolobulated, with small hemorrhagic foci, and yellow necrosis. No differences in color and consistence were found between lobules.\nMicroscopically, the tumor was composed of a proliferation of fusocelular cells with haphazardly distribution and varying degrees of stromal collagenization. The cellularity greatly varied in different areas with a predominance of hypercellular areas. Medium-sized thin-walled blood vessels in a hemangiopericytic growth pattern were observed, being more evident in hypercellular areas at the periphery of the lobules. Highly cellular spindle cell areas resembled fibrosarcoma and very occasionally multinucleated cells were seen. Mitosis were spare (≤ 2 mitosis in 10 HPF) but foci of coagulative necrosis existed.\nAt the periphery of the tumor and close to hipercellular areas we found three isolated and fairly well demarcated nodules each one measuring 12–15 mm, where cells adopted an epithelioid morphology with round, vesicular nuclei with micro nucleoli and abundant eosinophilic cytoplasm. These cells were mainly arranged in solid sheets but nests, pseudoglandular, or cleft patterns were also present. Focally artifactual shrinkage produced pseudovascular spaces. In these areas pleomorphism was moderate. No fusocellular cells were seen. Mitosis score was more than 10 in 10 HPF, some of them abnormal, and foci of necrosis were observed. A thin band of collagen isolated these epithelioid nodules from the fusocelular rich areas except in one of the nodules which both epithelioid and spindle areas merged in indistinct transition.\nCells from fusocelular and epithelioid areas showed the same immunophenotype expression: vimentin +, CD34 +, CD99 +, and bcl2 +, being completely negative for epithelial, neural and muscular markers. Ki67 immunolabeling was low in fusocellular areas (< 5%) and rather high (> 40%) in epithelioid ones. (All antibodies from Dako)\nPolymerase chain reaction (PCR) for presence of a SYT-SSX1 or SYT-SSX2 fussion transcript [] proved negative.
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Solitary fibrous tumor of the thigh with epithelioid features: a case report
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You are tasked with extracting and summarizing the essential information from this case report
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The patient is a 28-year-old woman with tetralogy of Fallot, pulmonary artery atresia, and major aortopulmonary collateral arteries (MAPCAs) and a right aortic arch. She underwent attempted pulmonary artery unifocalization as a young child but did not tolerate this physiology and required urgent reoperation with unifocalization takedown and reanastomosis of a large aortopulmonary collateral to the mid thoracic descending aorta in the early postoperative period. When she was 9-year-old, she underwent surgical placement of a modified Blalock–Taussig shunt from the left subclavian artery to a hypoplastic pulmonary artery confluence for worsening cyanosis. Since that time, she has remained cyanotic and over the past 10 years developed progressive systemic hypertension in the upper extremities. On a recent clinic evaluation, she was noted to have severe hypoxemia (oxygen saturation 62% on room air), upper extremity hypertension (systolic blood pressure [SBP] 150 mmHg) with a 40 mmHg gradient to the lower extremities, and significantly decreased left ventricular systolic function (ejection fraction [EF] 30%). A cardiac computed tomography (CT) scan revealed a 6 cm long calcified, narrowed segment in the descending thoracic aorta in the region of previous aortic surgical intervention (attempted collateral unifocalization and subsequent takedown) with the caliber decreased to 9 mm (proximal descending aortic diameter 18 mm). Importantly, a large MAPCA arose off the middle of this segment to supply the right lung [Figure and ]. A surgical shunt was stenotic and supplied a markedly hypoplastic right branch pulmonary artery (<3 mm diameter) and there was no central left pulmonary artery, making complete repair unattainable at this point. She had poor activity tolerance and was in New York Heart Association (NYHA) Class III–IV heart failure. While her systemic hypertension likely provided some improvement in pulmonary artery flow, the distal stenoses clearly limited this effect. Further, it was felt that her systemic hypertension, combined with severe chronic cyanosis, was contrinuting to decrease left ventricular systolic function, and if the systemic and pulmonary artery obstructions could be relieved, she would have clinical improvement. Given her overall condition, she was not felt to be an appropriate surgical candidate, so percutaneous intervention was planned.\nUnder general anesthesia, hemodynamics revealed a 35 mmHg peak gradient from the transverse aortic arch to the abdominal aorta. Aortic angiography showed the anatomy as before and confirmed the MAPCA supplying the right lung arising off the midportion of the narrowed segment []. Given the long narrowing and calcified aorta, stent therapy was felt to be the optimal intervention over angioplasty alone. However, because of the concern for obstructing any flow through the MAPCA and worsening her cyanosis, covered stents were not felt to be appropriate. Three IntraStent® Max™ LD stents (eV3, Inc., Plymouth, MN, USA) were deployed on 14 mm balloons in telescoped fashion. These were then postdilated with a 15 mm Z-Med II balloon (B. Braun Interventional Systems Inc., Bethlehem, PA, USA) and a 16 mm Atlas balloon (Bard Peripheral Vascular, Tempe, AZ, USA) with a marked improvement in vessel caliber and complete elimination of the gradient []. The surgical shunt and hypoplastic right pulmonary artery were both stented with improved vessel caliber. The procedure was tolerated well and she recovered without incident.\nOn 2-year follow-up, her oxygen saturation improved to 80%, she had only mild systemic hypertension (SBP 138 mmHg) with a 10 mmHg gradient to the lower extremities, left ventricular EF had improved to 60%, and her NYHA decreased to II–III. A cardiac CT showed continued patency of the aortic stents with no aneurysms and no obstruction of flow to the MAPCA [Figure and ].
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Percutaneous management of complex acquired aortic coarctation in an adult with tetralogy of Fallot and pulmonary atresia
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Your task is to provide a clear and precise title of this case report
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A 40-year-old Caucasian female presented to the emergency department with diffuse abdominal pain, nausea, emesis, and bloating for the previous 24 hours. She denied any pruritus or rash. She had been to a different ED two days prior with chest pain, abdominal pain, and nausea. An unremarkable cardiac work-up was performed, and the patient was discharged in stable condition. Her medical history included irritable bowel syndrome and newly diagnosed hypertension. Her daily medications included lisinopril 20 mg daily, which she had begun taking 3 days prior, and an oral contraceptive. Vital signs were unremarkable, and she was afebrile. On physical exam, no oropharyngeal or facial swelling was noted. There was moderate generalized abdominal tenderness without rebound, guarding, or rigidity. The remainder of her exam, including her skin, was unremarkable. Her complete blood count showed a mild leukocytosis of 13,000, but all other labs including electrolytes, liver functions, urinalysis, lipase, lactic acid, and troponin were unremarkable. EKG and chest X-ray were both within normal limits. The patient was given intravenous (IV) fluids and hydromorphone for pain. She continued to have diffuse abdominal pain and tenderness. A computed tomography scan of the abdomen with oral and IV contrast was obtained, which revealed a moderate amount of ascites with diffuse wall thickening, hyperenhancement, and mucosal edema of the entire small bowel (Figures and ). Angioedema of the small intestine due to ACE-inhibitor use was the primary differential. The patient was admitted for observation and further evaluation. Lisinopril was discontinued. Gastroenterology was consulted and agreed with the diagnosis and management. The patient's symptoms gradually resolved with supportive care after discontinuation of the lisinopril. A hereditary angioedema work-up was performed which showed normal complement and C1 esterase inhibitor levels. The patient was discharged one day later, and a repeat computed tomography scan performed one week later demonstrated complete resolution of her visceral angioedema and near complete resolution of the ascites.
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ACE Inhibitor Induced Isolated Angioedema of the Small Bowel: A Rare Complication of a Common Medication
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Summarize this medical case report, ensuring to cover the initial presentation
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A retired 77-year-old Caribbean woman presented to the emergency department with general fatigue and lower extremity weakness. She is known for type II diabetes mellitus, hypertension, and a recent episode of small bowel obstruction that had resolved without surgery.\nOn examination, she had a bilateral severe axonal sensory and motor polyneuropathy (confirmed by nerve conduction studies and electromyography) which was manifested by severe bilateral lower extremity weakness. She also had diffuse anasarca. She did not have any skin findings nor any ophthalmologic symptoms.\nShe had a previously normal creatinine of 70 μmol/L (0.79 mg/dL), but on admission was found to have an acute kidney injury with a serum creatinine of 122 μmol/L (1.38 mg/dL). The creatinine peaked over 3 weeks to 231 μmol/L (2.61 mg/dL) (Table ). This was associated with a decreasing albumin and increasing urine protein (Table ). Urinalysis showed significant proteinuria and hematuria and urine microscopy showed active sediments including dysmorphic erythrocytes. Urine eosinophils were positive twice. A serological panel, which included cytoplasmic and perinuclear anti-neutrophilic antibodies anti-cytoplasmic (p-ANCA and c-ANCA), complement (C3 and C4), anti-nuclear antibodies (ANA), hepatitis B, hepatitis C and human immunodeficiency virus (HIV) serologies were all negative (Table ). Rheumatoid factor (RF), C-reactive protein (CRP) and the immunoglobulin profile (IMM) were consistent with inflammation. Both the urine protein electrophoresis and the serum protein electrophoresis were normal. Given the neurological symptoms and impressive proteinuria, a Venereal Disease Research Laboratory (VDRL) and Treponema pallidum particle agglutination test (TP-PA) were requested and both were positive. A peripheral electromyography (EMG) with nerve conduction studies, was also consistent with syphilis-induced neuropathy. The patient declined a lumbar puncture to confirm neurosyphilis and confirmed she had never been diagnosed with nor specifically been treated for syphilis before.\nWhile waiting for the serological testing, a kidney biopsy was performed due to the increasing creatinine with an active urine sediment. The biopsy showed crescentic and necrotizing glomerulonephritis in 9/23 glomeruli (Fig. a). Some of the crescentic glomeruli even showed Bowman’s capsule rupture. Numerous plasma cells surrounded the crescentic glomeruli and some of the small blood vessels. There was also concomitant acute tubulo-interstitial nephritis with abundant plasma cells and occasional eosinophils (Figs. and ). The plasma cells showed an increased proportion (50%) of IgG-4 versus IgG (Fig. ). There was moderate interstitial fibrosis and tubular atrophy as well as moderate atherosclerosis. No granulomatous inflammation was identified. Glomerular basement spikes or vacuolization were not found. No Treponema pallidum were found by immunohistochemistry and there was no evidence for monoclonality by kappa/lambda in situ hybridization. Immunofluorescence showed only minimal focal non-specific C3 mesangial staining (1+) and fibrinogen positive crescents (3+). IgA, IgG, IgM, C1q, kappa and lambda immunofluorescence were negative. Electron microscopy did not show any significant electron dense deposits in any of the glomerular compartments (Fig. c).\nOverall, the case was diagnosed as a pauci-immune crescentic glomerulonephritis with a concomitant acute tubulointerstitial nephritis. This was combined with atypical perivascular and periglomerular nonclonal, but significantly positive IgG-4 plasma cells infiltrates. The histological differential diagnosis would include a pauci-immune vasculitis, an atypical post-infectious glomerulonephritis, a secondary drug reaction or inflammatory reaction. Background vascular findings were attributed to the patient’s diabetes type 2 and hypertension. Our biopsy findings being similar to Nandikanti et al. [] and given the clinical context, this presentation was most likely due to syphilitic infection. Absence of hypocomplementemia and of other organ involvement (thoraco-abdominal and pelvic computerized tomography showed no abnormalities) made IgG4-related disease and tubulointerstitial nephritis unlikely based on the proposed diagnostic criteria for IgG4-related disease [, ]. Furthermore, IgG4-disease with a lymphoplasmacytic pattern could not be diagnosed in the presence of an infection such as syphilis []. The immunoglobulin profile and RF were likely inflammatory given the C-reactive protein (CRP) of 174 mg/L. An elevated CRP is unlikely to be present IgG4-related disease []. The patient had a negative ANA and no symptoms of Sjogren’s syndrome and thus this diagnosis was excluded.\nGiven that we did not have the confirmatory syphilis test nor the ANCA serology test results initially and given this crescentic pauci-immune picture suggestive of ANCA vasculitis, we gave this elderly patient both intravenous (IV) penicillin G for 2 weeks and half-dose pulse methylprednisolone (500 mg IV daily X 3 days) concurrently. Once the ANCA results were negative, we continued with only the IV penicillin and a fast Prednisone taper. With this treatment, the patient’s serum creatinine decreased from a peak of 231 μmol/L (2.61 mg/dL) to 134 μmol/L (1.51 mg/dL) within 1 week. The serum creatinine remained at a new baseline of 110 μmol/L 1 month afterwards and 97 μmol/L a year later.
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Syphilis-related rapidly progressive glomerulonephritis: a case presentation
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You need to condense this case report into a succinct title
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On October 2015, a 78-years old male presented left testicular mass with swelling. His family Doctor suggested testicular ultrasound that showed a dishomogeneous left testicular mass measuring around 2 cm. Blood examination evidenced elevated liver enzymes and mild renal impairment. Contrast-enhanced computed tomography (CT) of chest and abdomen was performed and multiple liver metastases, left adrenal and kidney lesion, renal- and superior- cava vein thrombosis were detected. After surgical evaluation, the patient underwent to left orchiectomy for testicular mass. Histological examination and immunohistochemistry showed morphological features of malignant BT of epididymis (). At the time of hospitalization, patient had Karnofsky Performance Status (KPS) of 70%. Laboratory examinations confirmed mild renal impairment (serum creatinine = 1.78 mg/dl, uricemia = 8.1 mg/dl, blood urea nitrogen = 70 mg/dl); elevated liver enzymes (Aspartate aminotransferase = 110 U/l, alanine aminotransferase = 74 U/l, gamma-glutamyl transferase = 241 U/l); grade 1 anemia (hemoglobin = 9.6 gr/dl). Tumor markers for testicular cancer, such as α-fetoprotein and β-HCG were negative, as well as LDH was within normal values. To exclude a second tumor, on November 2015, the patient was admitted in Oncology division and liver biopsy was performed. Histological examination confirmed mBT metastasis. Due to the worsening of clinical conditions (KPS 50%), no chemotherapy was indicated and best supportive care was started. Unfortunately, because of metastatic worsening disease the patient died four months after the diagnosis.
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Molecular and Clinical Insights in Malignant Brenner Tumor of the Testis With Liver Metastases:A Case Report
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As a medical summarizer, your job is to condense this case report into its key points
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The patient is a 54-year-old male who presented to us with complaints of weakness in bilateral lower limbs for six months. The weakness was progressive in nature. There was no bladder and bowel involvement. On examination, there were three of five power in bilateral L3, L4, L5, and S1. The sensations were intact. The perianal examination was normal. MRI showed Intradural mass on dorsal aspect at L2-3 region or conus region and hyperintense on both T1 and T2- weighted images (Figures -). A provisional diagnosis of lipoma was made on the basis of MRI. Considering the progressive nature of neurological deficit, surgical management was planned. A single-stage procedure was done wherein decompressive laminectomy with an exploration of lipoma and excision was done. On opening the dura, lipoma was placed in subpial space with tight adhesions with cauda equina nerve roots. Subtotal resection was done. Instrumentation was also done as stability was compromised due to wide laminectomy and removal of facets too. Post-operatively, the neurology of the patient was the same as pre-op. The patient was discharged on the fifth postoperative day and was kept on regular follow-up. A biopsy of the excised tissue was sent which confirmed the diagnosis of lipoma. On subsequent follow-up, the patient showed improvement in neurology (Figures , ). At 2.5 years of final follow-up, the patient has complete recovery in neurological deficit (Figures , ).
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Intradural Conus Medullaris Lipoma With Neurological Deficit: A Rare Occurrence
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Your role is to provide a brief, accurate title of this medical case report
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We hereby elucidate the case of a 25-day-old male infant who presented to us with complaints of uncontrolled fits despite the uptake of anticonvulsants, including phenobarbitone and phenytoin, and intravenous antibiotics in order to combat his ostensible meningitis. According to the infant’s mother, she witnessed seizures for the first time on the third day of the neonate’s life. The first episode was reported to be three minutes in duration, and consisted of neck retraction, fisting and moaning sounds. The baby was afebrile during and after the episode. The infant had been breastfed since birth. Pertinently, his birth history was uneventful, with no prenatal complications. Interestingly, the baby was a product of a consanguineous marriage, with the mother having undergone one abortion previously at three months of gestation. Thereafter, the patient was admitted to our hospital. The initial impression deduced was that of meningitis; subsequent workup and treatment in line with this diagnosis were thus initiated. After a course of intravenous antibiotics for five days, the infant’s condition remained unaltered. As part of our workup, laboratory tests consisting of a complete blood count, blood culture, basic metabolic panel, and urinalysis were conducted on four separate days. The results obtained from these evaluations are delineated in Table .\nBy this time, besides sepsis, a possible inborn error of metabolism, was also considered in the list of the differential diagnoses. Subsequent metabolic and septic workup reports were normal except the arterial blood gases (ABGs), which divulged respiratory alkalosis (pH = 7.53) and a decreased blood urea nitrogen value of 6.3 mg/dL (Normal range = 7-20 mg/dL). This was in line with the physical examination findings, which revealed a neonate under obvious respiratory distress (Figure ).\nInterestingly, an exorbitantly elevated serum ammonia level of 722 µmol/L was noted, insinuating an underlying diagnosis of an inborn error of metabolism. A plasma aminogram was thus ordered to further ascertain the underlying etiology. The impression following the protocol described above was that of a urea cycle disorder, leading to the aforementioned clinical manifestations. However, an analysis of serum BCAAs revealed an increased leucine level of 854 μM (normal range = 75-165 μM) and an increased serum valine level of 443 μM (normal range = 126-220 μM), thereby favouring a diagnosis of MSUD. Given that the patient’s serum ammonia level was greater than 500 µmol/L, haemodialysis should have ideally been performed; however, our setup lacked this facility. The patient was therefore initiated on sodium benzoate, an ammonia scavenger. Thereafter, his serum ammonia levels dropped rapidly, and his clinical symptoms abated promptly.
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Maple Syrup Urine Disease Masquerading as Urea Cycle Disorder: A Tale of Two Clinical Mimics
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You need to condense this case report into a succinct title
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A 21-year-old female presented to the emergency department (ED) with a seven-hour history of distension and worsening diffuse cramping abdominal pain, greatest in the right lower quadrant. The pain was rated as a seven out of ten, with no aggravating or alleviating factors. It was associated with diarrhea and flatus. Her last meal was the night prior to presentation to ED. In the ED, the patient had six bowel movements. She denied any history of similar episodes of pain, as well as fever, chills, nausea, vomiting, weight gain or loss.\nThe patient’s medical history was significant for systemic lupus erythematous, patent foramen ovale, arteriovenous malformation of the lung status post coiling embolization, antiphospholipid syndrome and splenic and hepatic infarcts resulting in portal vein thrombosis requiring anticoagulation. The patient’s past surgical history was significant for an appendectomy. The patient was a gravida 1, para 1, status post natural spontaneous vaginal delivery, without any complications, approximately three months prior to her presentation. She denied history of sexually transmitted diseases or multiple sexual partners. Medications included Plaquenil, Coumadin, Prednisone, Ferrous Sulfate, Azathioprine, and Zoloft. She denied any tobacco, alcohol or illicit drug use.\nOn examination, her vital signs were included: temperature of 36.6 degrees Celsius, heart rate of 58 beats per minute, blood pressure of 96/58 mm Hg, respiratory rate of 16 breaths per minute, and oxygen saturation of 97% on room air. She appeared moderately ill, in apparent discomfort but no acute distress. Abdominal examination revealed diffuse tenderness on palpation, particularly in the right lower quadrant, tenderness to percussion, and high-pitched bowel sounds. A pelvic speculum exam revealed a normal cervix with no erythema or discharge. Bimanual exam revealed normal-sized uterus, with no adnexal masses and no tenderness to palpation. Her physical exam was otherwise benign.\nThe patient’s workup included a white blood cell count of 6.2 thous/mcL (reference range: 4.0–10.5) and elevated liver enzymes with aspartate aminotransferase (AST) of 66 IU/L (reference range: 8–40) and alanine aminotransferase (ALT) of 115 IU/L (reference range: 0–60). Normal total bilirubin was 0.4mg/dL (reference range: 0–1.4) and normal alkaline phosphatase was 50 IU/L (reference range: 26–110). Prothrombin time (PT) and international normalized ratio (INR) were elevated at 15.2 (reference range: 9.6–11.8) and 1.31 (reference range: 0.89–1.11), respectively. Partial thromboplastin time (PTT) was normal at 28.6 (reference range: 24.2–32.6). Urine analysis was negative for urinary tract infection. Urine pregnancy test was negative. Abdominal and pelvic duplex ultrasounds were unremarkable. Computed tomography (CT) scan of abdomen and pelvis showed a target lesion in right lower quadrant with obstruction of contrast and pericolonic fat stranding indicative of intussusception at the ileocecal junction ().\nAn acute care surgery consultation resulted in an exploratory laparotomy and ileocecectomy with primary repair. In the operating room, the intussuscepted portion appeared to be at the site of previous appendectomy scar, thickened cecum intussuscepted within itself. Patient tolerated the procedure well with minimal blood loss and no complications. The specimen showed a well-healed scar, measuring 0.7 cm in length and 0.1 cm in diameter. Specimen pathology revealed pseudomembranous colitis involving the cecum and inflammatory debris in the terminal ileum, eight reactive lymph nodes, without evidence of well-formed granulomas, vasculitis, polyps or malignancy. Post-operative course was unremarkable with normalization of liver enzymes, advancement of diet and return of normal bowel function. The patient was discharged three days after the operation.
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Ileocecal Intussusception in the Adult Population: Case Series of Two Patients
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As a medical summarizer, your job is to condense this case report into its key points
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A 67-year-old Mexican man presented to the emergency department with weakness, confusion, and lethargy after being discovered obtunded in the back of a semitrailer container where he was living. The patient is a yard worker and was last seen in his usual health 3 days before admission. He was indigent, homeless, without identification, somnolent, minimally responsive, and vaguely denied medication or substance use. He had no known family members, friends, or contacts. The emergency medical services retrieved information from the trailer owner and reported that he would intermittently cut the grass and care for the yard in exchange for a place to rest.\nOn examination, he was hypertensive (blood pressure=171/36 mm/Hg), afebrile, 17 breaths/min, SpO2 = 96% and tachycardia (heart rate = 113 beats/min). Pertinent laboratory results included BUN 43, creatinine 1.4 mg/dL [nl = 0.6.0–1.2 mg/dL], glomerular filtration rate 50.5 [nl>60], aspartate transaminase 138 IU/L [nl = 10–34 IU/L], and alanine transaminase 52 IU/L [nl = 10–40 IU/L] were mildly elevated. The lactic acid was elevated 2.7 mmol/L [nl = 0.5–1 mmol/L], creatine kinase was elevated 4,911 units/liter [nl = 17–150 units/L] (Dimension EXL Integrated Chemistry Siemens). Troponin 0.03 ng/mL [nl = 0–4 ng/mL], urine drug screen positive for opioids, and the urine analysis were positive for 2+ ketones blood, 2+ leukocyte esterase, 2+ protein. His rapid streptococcus test was positive. His chest roentgenography was read as vascular congestion, bronchogram, and cephalization (pulmonary veins of the superior zone dilate due to increased pressure). In the emergency department, he received ceftriaxone 1 g, azithromycin 500 gm, acetaminophen 500 mg, Narcan 4 mg, Clonidine 0.1 mg, and a 2,500 cc Normal Saline bolus.\nThe patient was admitted to the hospital with the diagnosis of altered mental status and presumptive sepsis, treated with fluid hydration, and ceftriaxone. Doxycycline and Acyclovir were added for possible Typhus and HSV meningitis. Computed Tomography (CT) of the head showed chronic findings without significant findings. SARS-CoV-2 PCR was negative. HIV results, hepatitis panel results, and febrile agglutinins results, were negative. There was no growth from blood/urine cultures.\nOur differential diagnosis included substance abuse, urosepsis, meningitis, and endemic typhus. outlines laboratory findings. Cerebral Spinal Fluid results from the lumbar puncture, done 3 days after admission day 1, were consistent with aseptic meningitis (pleocytosis elevated protein and predominantly lymphocytic). Immunoassays (enzyme immunoassay-reference range Negative) WNV-specific IgM and IgG were sent to the LabCorp (Burlington 1447, York Court, Burlington, North Carolina) and returned positive within the week. All other PCR and CSF meningitis/encephalitis molecular screening cerebral spinal fluid studies for patient 1 were sent to LabCorp and were negative.\nHis antibiotics and antiviral medications were discontinued, and the patient was maintained on a high-protein diet and observed for worsening neurologic symptoms (seizures, worsening confusion, gait disturbance). Eventually, his confusion improved. It was impossible to ascertain if he reached his baseline cognitive status without pre-morbid mental status evidence. We could not find a family member, and he had no insurance, and therefore remained in the hospital for 8 weeks until he was discharged to a local homeless shelter.
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Case Report: Neurologic Presentation of West Nile Virus: Difficult Diagnosis
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Your task is to provide a clear and precise title of this case report
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A 29-year-old man of Asian origin was admitted with constant abdominal pain localising to the right upper quadrant with no radiation. There was no history of fever, haematuria, diarrhoea, vomiting or trauma. He had no significant past medical or family history. He had been a lifelong non-smoker, was not on any regular medications and had no known drug allergies. On examination, his vital observations and chest examination were normal. His abdomen was soft on palpation and right upper quadrant tenderness was elicited with no signs of peritonism.\nErect chest and abdominal radiographs were unremarkable. Serum biochemistry showed normal renal and liver function while full blood count showed leucocytosis (total white cell count 21.3 × 109/L) and normocytic anaemia (haemoglobin concentration 10.2 g/dL). Urine dipstick showed trace of protein only. Computed tomography (CT) scan (contrast enhanced) of the abdomen and pelvis showed a mixed attenuation lesion associated with a large perinephric haematoma ( and ). The patient was initiated on intravenous antibiotics.\nAfter 48 h, the patient remained apyrexial and pain was well controlled while inflammatory markers improved. Four days following admission, the patient experienced severe acute onset right upper abdominal pain. Repeat blood tests showed a significant drop in the haemoglobin concentration to 6.3 g/dL. After resuscitation and blood transfusion, a repeat CT scan (contrast enhanced) showed a pseudoaneurysm in the inferior branch of the right renal artery (). The patient immediately underwent selective renal angiography confirming the presence of a bleeding 5.1 ×3.7 cm right renal artery pseudoaneurysm which was embolised successfully with two platinum coils ( to ).\nThe patient was monitored for further 48 h during which his pain improved, haemoglobin concentration remained stable and he was discharged from hospital. There was no evidence of undiagnosed hypertension as he remained normotensive prior to embolisation and during the 48 h period following the procedure. There was no history of familial hypercholesterolaemia and his lipid profile was within normal range. There was no evidence of vascular calcifications on CT scan to suggest severe atherosclerosis. An magnetic resonance imaging scan of his head did not show any vascular abnormalities. Anti-nuclear antibody and anti-neutrophil cytoplasmic antibody tests were negative. Repeat CT scan at three months showed significant reduction in the size of the perinephric haematoma while the CT scan and the ultrasound at seven months and 19 months, respectively ( and ), showed almost complete resolution. Full blood count and renal function profile at 12 months were normal (haemoglobin 15.5 g/dL, serum creatinine 101 µmol/L, estimated glomerular filtration rate 75 mL/min/1.73 m2). Both the follow-up CT and ultrasound showed good recovery of the right kidney with good residual renal parenchymal reserve. The patient remained asymptomatic with normal blood pressure and was discharged to his GP.
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Spontaneous rupture of a renal artery pseudoaneurysm with no precipitating risk factor
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You are tasked with extracting and summarizing the essential information from this case report
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A 82- year old male patient, with the only known comorbidities being hypercholesterolemia and sigmadiverticulosis, presented to a nearby hospital with productive cough and progressive dyspnea in the last 14 days. Chest x-ray showed a right lung opacification with pleural effusion. Subsequent chest CT scan revealed a 180° degree counterclockwise torsion of the whole right lung with partial atelectasis of the lower lobe and middle lobe as well as venous congestion and complete atelectasis of the upper lobe (Fig. ). The patient was then transferred to our thoracic surgical unit for further treatment. Upon arrival in our department a chest tube was placed on the right side and 1 l of pleural fluid was evacuated. Furthermore bronchoscopy was performed, showing torsion of the right mainstem bronchus with complete obstruction of the upper lobe. The intermediate bronchus showed even more profound rightward torsion with partial obstruction of the middle and lower lobe orifice (Fig. ). After drainage 12 h later a follow-up CT scan was performed, which showed complete evacuation of the pleural effusion with better ventilation of the middle and lower lobe but persistent lung torsion with suspected pulmonary venous occlusion and venous congestion of the upper lobe. A tumor was not suspected, but could not be excluded due to massive congestion of the whole upper lobe. Therefore the patient was taken to the operating room for diagnostic thoracoscopy. As suspected, the entire right lung was torqued in a 180-degree counterclockwise direction. Since thoracoscopic detorsion could not be achieved and the whole upper lobe showed hemorrhagic infarction, we converted to thoracotomy and performed anatomic resection of the right upper lobe (Fig. ). The upper lobe vein was centrally compressed by a tumor resulting in venous congestion and finally hemorrhagic infarction of the entire upper lobe. This finding was also confirmed by the pathologist who diagnosed a central bronchial adenocarcinoma in the upper lobe with compression and invasion of the upper lobe vein and additional hemangiosis carcinomatosa. The patient had an uneventful post-operative course and was discharged home in good condition on postoperative day 6. Because of concomitant malignant pleural effusion an adjuvant chemotherapy was recommended.\nUnfortunately the patient died 2 months later due to rapid tumor progression.
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Spontaneous right whole-lung torsion secondary to bronchial carcinoma: a case report
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Your task is to summarize this medical case report into a title
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A 60-year-old woman admitted to the general surgery department with nonspecific abdominal pain. On admission, she appeared obese with BMI 30.4. Physical examination was normal. Laboratory studies were within normal limits, including serum a-fetoprotein (AFP), CEA, CA 19-9, and HbA1c levels. An ultrasonography showed a 7 × 5 × 5 cm mass which attached to the gallbladder fundus and three small hypoechoic masses in segment 5 and two hypoechoic masses in segment 7. Magnetic resonance images showed lesions with markedly decreased signal intensities on T1-weighted and T2-weighted fat-saturated images. These findings are likely to contain microscopic fat. On dynamic contrast-enhanced MRI series, lesions markedly enhanced on arterial phase and showed wash out on delayed phase (Figures and ).\nShe was questioned for the risk factors for hepatic adenoma. No risk factors were identified other than obesity. An open cholecystectomy, liver segment 5-6 resection, and partial segment 7 resection were performed. Patology showed macroscopically, ectopic liver adenoma with no connection to the mother liver (Figures and ) and eight hepatocellular adenomas, some of them are microadenomas (<5 mm), within the resected liver parenchyma. During microscopic examination of ectopic adenoma, the possibility of well-differentiated hepatocellular carcinoma (over 50 years of age, 7 cm adenoma size, and arising in the ectopic liver) was considered, but we did not find any suspicious morphology for carcinoma. Also, nuclear beta-catenin was negative.\nHistologic examination showed hepatic adenoma at the gallbladder and other three adenomas within the resected liver segments (Figures and ). The postoperative course was favorable and uneventful. The patient was discharged on postoperative day 5. Additionally, she remains clinically and radiologically asymptomatic over 26 months after surgery.
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A First Report of Synchronous Intracapsular and Extracapsular Hepatic Adenoma
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As a medical summarizer, your job is to condense this case report into its key points
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A 16-year-old female Caucasian patient, smoker (10 cigarettes/day for 3 years), was referred to our observation showing a localized aggressive form of periodontitis.[] After retrieving general and dental anamneses, the patient underwent oral examination to assess periodontal conditions and dental health: complete periodontal chart was performed (full-mouth plaque score [FMPS]: 38%; full-mouth bleeding score [FMBS]: 28%), together with full-mouth periapical radiographs. Then, after receiving oral hygiene instructions and motivation, the patient underwent causal therapy according to full-mouth disinfection protocol,[] together with the following pharmacological therapy: 875 mg amoxicillin + 125 mg clavulanate twice a day and 250 mg metronidazole 3 times a day, for 10 days.[] The patient was reevaluated in 30 days and then recalled every 3 months for supportive periodontal therapy, based on periodontal risk assessment.[] New periapical radiographs and periodontal chart were collected after 1 year (FMPS: 16%; FMBS: 1%). No further pharmacological therapy was prescribed during the entire follow-up period and the patient did not quit smoking. Microbiological samples were collected at baseline and at 30, 100, 365 days follow-up from every pathological site (probing depth [PD] ≥5 mm).\nSupragingival plaque was gently removed; teeth were air-dried and isolated with cotton rolls. A sterile paper point (ISO45, Roeko Dental, Langenau, Germany) was inserted for 10 s in each site, and all paper points were pooled in a sterile test tube.\nDNA extraction was performed using the NucliSENS® easyMAG® system (Biomerieux, Gorman, North Carolina, USA). A real-time quantitative EvaGreen® dye (Fisher Molecular Biology, Waltham, Massachusetts, USA) PCR was performed with the degenerated primer 27FYM to better amplify several bacterial species, and the U534R primer, targeting the V1-V3 region of 16S gene. A nested PCR was performed with the primers B338F_P1-adaptor (B338F 5′-ACTCCTACGGGAGGCAGC-3′) and U534R_A_barcode (U534R 5′-ATTACCGCGGCTGCTGG-3′), to prepare a 200 base template for final sequencing, with a different barcode for each sample, to amplify the bacterial V3 region.[]\nThe correct size of the amplicon (260 bp) was assessed on a 2% agarose gel. Quantification of the amount of DNA was assessed with a Qubit® 2.0 Fluorometer (Invitrogen, Carlsbad, California, USA) and an equal quantity of PCR from each sample was used to produce the pooled library.\nThe pooled library was diluted at a concentration of 26 pM. Template preparation was performed using the Ion PGM Template OT2 200 kit on Ion OneTouch™ 2 System (Life Technologies, Gran Island, New York, USA), after which the enrichment percentage was carried out on Qubit® 2.0 Fluorometer. The templates were sequenced on the Ion PGM™ System machine, using the Ion PGM sequencing 200 Kit V2 (Life Technologies, New York, USA).\nQIIME 1.8.0 (Knight Lab, Boulder, Colorado, USA) was used to process the sequence data. High quality (Q > 25) sequences were demultiplexed and quality filtered using split_libraries_fastq.py with default parameters, except for length parameter (150 bp). Sequences were clustered into operational taxonomic units (OTU) using de novo OTU picking against the Greengenes 13_8 reference OTU database with a 94% and 97% similarity threshold. Alpha diversity was calculated using Shannon metrics. Statistical analysis was performed with SIMPER and ANOSIM tests.
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Shifts of subgingival bacterial population after nonsurgical and pharmacological therapy of localized aggressive periodontitis, followed for 1 year by Ion Torrent PGM platform
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You are to provide a brief yet comprehensive title of this case report
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A 30-year-old male was admitted to the Ankara Oncology Research and Education Hospital (Ankara, Turkey) presenting with weight loss and abdominal pain. The patient exhibited no other systemic symptoms. On physical examination, a tender mass in the epigastrium was palpated. The laboratory examination results, including hemoglobin, liver function tests, amylase and tumor marker levels (carbohydrate antigen 19-9 and carcinoembryonic antigen) were in the normal ranges.\nAbdominal ultrasonography revealed a hypoechoic mass measuring 7.6×3 cm in the pancreatic head. Upper abdominal computed tomography (CT) showed a hypodense mass measuring 10×7 cm arising from the head of the pancreas. Upper abdominal T1-weighted dynamic magnetic resonance imaging (MRI) revealed a hypointense, bilobular, contoured, encapsulated mass measuring 8.7×9 cm, which exhibited cystic components arising from the head and the uncinate process of the pancreas and portal hilus; the mass encased the superior mesenteric artery and laterally replaced the portal vein. Following the administration of gadolinium, an early and persistent enhanced signal was noted in the T2-weighted fat saturation sequences ( and ), and the lesion was markedly hyperintense ( and ). Based on the patient’s history, and the clinical and imaging findings, an ultrasonography-guided Tru-cut needle (WestCott 16G, Beckton Dickinson, Downers Grove, IL, USA) biopsy was performed and pathological evaluation showed characteristic spindle cells and strong positive immunoperoxidase staining for S-100 protein, which was consistent with schwannoma. Therefore, a duodenopancreatectomy was performed.
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Pancreatic schwannoma: A case report and review of the literature
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As a clinical title specialist, your goal is to synthesize the key elements of this case report
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A 38-year-old male sustained trauma to the left eye while hammering farm machinery without protective eyewear. At presentation, 15 h later, the visual acuity (VA) was hand movements. Anterior segment examination confirmed a 3-mm linear corneal laceration with iris tissue and lens capsule to the wound. A fibrinous reaction and 0.5-mm hypopyon were evident. Fundoscopy revealed a healthy posterior pole, with no vitritis. A CT scan of the orbit identified the presence of a metallic intraocular foreign body (IOFB). The patient proceeded to primary repair, pars plana lensectomy, vitrectomy, removal of IOFB, and partial air-fluid exchange. The patient was left aphakic. Intraoperatively, dense vitritis and florid vasculitis, obscuring the optic disc and vessels, were noted to have developed in the short interval between presentation and surgery. A vitreous specimen was sent for microbiologic evaluation, and intravitreal vancomycin 1 mg/0.1 ml, ceftazidime 2.25 mg/0.1 ml, dexamethasone 0.4 mg/0.1 ml, and intravenous moxifloxacin 400 mg were administered. On post-operative day 1, VA dropped to light perception, with a 2-mm hypopyon and absent red reflex. Initial gram stain of the vitreous specimen identified gram-positive cocci in pairs. A second intravitreal injection of vancomycin 1 mg/0.1 ml was administered empirically. Oral moxifloxacin 400 mg once daily and topical fortified vancomycin, fortified ceftazidime, and prednisolone 1% were commenced. On post-operative day 2, there was no clinical improvement. The primary organism was identified as vancomycin-resistant E. gallinarum, sensitive to ampicillin and gentamicin. Light growth of a gram-negative bacillus was also seen. Intravitreal ampicillin 5 mg/0.1 ml and amikacin 0.4 mg/0.1 ml were administered. A 2-week course of intravenous ampicillin 2 g every 4 h was commenced, plus intravenous clindamycin 600 mg every 8 h and oral moxifloxacin 400 mg once daily to cover the gram-negative organism (subsequently identified as an Acinetobacter species). Topical therapy was switched to fortified gentamicin and prednisolone 1%. The infection responded quickly to this regime, and topical therapy was tapered over subsequent weeks. Recovery was complicated by subsequent inferior retinal detachment, which underwent successful surgical management. At 7 months post-injury, the VA improves to 20/80 (aphakic correction).
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Post-traumatic vancomycin-resistant enterococcal endophthalmitis
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You are required to condense this medical case report into a title
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A 53-year-old male was admitted to our emergency room with a deep stab wound in his neck after attempting suicide. The wound started to the left of the medial head of the sternocleidomastoid muscle and continued horizontally to the right of the medial head of the right sternocleidomastoid []. The laceration was at the level of the lower third of the thyroid cartilage. The wound continued deep into the larynx. The thyroid cartilage was cut horizontally and away from the supraglottic region, and the damage continued to the hypopharynx and ended anterior to the prevertebral mucosa []. When initially examined in the emergency room, he was in moderate respiratory distress. There was no massive bleeding. His larynx was obviously badly damaged. Shortly after admission, he developed respiratory distress and started bleeding, preventing a radiological examination. We did not attempt orotracheal or nasotracheal intubation because of the badly damaged larynx. Under local anesthesia, we made a tracheotomy and then induced general anesthesia. Using his self-inflicted wound, when we dissected the neck, we saw that the thyroid ala, both laryngeal ventricles, and the lower third of the epiglottis were cut horizontally. The supraglottic and infraglottic regions were separated horizontally. We consulted a vascular surgeon in the operating room. The patient has no significant carotid or venous injuries, although there were some minor venous injuries. We reconstructed all of the damaged structures and sutured the sinus piriformis mucosa, epiglottis petiole, and thyroid cartilage alae. We used Prolene sutures to reconstruct the epiglottic and thyroid cartilages. After 5 days’ follow-up, he was transferred to the psychiatric ward. We closed his tracheotomy after 3 months. He has not had any voice, swallowing, or breathing problems since his tracheotomy was closed. There is some residual damage to the epiglottis on the right side [].\nWe gave all patients second-generation antibiotics for surgical prophylaxis. After 5 days’ follow-up, the first and second patients were discharged without any complications.
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Timely management of penetrating neck trauma: Report of three cases
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Your task is to provide an accurate and brief title of this case report
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A 49-year-old male was referred to our emergency department complaining of progressive aggravated abdominal pain for 3 d.\nThe initial pain was in the hypogastric region and worsened to diffuse abdominal pain 1 d prior, along with nausea, abdominal distension, and vomiting.\nThe patient had suffered from hypertension for 10 years, which was well controlled medically by nifedipine and metoprolol. His past surgical history of renal transplantation had been 4 years due to chronic kidney disease. The immunosuppression therapy included prednisolone, mycophenolate mofetil, and tacrolimus.\nThe patient had a free personal and family history.\nClinical examination revealed tenderness on palpation of his full abdomen with rebound tenderness and muscle guarding.\nLaboratory evaluation showed that the leucocytes count was elevated at 31 × 109/mL, hemoglobin was 13 g/dL, and C-reactive protein was 33.86 mg/dL. The hepatitis serology and cytomegalovirus results did not suggest clinical virus infection.\nThe abdominal contrast-enhanced computed tomography (CT) scan exhibited an extensive filling defect within the portal vein and right branch, extending to the superior mesenteric vein as well as splenic vein (Figure ).
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Idiopathic acute superior mesenteric venous thrombosis after renal transplantation: A case report
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Your role is to extract the core information from this case report
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A 35-year-old male patient without a significant medical history presented with substernal chest pain of one-day duration. The patient described his substernal chest pain as radiating to his back and worsening with inspiration and leaning forward. His history was remarkable for having a cold two weeks prior to his presentation.\nUpon arrival to the hospital, his vital signs were unremarkable. Laboratory investigations showed normal while blood counts, normal lipid profile, and normal hemoglobin A1c. A chest X-ray didn’t show any evidence of pneumonia. A chest CT angiography was negative for pulmonary embolus or aortic dissection.\nTwo assays of troponin were performed six hours apart and were negative. His ECG showed diffuse ST-PR discordance, which was highly concerning of pericarditis, along with type II Brugada pattern, which manifested in lead V2 as a saddle-back pattern with at least 2-mm J-point elevation and at least 1-mm ST elevation with a positive T-wave (Figure ). An echocardiogram was performed and showed normal left ventricular ejection fraction of 55% without regional wall motion abnormality or pericardial effusion.\nGiven the history, clinical picture, and lack of family history of arrhythmias or sudden cardiac death, his ECG features in lead V2 were interpreted as Brugada phenocopy rather than Brugada syndrome. The patient was treated as a case of post-viral pericarditis. He was started on nonsteroidal anti-inflammatory drugs and colchicine, which lead to significant improvement in his symptoms and complete resolution of ECG features within two weeks (Figure ) (Poster: Malik Shehadeh, John Costello, Vijaywant Brar, Susan O'Donoghue. Acute Pericarditis Mimicking Brugada Syndrome. Society of General Internal Medicine, May 2020, Birmingham, AL, USA).
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Acute Pericarditis-Induced Brugada Phenocopy: A Case Report and Review of the Literature
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You are required to condense this medical case report into a title
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An 83-year-old male patient presented with a gross caries on the disto-cervical surface of the maxillary right lateral incisor with food impaction and discoloration. Clinical and radiographic evaluation indicated that the tooth was non-vital, and that the cavity extended to the crestal bone level (). Among several treatment options, ranging from a post-and-core crown to implant placement following a tooth extraction, the patient decided to submerge the root of the lateral incisor and undergo restoration with a three-unit fixed dental prosthesis. The prosthesis was intended to have the additional benefit of addressing severe attrition in the adjacent maxillary right central incisor and canine. Single-visit endodontic treatment was performed on the maxillary right lateral incisor, with decoronation at the level of the alveolar crest. No soft tissue augmentation was performed on the decoronated area, and the root was completely covered by gingival tissue five months after the decoronation procedure. A three-unit metal ceramic restoration was fabricated and cemented with a resin-modified glass-ionomer cement. At a three-month follow-up visit, the architecture of the hard and soft tissue was found to have been preserved at the pontic site, and no pathology was noted ().
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A root submergence technique for pontic site development in fixed dental prostheses in the maxillary anterior esthetic zone
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You are tasked with extracting and summarizing the essential information from this case report
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A 47-year-old man presented to his local primary care physician with symptoms of diarrhea and clay-colored stools in April 2018. Laboratory studies revealed direct hyperbilirubinemia which prompted further workup. A right upper quadrant ultrasound showed gallbladder sludge and dilation of the common bile duct to 12 mm indicating obstructive jaundice. No intrahepatic ductal dilatation was appreciated. Computed tomography scan of the abdomen showed a mass in the head of the pancreas which was found to measure approximately 2.6 cm × 1.4 cm in subsequent magnetic resonance imaging (MRI) examination. No evidence of metastasis was found. The patient then underwent an endoscopic retrograde cholangiopancreatography and placement of a plastic biliary stent across a focal stricture of the distal common bile duct secondary to the pancreatic head mass. A diagnosis of pancreatic adenocarcinoma was made.\nUpon transfer to our institution in May 2018, laboratory workup revealed hyperbilirubinemia and elevated liver enzymes. In response to the hepatic workup abnormalities, we started the patient on a neoadjuvant regimen of FOLFIRINOX with reduced doses of 5-FU and irinotecan plus standard doses of oxaliplatin and leucovorin. In cycle 1, the standard dose of irinotecan (180 mg/m2) was reduced by 50% and 5-FU was only administered as a bolus due to lack of port in the patient in the first cycle and the hyperbilirubinemia. The patient received full dose of oxaliplatin (85 mg/m2 = 190 mg) and leucovorin (400 mg/m2 = 900 mg) along with the reduced dose of irinotecan (90 mg/m2 = 200 mg) and the 5-FU bolus (400 mg/m2 = 900 mg) on day 1 (Table ). The dosing adjustments were implemented to prevent potentially serious toxicity-related adverse effects from 5-FU and irinotecan while we awaited the results from the UGT1A1 and DPYD genotyping tests, which we have recently integrated into our clinical practice as a quality improvement initiative. We planned to escalate the chemotherapy regimen to full dose for cycle 2 depending on the results from the genetic tests. Despite the marked dose reductions in cycle 1, blood tests prior to initiation of cycle 2 revealed grade 2 neutropenia with an absolute neutrophil count of 1.17 × 109/L.\nPrior to administration of cycle 2 of the dose-adjusted FOLFIRINOX, we received the pharmacogenomic test results, which indicated that the patient is homozygous for the UGT1A1 allele and an heterozygous carrier of a DPYD variant identified as c.536dupC, a no-activity allele. The pharmacogenomics findings in our patient guided us to maintain some of the dose reductions alongside further modifications based on pharmacogenomics e-consult. Additionally, given the neutropenia, growth factor support was also added to maintain the curative-intent intensity of neoadjuvant therapy. Adjustments in cycle 2 consisted of the same 50% reduction in the dose of irinotecan and a 75% reduction in the 5-FU dose (600 mg/m2 = 1350 mg administered over 2 days from day 1 to day 2) plus omission of the 5-FU bolus. The patient continued receiving standard doses of oxaliplatin and leucovorin in both cycle 2 and 3. Dosing adjustments from cycle 2 were maintained in cycle 3, except for 5-FU which was given as the bolus dose reduced by only 50% (200 mg/m2 = 450 mg on day 1) and the continuous infusion was escalated to 50% (1200 mg/m2 = 2700 mg administered over 2 days) along with pegfilgrastim support starting in cycle 2. No other dosing modifications or escalations were done in cycles 3–5. There was one admission to the ER for diarrhea during cycle 3 requiring IV fluids. This did not occur in cycles 4 and 5.\nBecause of the young age of onset of pancreatic adenocarcinoma in the patient and a maternal history of breast cancer with a confirmed RAD51C variant (c.790G > A), we performed comprehensive testing to evaluate the following genes: APC, ATM, BMPR1A, BRCA1, BRCA2, BRIP1, CDH1, CDK4, CDKN2A (p14ARF), CDKN2A (p16INK4a), CHEK2, EPCAM, FANCC, MEN1, MLH1, MSH2, MSH6, NBN, NF1, PALB2, PALLD, PMS2, PTEN, RAD51C, RAD51D, SMAD4, STK11, TP53, TSC1, TSC2, and VHL. Results were negative for all genes that were evaluated.\nTo date, the patient initially received 5 cycles of neodjuvant FOLFIRINOX. The treatment had been well-tolerated with no evidence of severe adverse effects. At the most recent follow-up, MRI examination showed reduction in the size of the tumor to approximately 1.9 cm × 1.6 cm. Furthermore, serum levels of CA 19-9 have steadily declined (Figure ). Patient subsequent had the disease resected (R0 resection) and is completing the remainder of the cycles adjuvantly with a plan for a total of 6 months of chemotherapy (12 cycles). Clinical course so far indicates both response to the treatment and tolerability despite the deleterious polymorphisms in UGT1A1 and DPYD and the implemented dose adjustments.
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Clinical Value of Pharmacogenomic Testing in a Patient Receiving FOLFIRINOX for Pancreatic Adenocarcinoma
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Your objective is to distill this medical case report into a succinct title
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A 1-year-old boy was noted to have protrusion of his right eye and was diagnosed with the fetal type of orbital rhabdomyosarcoma in October 2008. The size of the mass was reduced by a peripheral blood stem cell transplantation, chemotherapy and radiation therapy with 50 gray units in the period from November 2008 to June 2009. He developed a cataract in the right eye in May 2011, and his visual acuity in that eye decreased to hand motion. He underwent phacoemulsification and aspiration, and intraocular lens implantation in the right eye in July 2011. There were no abnormal findings on fluorescein angiography, which was performed soon after the cataract surgery. His visual acuity after the cataract removal was 20/200 and, with amblyopia training, his visual acuity improved to 20/25. In May 2016, he underwent YAG-laser posterior capsulotomy and his visual acuity was maintained at 20/25.\nAt a regular examination in January 2017, his visual acuity was 20/60 in the right eye and 20/20 in the left eye. The intraocular pressure was 13 mm Hg in both eyes, as measured with noncontact tonometry. Slit-lamp microscopy showed superficial punctate keratopathy of the right eye. The left eye was clear. The bulbar conjunctiva was not injected in either eye. The anterior chamber of the right eye was deep and there were no signs of inflammation. The depth of the anterior chamber of the left eye was normal and the lens of the left eye was clear. Examination of the fundus by indirect ophthalmoscopy showed neither a retinal detachment nor retinal hemorrhages in either eye. Optical coherence tomography (OCT) showed macular edema in the right eye (Fig. ). There were no soft exudates or retinal hemorrhages (Fig. ). Fluorescein angiography showed a hyperfluorescent site on the right side of the fovea of the right eye, but there were no nonperfused areas (Fig. ). The macular edema was considered to be due to the prior radiation therapy.\nAs mentioned above, different types of treatment have been used for radiation maculopathy, including a sub-Tenon's injection of triamcinolone acetonide, intravitreal anti-VEGF agents and PDT using verteporfin.[ We explained these options to his parents, and they chose PDT because the anti-VEGF treatment would have required repeated intravitreal injections. However, PDT for this type of disorder had not been approved in Japan at that time. After receiving approval for PDT from our Ethics Committee, we performed low-emission energy PDT, in June 2017 with irradiation energy of 25 J/cm2 for 45 seconds. The patient's visual acuity improved after the treatment, and the macular edema decreased after the PDT (Fig. ). OCT showed that the foveal thickness decreased between 1 month and 3 months after the PDT but then gradually increased (Fig. ). However, in the long run the Ganglion Cell Complex is gradually decreasing after the PDT (Fig. ).\nAt a follow-up visit in July 2020, his visual acuity was 20/50 in the right eye and 20/20 in the left eye. OCT showed macular edema in the outer plexiform layer of the right eye, but the left eye was completely normal.
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Photodynamic therapy for radiation maculopathy
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Your objective is to distill this medical case report into a succinct title
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A 31-year-old male was referred to our community allergy practice for assessment of suspected cannabis allergy. He had previously experienced several episodes of localized pruritus and erythema after direct contact with various strains of cannabis and noted that the severity of his reaction appeared to be strain dependent. He had developed a severe local reaction involving bilateral periorbital edema shortly after coming into direct contact with one particular strain of cannabis (believed to be Blue Moonshine, but patient uncertain). This particular episode was also associated with dyspnea in the absence of any other systemic symptoms. For this reaction he presented to a local emergency department and was treated with antihistamines and corticosteroids with good effect. He had never had an immediate reaction after smoking cannabis. After this particular episode and prior to his allergy consultation, he continued to smoke cannabis without adverse reaction but tried to avoid direct contact, particularly with his mucous membranes. His past medical history was notable for asthma and seasonal rhinoconjunctivitis.\nThe patient was diagnosed with recurrent local allergic reactions after direct contact with cannabis and he had a suspected selective cannabis strain allergy based on his clinical history. Skin testing was performed to environmental inhalants and the patient had positive reactions to dust mite, grass pollens and various tree pollens. The patient also brought in multiple strains of cannabis for skin testing including “Blue Moonshine” (Cannabis indica dominant strain), “Blue Dream” (Hybrid strain that is largely Cannabis sativa dominant), “Sweet Island Skunk” (Cannabis sativa dominant strain), “Sweet Skunk” (Hybrid) and “Blueberry Haze” (Hybrid). The cannabis strains where mixed with small aliquots of water for skin testing. Fresh testing was required due to the absence of commercially available abstracts. He had positive testing to the strains “Blue Dream” (7 mm), “Sweet Island Skunk” (10 mm) and “Blueberry Haze” (6 mm) while he had negative testing to “Blue Moonshine” and “Sweet Skunk” (Table ). Histamine and saline controls were appropriate (3 mm and 0 mm respectively).\nThe patient was advised to avoid direct cutaneous or mucosal contact with cannabis due to his reported clinical history and skin testing. Due to the inconsistences in strain identification by history and skin testing, he was advised to avoid all strains. An epinephrine autoinjector was prescribed in case he developed a more severe systemic reaction on repeat exposure. A telephone follow-up visit was conducted 6 months after the initial consultation. The patient endorsed that he was still smoking cannabis regularly but had not had any new significant reactions. He continued to use all above tested strains of cannabis in addition to a few new ones. He was still avoiding direct cutaneous and mucosal contact as much as possible.
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Selective cannabis strain allergy in a patient presenting with a local allergic reaction
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Your task is to provide a clear and precise title of this case report
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Patient 1 (IV-1) was 11 years old girl at the time of examination and blood extraction. She presented with proptosis, delayed speech, developmental delay, dysmorphic features and microcephaly. Head circumference was 48 cm<1 percentile -3.8 SD. She also have tumor in the chest cage. She had no other neurological problem such as progressive cognitive decline, seizures and spasticity.
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Novel compound heterozygous mutations in WDR62 gene leading to developmental delay and Primary Microcephaly in Saudi Family
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Your job is to distill the important information into a title from this case report
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A 8-month-old girl presenting with restlessness and intermittent fever of unknown etiology was brought to the daily clinic by her parents. The parents did not complain about any problems related to urination, and there was some amount of daily urine output.\nShe had been born term after an uneventful pregnancy via normal vaginal delivery. Far to the parents' knowledge the newborn examination was normal. On physical examination, she had normal vital signs. She was found to have a midline abdominal mass. The rest of the examination was normal. Initial laboratory values were unremarkable, except for a mild leukocytosis and plenty of erythrocytes in the urine. The urine culture did not reveal any pathological findings. Blood urea levels and creatinine levels were normal.\nAbdominopelvic sonography showed bilateral grade 4 hydronephrosis and a large well-circumscribed midline cystic mass including internal echoes. The cyst reached up to the umbilical level (). No bladder could be identified on control pelvic ultrasonography (US) exams until the exam was repeated after the insertion of a Foley urethral catheter (). Magnetic resonance (MR) scan of the abdomen and pelvis was obtained; it revealed hematocolpos that was causing marked distention of the uterus and cervix. The urinary bladder was significantly compressed (). The presumptive diagnosis of hydrometrocolpos secondary to an obstructing lesion was made.\nThe patient underwent voiding cystourethrogram (VCUG) which demonstrated no reflux but a compressed urinary bladder with a diminished urine volume of approximately 25cc (). The diagnosis of imperforate hymen was made under sedation during the instrumentation for the procedure by the inspection of a protuberant mass on retraction of the labia. The family had not noted any perineal abnormalities prior to presentation to the clinic.\nThe patient was taken into the operating room, and a simple cruciate incision was made over the hymen under general anesthesia which resulted in drainage of approximately 500 mL cloudy, yellowish, nonbloody mucosal secretions from the vagina. No acute or subacute complications occurred.\nDuring a period of 6-month followup, repeated ultrasound exams documented the gradual resolution of bilateral hydroureteronephrosis. The suspicion of bicornuate uterus raised by pelvic control ultrasound was verified by a postoperative MR exam (Figures , , and ).
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Imperforate Hymen Causing Bilateral Hydroureteronephrosis in an Infant with Bicornuate Uterus
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Your objective is to distill this medical case report into a succinct title
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A 26-year-old woman presented with history of backache for the past several months and increasing in severity. This was associated with low-grade fever and lethargy. Routine physical examination and investigations including total white count, sputum test and urine examination were all negative for tuberculosis (TB) infection, and there was no evidence of lung infections. Other imaging studies including the ultrasonography examination demonstrated that there was an abscess found in her left psoas muscle. Whole body FDG PET/CT examination was done to localise the lesion and identify the extension of the infection. She was confirmed for TB through response to anti-TB treatment where there was a complete metabolic remission upon repeating follow-up PET/CT scanning after six months following completion of the treatment.
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Dual time point imaging of FDG PET/CT in a tuberculous spondylodiscitis
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Your objective is to distill this medical case report into a succinct title
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A 49-year-old male experienced recurrent obstructive ileus, counting two admissions in our department within three months, treated conservatively. The third time he underwent an exploratory laparotomy when all conservative measures failed.\nThe patient's previous medical history included only hyperlipidemia, treated with an oral agent. One month before the first episode of intestinal obstruction he underwent emergency surgery in another institution for acute appendicitis and appendectomy was performed. The surgeon noticed an abnormal membrane covering part of the ileus, and a sample of the tissue was sent for histological examination. The findings were non-specific, indicating a membrane formed of connective tissue.\nThe diagnostic workup during his second admission included an upper GI endoscopy and a barium-contrast examination. A CT scan with oral and intravenous contrast was scheduled in the last admission. The endoscopy revealed gastritis, caused by helicobacter pylori, while the barium study showed no abnormalities. The CT scan revealed a distended stomach and upper jejunum, especially near the ligament of Treitz (Figures , ). It also revealed an area of the jejunum with thickened wall and narrowed lumen.\nThe patient experienced incapacity of feeding properly and was malnourished. During hospitalization he was supported with parenteral nutrition and a decision of laparotomy was made, as no amelioration of his condition was observed with conservative measures.\nHe underwent laparotomy through a midline incision. By entering the abdominal cavity, a dense membrane was found encapsulating the stomach, the small intestine and part of the large intestine (transverse colon and the front of the ascending and descending colon) (Figures , ). The whole membrane was excised and extended adhesiolysis was performed, releasing the small bowel loops (Figure ). The entire small intestine was viable, without serosal tears. The patient had an uncomplicated postoperative period and left hospital the 12th postoperative day.\nThe membrane was sent for histological examination. The pathology report of the membrane revealed connective tissue with the presence of inflammatory cells.\nOne week after he was discharged, the patient experienced retching and vomiting when consuming liquids, while surprisingly he could tolerate eating solid food. He was advised to be hospitalized again with food restriction and Levin catheter. There was a high suspicion of cocoon syndrome and the histological results would confirm the diagnosis. He denied admission and visited another institution, where he underwent another laparotomy.
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Abdominal Cocoon Syndrome: An Extremely Rare Cause of Small Bowel Obstruction
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Your objective is to distill this medical case report into a succinct title
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The patient was a 59-year-old Caucasian woman with a medical history of chronic hypertension treated with amlodipine. She presented to the emergency department complaining of multiple ecchymoses and abdominal pain, which had been progressing for several days. She denied any history of trauma, abnormal bleeding, a familial history of bleeding disorders or use of any anticoagulant medications.\nThe previous month, she had presented a diffuse maculopapular rash. The skin biopsy showed leucocytoclastic vasculitis and the patient was diagnosed with urticarial vasculitis. There was no other impairment such as renal or pulmonary involvement. The aetiological assessment was negative. The patient was treated with prednisolone for 3 weeks with a rapid, good outcome.\nOn clinical examination, the patient was in good general condition, BP 123/60, pulse 85 and temperature 37°C. There was a large subcutaneous haematoma occupying the whole of the left upper limb, a superficial haematoma on the right calf and numerous ecchymoses around the 2 ankles. She denied bleeding from the nose or gastrointestinal tract. The patient also reported pain in the left iliac area without psoitis. She had no adenopathy and her spleen was nonpalpable.\nA complete blood count (CBC) revealed a haemoglobin (Hb) level of 8.8 g/dl, and a platelet count of 540 G. A coagulation profile showed a prolonged APTT of 107 seconds, a normal prothrombin time (PT) and a normal international normalized ratio. The results of the FVIII assay were low at 1% (N: 70–100) and inhibitor levels were elevated at 16 Bethesda units (BU), suggestive of AHA. As the patient complained of abdominal pain, an abdominal CT scan was performed and showed a large haematoma on the left psoas measuring 47×12 mm.\nScreening for malignancies, lymphoproliferative disease and autoimmune disorders was negative.\nTreatment was started with factor eight inhibitor bypassing activity (FEIBA) 100 U/kg twice daily and prednisolone 2 mg/kg/day with a good outcome. The different haematomas reduced in size, and the patient did not experience any further bleeding during the hospitalization. Ten days later, the FVIII level increased to 55% and the anti-VIII inhibitor level decreased to 2 BU. After 6 weeks, the coagulation profile revealed an APTT of 28 seconds and a FVIII level of 61%. There was no need for either cyclophosphamide or rituximab.\nThe patient was later discharged on a prednisone taper and with an outpatient haematology follow-up.
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Acquired Haemophilia Associated with Urticarial Vasculitis
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You are to provide a brief yet comprehensive title of this case report
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Case 4: An unsatisfied patient with a long history of using different topical therapies who switched to cal/BD aerosol foam\nA 35-year-old male had experienced chronic recurrent psoriasis since early adulthood but without attendant joint pain. Previous treatment had included systemic therapy with fumaric acid esters a few years earlier, but this had to be discontinued because of tolerability issues. The patient had used several topical treatments, such as mometasone and betamethasone ointments, and various skin care preparations, but without success. Most recently, the patient had used topical Cal/betamethasone ointment once daily, but no significant skin improvement was attained. The patient was also dissatisfied with the fatty consistency of the ointment. He had reported no significant previous illnesses, other than mild allergic rhinitis and lipomatosis.\nPhysical examination at presentation revealed classic psoriatic plaques, each about 3–4 cm in diameter, on the elbows and knees, and on the posterior thigh (). PASI score at presentation was 4.8, BSA involvement was 5%, and the patient started treatment with once-daily application of Cal/BD aerosol foam.\nAfter only 1 week of Cal/BD application, reddening and infiltration of the plaques had significantly decreased (); pruritus had also completely subsided within the first week of treatment. After 4 weeks’ application, most of the plaques had completely healed and existing residual lesions showed only minimal erythema without signs of infiltration or desquamation. The PASI score had decreased to 0.8. The patient was satisfied with Cal/BD aerosol foam treatment, particularly the fast retraction of the foam.
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Calcipotriol/betamethasone dipropionate aerosol foam for the treatment of psoriasis vulgaris: case series and review of the literature
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Your job is to distill the important information into a title from this case report
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A 26-year-old male presented with complaints of diplopia for past 3 years and gradually progressive right-sided hemiparesis for 6 months duration. For the past 2 weeks, he was having a severe headache and worsening of sensorium. On examination, the patient was conscious but drowsy. He had left-sided 3rd and 6th cranial nerve palsies, and right-sided spastic hemiparesis. The patient was carrying magnetic resonance imaging (MRI) performed 6 months back, showing an extra-axial mass on the left side, arising from clivus [Figure -]. Computed tomography (CT) scan after recent clinical deterioration showed a hemorrhagic transformation of clival mass with spillage of bleed into left lateral ventricle []. The patient underwent transsylvian approach after a left pterional craniotomy to reach the tumor. The tumor was arising from clivus, located intradurally, firm in consistency, grayish, lobulated, with evidence of blood clots with in tumor tissue, interspersed with yellow, and gelatinous material. Subtotal excision of the tumor was achieved due to hemodynamic instability, and histopathological examination was diagnostic of chordoma [Figure and ]. Postoperatively, the patient had eventless recovery, and follow-up MRI scan showed residual lesion for which gamma-knife radiosurgery was administered [Figure -].
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Apoplexy in an intradural clival chordoma causing intraventricular bleed
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You are tasked with extracting and summarizing the essential information from this case report
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A 65-year-old female came to our clinic with a complaint of burning pain sensation in the perineal region. Pain in the perineal region increased progressively despite treatment with a combination of codeine, paracetamol, and tramadol. The pain did not radiate, no interference in defecation and urination. The patient had a history of backward fall, 1 year earlier. The pain sensation became worse despite the drugs combination added with pregabalin 300 mg/day. Her Visual Analog Score (VAS) score was 8–9. Daily activities were hampered because of the pain. Magnetic resonance imaging examination T2 sequence showed hypointense around the sacrococcygeal joint, suggestive of inflammation of the sacrococcygeal area, indicative of coccygeal hypermobility [].\nThe patient was planned to be given impar ganglion block with neurolysis agent (alcohol 96%) in combination with radiofrequency thermocoagulation. The patient had been explained about the consent before the procedure and to be enrolled and have her data published. This study had also been approved by our institution for publication. Briefly, in the operating room, the patient was kept in a prone position; hemodynamic monitoring and sterilization were conducted at sacrococcygeal area and covered with sterile operating towel. A local anesthetic injection was performed with 2% lidocaine at sacrococcygeal joints, followed by a 22-gauge RF cannula needle insertion (100 mm, with 5 mm active tip, Cosman Medical, Inc., Burlington, USA) transdiscal, up to the retroperitoneal area at the anterior of sacrum under guidance of a C-arm. Two milliliters of iopamiro contrast agent was injected to ensure that the needle has entered in the retroperitoneum, anterior of sacrum; this was confirmed with C-arm at lateral view []. Radiofrequency electrode was inserted (TCD-10P, Cosman Medical, Inc., Burlington, USA) into the needle cannula. The electrodes were connected to the radiofrequency generator (Cosman G4, V2 RF Generator, Cosman Medical, Inc., Burlington, USA) showing the measured impedance of 320 Ohm. Sensory (50 Hz) and motor (2 Hz) stimulation were conducted, and they showed negative results. The thermocoagulation was performed for 90 s at 80°C. There were no complaints of heavy or spreading pain during and after the procedure. Vital signs were stable, no complications arised. Neurolysis was performed after thermocoagulation with a mixture of 2.5 mL of alcohol 96% and 0.25% bupivacaine.\nOne hour after the thermocoagulation procedure, the VAS score was 2–3, which showed significant pain reduction. Patient discharged on the same day. One week after treatment, the patient came to our clinic again, and VAS score was 1–2. She resumed her normal daily activities, without taking any oral analgesics or opioids.
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Impar Ganglion Block with Combination of Neurolysis Drugs and Radiofrequency Thermocoagulation for Perineal Pain
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As a medical summarizer, your job is to condense this case report into its key points
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The 21-year-old man was presented with a one-month history of mediastinal tumor, which was found during the regular medical examination in school, and he was then sent to our department of cardiothoracic surgery. Physical examination was negative for blepharoptosis, muscle weakness and palpable superficial lymph nodes, and the chest X-ray scan revealed a limited semicircle shadow located in the left heart edge (Figure ). The blood counts assay, erythrocyte sedimentation rate, clinical blood biochemistry, blood urea nitrogen and serum creatinine, urine analysis, and endocrine profile were all within normal ranges.\nThe surgery was performed under general anesthesia and supine position. An oval tumor in the anterior mediastinum, which was closely to the thymus, was observed during the procedure. The tumor and circumambient thymus were excised. In gross, the tumor was oval and with the volume of 10cm×6cm×4cm, in which the cut surface was a solid appearance, grey in color and hard in quality (Figure ). The volume of remaining thymus was 6cm×4.5cm×2cm.\nUnder the microscope, a clear boundary was shown between the tumor and the remaining thymus. The tumor was observed with irregularly connected figurate strands of thymic epithelial cells in a fibrous tissue, in which the fat cell was distributed singly or multifocally. The elongated epithelial were recorded to be formed various “animal-like” structures and sparse lymphocytes were infiltrated (Figure A). The epithelial cells were without obvious atypia and the mitosis was not observed. In some area, thymic corpuscle could be found (Figure B).\nUsing immunohistochemical staining, the epithelial strands of the tumor were positive for AE1/AE3 and CK19 (Figure C), and the lymphocytes were immunostained with CD3 and CD20 (Figure D). The Ki67 labeling index was also calculated to be approximately less than 1%. Based on histological features and immunohistochemical characters, a diagnosis of LFA of the thymus was made, and the total follow-up period was determined to be forty-six months. The repeated X-ray scan revealed no recurring or residual lesion was found during the post-surgical course.
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Lipofibroadenoma of the thymus: a case report
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You are required to deliver a compact title of this case report, outlining the significant findings
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A 35-year-old woman (gravida 0, para 0, abortus 0) presented with dysmenorrhea and vague lower abdominal pain. Her past history was unremarkable. At the time of presentation, she was having regular menstrual cycles. She was afebrile and her abdomen was soft and flat without any tender points. Laboratory data were normal except for the elevated level of CA 125 (44 U/mL; normal 0-35 U/mL) and CA 19-9 (271 U/mL; normal 0-37 U/mL).\nMRI showed an elongated tubular cystic lesion with high signal intensity on both T1- and T2-weighted images in the left adnexa, which was diagnosed as hematosalpinx. An axial T2-weighted image showed a stellate low signal intensity lesion with obliteration of the cul-de-sac, suggestive of deep infiltrating endometriosis. The uterus was diffusely enlarged with focal adenomyosis and an intraumral myoma in the posterior wall. Two small cystic lesions with mural nodules were present in the cul-de-sac along the posterior margin of the uterus. These cystic components showed high signal intensity similar to that of urine on T2-weighted images as well as high signal intensity that was slightly higher than that of myometrium on fat-suppressed T1-weighted images. Peripheral nodular enhancement was seen in the cystic lesions on gadolinium-enhanced T1-weighted images, raising the possibility of malignancy (). Mural nodules were not definitely seen in the left fallopian tube.\nSurgery revealed severe pelvic endometriosis involving bilateral ovaries, the cul-de-sac, rectosigmoid colon and left hydrosalpinx. On histopathologic examination, cul-de-sac masses and the left fallopian tube showed mucin-filled cysts and branching papillary projections. The papillae were lined by endocervical type mucinous cells. Microscopic examination revealed a gradual transition from the epitheliums of endometeriosis to mucinous tumor cells. The pathologic diagnosis was confirmed as endocervical mucinous boderline tumor involving the cul-de-sac and left fallopian tube arising from extensive pelvic endometriosis.
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MR Imaging Findings of Extraovarian Endocervical Mucinous Borderline Tumors Arising from Pelvic Endometriosis
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You need to condense this case report into a succinct title
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A 44-year-old man was admitted to the hospital with right limb hemiparesis and dysarthria. On admission, the NIHSS and mRs scores were 8 and 4, respectively. He awoke with stroke symptoms at 05.00 AM and was admitted to hospital at 08.30 AM. He had a history of hypertension and tramadol, heroine, amphetamine abuse. Following the blood investigations and computed tomography (CT) scan, MRI with DWI and FLAIR sequences was performed. This is where the mismatch was noticed. The patient was admitted to the stroke intensive care unit at 09.28 AM with a blood pressure of 205/110 mmHg; therefore, a decision to simultaneously administer alteplase and a continuous intravenous urapidil infusion was made. Despite the use of a hypotensive drug, the systolic blood pressure averaged between 180 mmHg and 210 mmHg. Nonetheless, the patient received the full alteplase dose (90 mg). Ultimately, the patient had no hemorrhage on the control neuroimaging and was discharged with NIHSS and mRs scores of 6 and 3, respectively.
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Safety and efficacy of intravenous thrombolytic treatment in wake-up stroke: Experiences from a single center
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Your role is to extract the core information from this case report
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A 64-year-old woman underwent a urine mercury assay ordered by her primary care physician (PCP). The result of this test, which was ordered for unknown reasons, was markedly elevated (216 μg/g creatinine, range <4 μg/g creatinine). The result was not reported to the local health department or addressed in the patient’s medical records until 3 years later, when her new PCP reviewed the result and ordered a repeat 24-hour urine assay. This test result was also abnormal (30 μg/L, range <20 μg/L), and the patient was referred to an outpatient medical toxicology clinic for further evaluation.\nUpon toxicology clinic evaluation, the patient denied having symptoms of mercury toxicity including tremors, myalgias, paresthesias, or weakness. The physical examination was unremarkable. Laboratory testing was significant for proteinuria.\nThe patient was a retired human resources specialist. Her hobbies included reading and exercising, although she stated that she had not recently left her home for significant periods of time due to the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic. She reported that her husband, a retired naval engineer, was the likely source of her mercury exposure, as he had a hobby of repairing barometers in the basement of their home. The patient’s husband was also evaluated in the medical toxicology clinic after he was discovered to have a 24-hour urine mercury concentration of 22 μg/L. He reported that he had purchased elemental mercury from an online source on multiple occasions and had the mercury mailed to their home. The element arrived at their home packaged in a glass vial; he poured it into glass barometers to calibrate them, using different workstations in the basement of the home. He had spilled elemental mercury on occasion on the unfinished concrete basement floor and had attempted to clean it up using a traditional vacuum cleaner as well as a shop vacuum.\nUpon discovery of this information, the local health department was contacted, and a hazardous materials response team was dispatched to the residence for mercury vapor assessment. Elevated mercury vapor concentrations were detected throughout the home, with the highest levels noted in the basement. The couple was evacuated from their home and placed in temporary housing. Chelation with dimercaptosuccinic acid was prescribed for both patients.\nA private company performed mercury remediation of the home. Many items in the home were confiscated and destroyed due to mercury contamination, including the couple’s wedding attire, former military uniforms, and basement furniture. After several weeks of remediation, the home was declared safe for occupancy, and the couple moved back in. Follow-up 24-hour urine testing revealed decreasing mercury concentrations, although proteinuria persisted for several months after the conclusion of remediation.\nWritten consent for publication was obtained from the patients described in this report. Institutional review board approval was not required for publication of this case report.
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Effective Decontamination and Remediation After Elemental Mercury Exposure: A Case Report in the United States
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Your role is to extract the core information from this case report
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Patient 4 is a 5 year and 6 months old girl born prematurely after 27 weeks of gestation because of a placental hematoma. Her unrelated parents are of French descent and there is no particular familial history of genetic disease. Birth weight was 950 g (65th centile, +0.5 S.D., age-corrected), height was 34 cm (37th centile, −0.5 S.D.), and OFC 24 cm (29th centile, −0.5 S.D.). Bilateral talipes equinus and a patent ductus arteriosus which required surgical treatment were noted at birth. She had retinopathy of prematurity with vitreous hemorrhage as well as bilateral microphtalmia and alternate strabismus. At the age of 2 months, she presented with generalized seizures with persistent, almost daily crises which were resistant to treatment. A brain MRI gave normal results. Arm and forearm X-rays showed diffuse bone demineralization and radiocubital synostosis.\nShe was first referred for clinical genetic evaluation at the age of 5 months. Dysmorphic features including high frontal hairline, telecanthus, upslanting palpebral fissures, arched eyebrows, flat nasal bridge, thin upper lip, and retrognathism were noted (Fig. ). She also had bilateral 5th finger clinodactyly, absent thumb nails, and arched and abnormal nails of both index fingers. Her weight was 3625 g (5th centile, −1.9 S.D., age-corrected), height 49.5 cm (1st centile, −2.5 S.D., age-corrected), and OFC 35 cm (<3rd centile, −3.2 S.D.). Standard karyotyping gave normal results. At last examination at the age of 5 years and 6 months (Fig. ), she still had developed no active language but showed eye contact and was able to smile. Sitting without support had not been acquired. Her weight was 16 kg (8th centile, −1.8 S.D.), height 96 cm (below the 1st centile, −3.5 S.D.), and her OFC 47 cm (2nd centile, −2.2 S.D.). Nephropathy was diagnosed and CT scans at the age of 5 years and 6 months showed non-ossified and dislocated patellae, with bilateral patellar tendon hypoplasia.
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Microdeletions in 9q33.3-q34.11 in five patients with intellectual disability, microcephaly, and seizures of incomplete penetrance: is STXBP1 not the only causative gene?
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You are tasked with extracting and summarizing the essential information from this case report
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A 67-year-old white female with urinary hesitancy, frequency, and urgency incontinence was referred to our clinic for urogynecology consultation after failing standard therapy with approximately 6 months of anticholinergic medications and behavioral modifications. Past surgical history was significant for a Burch colposuspension about 10 years prior to examination. Past medical history was significant for chronic obstructive pulmonary disease having been a prior smoker. She quit approximately 5 years prior to evaluation. Physical examination revealed a Grade 3 rectocele and Grade 3 enterocele. Cough stress test in lithotomy was negative. Urethral hypermobility was less than 30 degrees. Urodynamics confirmed elevated bladder pressures and increased bladder sensation which was consistent with obstructed voiding.\nCystourethroscopy was performed which showed an eroded suture at the level of the proximal urethra near the bladder neck (). We utilized a 24 Fr resectoscope with a cold-knife to cut the suture. The suture retracted back into the bladder and was removed with cystoscopy at the end of the case.\nThe prolapse and obstructed voiding was treated with abdominal sacrocolpopexy. Her postoperative course was uneventful and the patient had complete resolution of symptoms by her 6-week postoperative visit.
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Delayed Presentation of Suture Erosion following Burch Colposuspension
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You are required to condense this medical case report into a title
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An 11-year-old female was brought to the emergency department with left hip and knee pain as well as limping for three weeks. There was no fever or recent trauma. Physical examination revealed restricted range of movement due to pain on hip flexion, internal and external rotation. A point-of-care ultrasound (POCUS) performed by an emergency physician () raised the suspicion for her diagnosis when compared with right side (), which prompted expedited immobilization and pain control. POCUS was performed using a linear, high-frequency probe (14–5 MegaHertz) aligned parallel to the femoral neck. Subsequently, her pelvic radiograph () confirmed the diagnosis.
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Point-of-care Ultrasound Diagnosis of Slipped Capital Femoral Epiphysis
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As a medical summarizer, your job is to condense this case report into its key points
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The first patient is a 42-year-old woman with no significant past medical history who presents with loss of 6 kg over the course of two months and a two-week history of epigastric pain and jaundice. No abdominal mass is palpated on physical exam. Initial laboratory tests are significant for cholestasis, with serum bilirubin of 9.3 mg/dL. Computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) imaging reveal a gallbladder with stones and asymmetrical malignant-appearing wall thickening and a contiguous hepatic hilar mass. The mass infiltrates hepatic segment IVb as well as the common and bilateral hepatic ducts, with intrahepatic biliary dilatation (Figure ). There is extensive contact between the mass and the right portal vein, without any apparent plane of separation. No hilar lymphadenopathy is observed. Given these imaging findings suggestive for resectable biliary tract cancer, the decision is made to perform radical surgery. Intraoperatively, a petrous lesion enveloping the gallbladder and the biliary confluence, with retrograde biliary dilatation, is observed. Right trisectionectomy with cholecystectomy and complete extirpation of the extrahepatic bile duct, hilar lymphadenectomy, and double Roux-en-Y hepaticojejunostomy is performed. The specimen is not opened, but the proximal and distal bile duct margins are sent for perioperative frozen-section analysis (negative for malignancy). The intraoperative and postoperative courses are uneventful, and the patient is discharged home on postoperative day thirteen. Pathological analysis of the surgical specimen reveals chronic cholecystitis with areas of xanthogranulomatous inflammation and absence of malignancy. With over ten years of follow-up, the patient remains well and asymptomatic.
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Infiltrative xanthogranulomatous cholecystitis mimicking aggressive gallbladder carcinoma: A diagnostic and therapeutic dilemma
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Your role is to provide a brief, accurate title of this medical case report
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A 47 year old South Asian male teacher presented to our institute in June 2012 with a diagnosis made elsewhere of accelerated hypertension and acute left ventricular failure following a recent anterior wall myocardial infarction. He was admitted to hospital for further cardiac management, and a nephrology consultation was sought for renal insufficiency (serum creatinine 1.9 mg/dl). The presence of an active urinary sediment (urine albumin 3+ by dipstick and microscopic hematuria) necessitated a renal biopsy which showed IgA nephropathy (\n) with an Oxford Pathological score of M1E0S1T1, 5/10 glomerular sclerosis and 30% IF/TA with hypertensive changes in blood vessels (\n). The patient was initiated on olmesartan 20 mg/day and prednisolone 50 mg/day and a follow up for management of proteinuria was advised.\nHe presented again 7 months later with swelling pain and erythema of the right clavicle that had been present for 2 months. He was evaluated for these complaints at another centre before presentation to ours and was diagnosed with synovitis of the medial end of the right clavicle. Ultrasound guided aspiration of fluid from the swelling and analysis of bacterial cultures in an external laboratory did not reveal any organism. The patient was subsequently treated with non steroidal anti inflammatory drugs and prednisolone for 1 week.\nPhysical examination following admission at our centre revealed a normal body mass index (BMI) and vitals with an otherwise unremarkable systemic examination. Local examination of the right clavicle revealed a swelling of 2×3 cm with erythema, induration, warmth and tenderness with a firm consistency. The skin did not show discharging sinuses. Laboratory investigations revealed the following: white blood cells (WBC) count 12,400 cells/mm\n3 with predominant polymorphonuclear cells, platelet count 290,000/mm\n3, erythrocyte sedimentation rate (ESR) 93 mm/hr, urea 42 mg/dl and serum creatinine 1.5 mg/dl. Liver function tests revealed: serum glutamic oxaloacetic transaminase (SGOT) 69 IU, serum glutamic-pyruvic transaminase (SGPT) 44 IU, alanine aminotransferase (ALP) 130 kU, total protein 7.3 g/dl serum albumin 3.3 g/dl. Serology for HIV, hepatitis B and the venereal disease laboratory test (VDRL) were negative, anti-streptococcal antibody (ASO) was titre-negative, and C3 and C4 levels were within the normal range.\nUrine analysis showed 1+ albumin by dipstick, and microscopic examination of the urine showed 6–8 WBC/high power field (hpf), 2–3 epithelial cells/hpf, 4–6 RBCs/hpf and occasional granular casts. Sonography of the abdomen showed bilateral normal sized kidneys with increased echogenicity and maintained corticomedullary differentiation. Ultrasound guided aspirate of the pus from the right clavicle was cultured using BacT Alert 120 (bioMerieux, France) which showed Gram-negative and oxidase-positive rods. This suggested the presence of\nP. aeruginosa that was found to be sensitive to cefoperazone and sulbactam, using Vitek Compact II (bioMerieux, France). Repeated staining for Acid Fast Bacilli was negative. Tuberculosis (TB) PCR analysis and staining for fungal elements were negative. CT scan of the clavicle showed cortical and subcortical irregularity with soft tissue swelling of the medial end of right clavicle suggestive of osteomyelitis. Curettage and lavage of the site was followed by a gentamicin impregnated dressing (Septocoll E, Biomet Deutschland GmbH, Berlin), and histopathological examination of the sequestrum revealed non-caseating granulomas surrounded by many neutrophils, lymphocytes and plasma cells, suggestive of chronic osteomyelitis. The patient was begun on intravenous cefoperazone and sulbactum 1.5 g BD as per the sensitivity report for a period over 3 weeks.
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Case Report: Rare occurrence of\n Pseudomonas aeruginosa osteomyelitis of the right clavicle in a patient with IgA nephropathy
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Please create a concise title of this case report, focusing on critical details
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A 55-year-old man presented in November 2008 with fatigue, headache, left upper quadrant abdominal discomfort, and palpable splenomegaly. He had a hemoglobin of 11.6 g/dL, a white cell count of 53.7 × 109/L, and platelets of 165 × 109/L. Bone marrow aspirate revealed moderate hypercellularity with less than 2% myeloblasts, and cytogenetics demonstrated a karyotype of 46,XY,t(9;22)(q34;q11.2). Molecular analysis revealed high levels of e14a2 BCR-ABL1 transcripts, all consistent with a diagnosis of chronic phase CML with a low-risk Sokal score of 0.75.\nThe patient was enrolled on an open label, single stage, multicentre, nonrandomized, phase II clinical trial to assess the efficacy of upfront nilotinib 300 mg twice daily []. Prospective molecular BCR-ABL1 monitoring was performed in a European Treatment and Outcome Study (EUTOS)-certified laboratory according to standardized procedures with results reported in line with standardized definitions of response [, ]. The patient achieved a major molecular response (MMR; BCR-ABL1/ABL1 IS ≤ 0.1% on the International Scale) at 16 months that was maintained for seven years (). Thereafter, a deeper molecular response (MR4; BCR-ABL1/ABL1 IS ≤ 0.01% on the International Scale) was transiently noted.\nDuring his treatment he continued to have mild fatigue and headaches. Transient grade-II increase in serum lipase was also noted which normalised on temporary interruption of nilotinib. Later in the treatment, he reported having frequent nightmares, sleep disturbances, poor concentration, and in general, poor quality of life. Overall, his treatment was continuous with three short (<7 days) interruptions due to impairment in baseline renal functions and transient increase in serum lipase at one instance but was not considered a candidate for attempting TFR at any time due to the lack of a prolonged, deep molecular response. However, at a follow-up appointment, the patient stated that he had stopped taking his TKI in March 2018 and reported feeling much better having stopped nilotinib and did not wish to restart. He had not noticed any symptoms suggestive of a TKI withdrawal syndrome. Counselled that his response could be lost and being offered treatment with an alternative TKI, he preferred to pursue a trial of treatment cessation, prompting immediate monthly BCR-ABL1 monitoring to detect any loss of molecular response as per European guidelines []. The patient is now 18 months after TKI discontinuation maintaining a stable BCR-ABL1 level of 0.01% () and remains clinically well. Given the less than optimal BCR-ABL1 history, molecular monitoring continues at six weekly intervals.
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Patient-Initiated Discontinuation of Tyrosine Kinase Inhibitor for Chronic Myeloid Leukemia
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Your task is to summarize this medical case report into a title
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A 77-year-old woman (body mass index [BMI], 19.6 kg/m2) presented with 1 week postmenopausal bleeding, which was preceded by vaginal spotting for 1 year and concomitant genital itching that had continued for 2 weeks. Transvaginal ultrasound revealed abnormally thickened endometrium (1.47 cm) and biopsy was recommended, but she refused. After 2 weeks, follow-up ultrasonography showed remarkably increased endometrium thickness (2.36 cm) with a 7 cm mixed-echoic lesion within the endometrial cavity. Endometrial curettage revealed poorly differentiated carcinoma. Magnetic resonance imaging (MRI) showed 8.6 × 3.7 cm heterogeneously enhanced mass on contrast-enhanced T1-weighted images (CET1WI) (Fig. ). In addition, tumor involvement of the cervical stroma was observed on CET1WI. The patient subsequently underwent total hysterectomy (TH) with bilateral salpingo-oophorectomy (BSO) and pelvic lymphadenectomy. The surgical specimen of the uterus showed white gray polypoid mass filling the endometrial cavity (Fig. ). Upon microscopic examination, the tumor with high cellularity and patternless growth without glandular differentiation invaded the full thickness of the lower uterine segment (Fig. ) extending to the cervical stroma. The tumor consisted of medium–sized monotonous cells with brisk mitosis (5 per high-power field (HPF)) and atypical mitotic figures (Fig. ). Moderately differentiated endometrioid adenocarcinoma component with squamous differentiation comprised the major proportion of the tumor mass of the uterine body and fundus, which invaded more than one half of the myometrial thickness. No lymph node (LN) metastasis was found. Cytokeratin 8/18 (CK8/18) and pancytokeratin (CK AE1/AE3) expressed both components but in different patterns. In the UC component, they were expressed as dot-like patterns, whereas they showed cytoplasmic expression in differentiated component (Figs. ). Epithelial membrane antigen (EMA), estrogen receptor (ER), progesterone receptor (PR), E-cadherin, and PAX-8 were expressed in the differentiated component alone (Table ). Based on the FIGO system, the patient had stage II. She was recommended adjuvant external beam pelvic RT (EBRT), but she refused. A month after the surgery, she presented with difficulty in urination. Abdominal pelvic computed tomography (CT) revealed multiple, large, peritoneal seeding masses, and multiple lymph node metastases in the external and internal iliac chains with large amount of ascites which was positive for malignant cells on cytologic examination. She died 7 weeks later after surgery due to tumor lysis syndrome.
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Dedifferentiated endometrioid carcinoma of the uterus : report of four cases and review of literature
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You are to provide a brief yet comprehensive title of this case report
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An intubated 53-year-old man was transferred to a tertiary burn centre with 24% total body surface area (TBSA) burns to the head, back, arms, legs and inhalation injury secondary to a caravan explosion. Medical history included chronic alcoholism, active smoker and a previous open appendicectomy. Despite fluid resuscitation as per Parkland’s formula, inotropic support was still required. Computer tomographic (CT) trauma series demonstrated stable old and new cervical, thoracic and sacral fractures. He was admitted to the intensive care unit for continued resuscitation.\nBy day five of admission all burns, including full thickness burns on his back and arms, were debrided and grafted with no further coverage required. On day nine, he developed paralytic ileus, which required colonoscopic decompression. Colonoscopy showed faecal impaction and large, coalescent ulcers in the sigmoid colon suggestive of stercoral colitis.\nSubsequently, he remained stable in his systemic inflammatory state tachycardic to 115, blood pressure of 114/59 with minimal noradrenaline requirement, and febrile to 39°C. He had continued small liquid stools and developed larger nasogastric aspirates. Abdomen was tense, distended and tender on the right lower quadrant. He was not peritonitic and bowel sounds were not appreciable. Repeat imaging demonstrated a thickened caecal wall, pericaecal fat stranding and a transition point in the ascending colon secondary suspected stercolith ().\nDue to failure of medical management and a mechanical obstruction, the patient received an emergency laparotomy. The greater omentum off the hepatic flexure was found to be adhered to the right iliac fossa at the previous open appendicectomy site causing flexion narrowing of the ascending colon. This was released with diathermy ablation. Multiple segments of viable small bowel appeared oedematous with venous congestion. No bowel resection was performed however 1.3 L of fluid was suctioned from the peritoneal cavity and 1.2 L aspirated from the nasogastric tube. Given the distended loops of bowel, tight abdominal wall, and plan for relook, temporary abdominal closure was achieved with ABTHERA ADVANCE™ Open Abdomen Dressing ().\nRelook 24 h later, demonstrated viable bowel and abdomen closure was achieved. Total parental nutrition was subsequently weaned over the week. Extubation and discharge to the ward occurred 2 weeks after presentation. His recovery was complicated by a hospital-acquired pneumonia and large pleural effusion, which was managed with antibiotics and a chest drain. He was discharged to rehabilitation 7 weeks from presentation.
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Rare case of adhesive large bowel obstruction in acute burn patient: management of open abdomen with ABTHERA ADVANCE™ Open Abdomen Dressing
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You are tasked with extracting and summarizing the essential information from this case report
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A 60-year-old woman presented to our department with a 4-day-old swelling and erythema around the right thumb, having already been treated with cefuroxime for 3 days by her general practitioner without any improvement. She reported an accidental injury 5 days previously caused by a rose thorn while she was gardening. The patient was in good health and had not taken any immunosuppressives or other drugs. There was no history of any contact with avian excretions, pigeons, or other animals, and she denied recent travelling.\nOn dermatological examination, we found an erythematous ulcerated nodule with elevated borders, suppuration, and central necrosis (Fig. ). There was no regional lymphadenopathy and no other skin involvement. Routine blood examination, a total lymphocyte count, and blood immunoglobulins were normal. The C-reactive protein level was 55 mg/L, while the erythrocyte sedimentation rate was 77 mm/h. HIV and hepatitis B and C serology results were negative. X-rays of the chest and the right thumb were also normal. At first, we suspected a bacterial or herpetic infection, but the lesion swab cultures for bacteria and the PCR examination for Mycobacterium as well as herpes simplex virus were also negative. We performed a biopsy for histological examination from skin lesion fragments after surgical debridement, removing necrotic tissue from the right thumb (Fig. ). The histology picture showed cutaneous and subcutaneous fibrinoid necrosis with bleeding, an abscess forming, neutrophil-rich cellular infiltration, and the presence of multiple PAS-, colloid iron- and mucin-positive spores (Fig. ).\nA swab sample from the lesion was inoculated on tubes with slide Sabouraud chloramphenicol and BBLTM MycoselTM agar and incubated at 30 and 35°C. On day 3, milky and creamy colonies of C. neoformans started to grow on the Mycosel agar at 30°C. Then, colonies were transferred to an agar plate (Sabouraud chloramphenicol agar and ChromID Candida; bioMérieux) and incubated at the same temperatures. Microscopical examination showed globose-to-ovoid, budding, yeast-like cells. Identification of C. neoformans was possible with matrix-assisted laser desorption ionization-time of flight mass spectrometry []. We diagnosed PPC in an immunocompetent patient.\nFor antifungal susceptibility assessment, we used the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines []. The antifungals tested were amphotericin (0.5 mg/L), ketoconazole (0.64 mg/L), itraconazole (0.121 mg/L), 5-fluorocytosine (1 mg/L), voriconazole (0.064 mg/L), and fluconazole (4 mg/L).\nIn addition to the debridement, we performed two lateral incisions in a sterile area next to the medial and lateral perionychium to drain collections. The necrotic epidermis of the fingertip was completely detached in its superficial layer. After the surgical debridement, the patient needed periodic dressing. Complementary to surgical therapy, we started treatment with itraconazole 100 mg/12 h for 6 months, with rapid clinical improvement and without relapse to infection during the 6-month follow-up after the systemic antifungal therapy (Fig. ).
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Primary Cutaneous Cryptococcosis due to Cryptococcus neoformans in an Immunocompetent Host Treated with Itraconazole and Drainage: Case Report and Review of the Literature
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Your role is to extract the core information from this case report
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A 35-year-old male presented with complaints of decreased vision in both eyes for 15 years. There was no history of intraocular surgery in either eye. His best-corrected visual acuity was no perception of light in the right eye and 20/400 in the left eye with + 9.0 diopter sphere (Dsph). Horizontal pendular nystagmus was noted in both eyes. Examination of the right eye revealed corneal stromal edema and an intercalary staphyloma. The cornea in the left eye had mild corneal haze. Both eyes had aniridia and were aphakic. The view in the left eye was clearer and showed aphakia with total absence of zonules []. Intraocular pressure (IOP) measured by Goldmann applanation tonometry was 28 mm Hg and 36 mm Hg in the right and left eye respectively. Corneal edema obscured visualization of the angle in the right eye. Gonioscopy in the left eye with a four-mirror lens showed open angles up to the cilliary body inferiorly; the stump of the iris had formed peripheral anterior synechia (PAS) superiorly. Fundus details were not clear in the right eye but a total glaucomatous optic atrophy was noted. Fundus examination of the left eye showed a near total glaucomatous optic atrophy (vertical disc diameter of 2.1 mm, 0.9:1 cup disc ratio with bipolar notch) as well as foveal hypoplasia. As the IOP was uncontrolled with topical 0.5% timolol maleate eye drops and 0.15% brimonidine tartarate eye drops, the patient underwent trabeculectomy with Mitomycin C under local anesthesia in his left eye. Partial anterior vitrectomy was performed at the same time.\nAt five weeks postoperatively the patient maintained a best-corrected visual acuity of 20/400 (using + 9 Dsph and 1 diopter cylinder (D cyl) at 180 degree) in the left eye []. At the three-month follow-up the vision remained the same; there was a diffuse bleb and the IOP was 7 mm Hg without any anti-glaucoma medications. When last seen (six months postoperatively), the best-corrected visual acuity of 20/400 was maintained; the IOP was 6 mm Hg without any anti-glaucoma medications.
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Aniridia associated with congenital aphakia and secondary glaucoma
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Summarize this medical case report, ensuring to cover the initial presentation
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A 51-year-old Chinese male presented with a 6-month history of right ptosis and progressive muscle weakness. The patient had been diagnosed as myasthenia gravis at local hospital 6 months before, but for unknown reasons, he failed to receive workup and management at that time. Before one day the patient was admitted to our hospital, he suffered with a sudden onset of dysarthria. Therefore, the patient referred to our hospital for further examination and treatment. Physical examination showed right-sided partial ptosis. Diplopia was noticed on right lateral gaze due to right lateral rectus weakness. The patient did not have dysphagia or dyspnoea. But he was having generalized weakness in all his extremities, both proximal and distal, with marked diurnal variation in the form of more weakness during the evening. A confirmatory electrophysiological study with repetitive nerve stimulation showed decrement in amplitude of action potentials with further reduction post exercise and recovery after 15 minutes. Acetylcholine receptor (AChR) binding antibodies were markedly elevated. However, other routine laboratory test, including blood count, differential, liver and renal function, were within the normal range. A chest computed tomography (CT) scan demonstrated a solid mass, measuring 5.4 × 3.7 × 2.6 cm, with focal heterogeneously enhancement, in the right anterior mediastinum. The tumor was observed to adhere to the wall of aorta but did not infiltrate it. Minimal amount of right pleural effusion and pericardial effusion were associated, but neither enlarged lymph node nor remarkable image finding was noted in the lung parenchyma (Figure ). A CT guided fine needle biopsy of the anterior mediastinal mass was performed and pathological examination showed predominantly epithelial neoplastic cells with pan-cytokeratin (AE1/AE3) positive in a lymphoid component background suggesting a thymoma. Therefore, a preoperative diagnosis was thymoma and the tumor was totally resected. At surgery, the main tumor located in the right lobe of the thymus was found to have adhered to the periaortic tissues, but no invasion of the wall of aorta was observed. Thymectomy and resection of the adherent tissues were performed.\nMacroscopical examination revealed a gray-red solitary nodular mass, and measured 5.0 × 3.5 × 2.0 cm. The mass was well-circumscribed, but there was no fibrous capsule around the mass and no cystic cavity observed in the mass (Figure ). Under the microscopical examination, part of nodular mass was composed of solid and invasive nests of well-differentiated epidermoid cells with desmoplastic stroma. The mucin-producing and intermediate cells were also observed in the tumor. These tumor cells were intermingled or intimately mixed with epidermoid cells. Mucin-producing cells were cuboidal, columnar, or goblet-like with bland nuclear morphology. Bands of fibrous connective tissue were observed among the neoplastic elements. There was no extensive necrosis and neural invasion. Mitotic figures were infrequent and there was no remarkable cellular pleomorphism. Immunohistochemically, the epidermoid cells of the tumor were positive to pan-CK (AE1/AE3), CK5/6, CK7 and p63, but negative to CD5. Mucin-producing cells were negative to CK5/6 and p63. Alcian blue staining revealed mucin in the cytoplasm of the mucin-producing cells (Figure ). This part of tumor was diagnosed as low-grade MEC according to the histopathological criteria of WHO classification []. Interestingly, however, type B2 thymoma could be observed in other area of the same nodular mass. In this area, neoplastic cells were large and polygonal with large nuclei and prominent central nucleoli. The neoplastic cells formed delicate lose network, and small epidermoid foci resembling abortive Hassall’s corpuscles could be observed among the neoplastic epithelial cells, but no mucin-producing cells were found in these epidermoid foci. In these areas, the neoplastic cells were outnumbered by non-neoplastic lymphocytes. By immunohistochemical staining, the neoplastic cells revealed the positivity for pan-CK (AE1/AE3), CK5/6, CK19 and p63, as well as negativity for CD5 and CD117 (Figure ). The field of MEC and type B2 thymoma was distinct in the mass, there was no gradual transition of these two parts observed in mass although they were close to each other in some areas. Based on above findings, a final histological diagnosis of primary combined type B2 thymoma/MEC of thymus was made, and the final staging of this tumor was stage II (Masaoka staging system).\nThe postoperative phase was uneventful and the dysarthria resolved. After diagnosis, the patient was started on pyridostigmine with a remarkable improvement in weakness, diplopia and ptosis. Chemotherapy with regiments of cisplatin and mitomycin, and radiotherapy of the main tumor bed were performed on the patient. Since there was a possibility of tumor metastasis to another anatomical location, the patient was referred to a whole body positron emission tomography (PET)/CT study to search for the potentially secondary tumor, but no abnormality was found. The patient was on regular follow-up for 12 months after discharging from hospital. He had remained asymptomatic, and there was no evidence of tumor recurrence during the period of postoperative follow-up.
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Unusual combined thymic mucoepidermoid carcinoma and thymoma: a case report and review of literature
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You are required to deliver a compact title of this case report, outlining the significant findings
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A 33-year-old man, without known co-morbidities, was brought into the emergency department with sudden onset of headache and severe central chest pain, radiating to the back. The patient arrived 3.5 hours after the onset of symptoms and was still in severe pain.\nThe blood pressure was 180/125 mmHg, heart rate 105 beats per minute (bpm), temperature 36.1°C, oxygen-saturation 98% and the respiratory-rate was 28 per minute. An arterial blood gas (ABG) revealed significant lactate acidosis with pH 7.14, pO2 of 15.4 kPa, pCO2 of 4.5 kPa, bicarbonate of 12 mEq/L, base excess of −16 mmol/L and lactate value of 12 mmol/L. A 12 lead electrocardiography showed sinus rhythm with slight ST-depressions in the leads V4–6.\nBedside echocardiography revealed regional hypokinesia in the lateral area of the left ventricle, and an estimated left ventricular ejection fraction (LVEF) of 20–30%.\nThe patients’ blood samples demonstrated abnormal with a troponin T of 300 ng/L, white blood cell count of 39 × 109/L and normal c-reactive protein.\nAn immediate thoracic/abdominal computed tomography (CT) scan was performed, testing negative for aortic dissection or large pulmonary embolism. However, a 6 cm large tumor in the left adrenal gland was found in .\nDuring the first hours of observation, the patient’s symptoms spontaneously resolved. His vitals normalized and a repeated ABG showed a rising pH (7.33) and decreasing lactate (5.6 mmol/L).\nMeanwhile, the patient’s previous history was explored in more detail. The evening before his admission, he had consumed multiple energy drinks, but denies the intake of alcohol or any other substances.\nNine years earlier, he presented with similar symptoms at another hospital, likewise had spontaneously recovered and was quickly discharged without a firm diagnosis. Similarly, 4 years prior to this admission, the patient was acutely hospitalized with headache, back pain, nausea, elevated lactate, white blood cell count and blood pressure. That admission summary described that all symptoms remitted, his vitals as well as blood values normalized over a few hours and the patient was discharged after a day of observation, without finding a plausible explanation to his symptoms.\nDue to these findings and the suspicion of pheochromocytoma-induced cardiomyopathy, the patient was admitted.\nDuring the 7-day admission, the patient’s vitals remained normal and blood samples including troponin T slowly normalized. A repeated transthoracic echocardiography showed a LVEF of 45% in .\nPlasma cortisol, renin, aldosterone and a 24-hour urine sample for steroid metabolites were within normal range. 3-Metthoxyadrenalin was elevated to 2,5 nmol/L (normal range: < 0,46 nmol/L) as well as 3-Metthoxynoradrenalin at 29,6 nmol/L (normal range < 1,09 nmol/L).\nDuring this observation, the patient reported no symptoms and was discharged for planned surgery in an outpatient setting.\nDue to the size of the tumor (6 cm in diameter) and hence a slightly increased risk of malignancy, open left-sided adrenalectomy was performed [].\nThe patient was discharged on the fifth postoperative day after uncomplicated surgery and observation period. Follow-up showed normalization of 3-metthoxyadrenalin and 3-metthoxynoradrenalin, and the patient had not experienced any symptoms or complications.\nThe left adrenal gland was found with a well-defined pheochromocytoma with a maximum diameter of 25 mm. The tumor morphology was with the growth of large nests and solid areas, high cellularity and areas with spindle cells as well as areas with profound nuclear pleomorphism and nuclear hyperchromasia. Thus, the Pheochromocytoma of Adrenal Gland Scales (PASS) score was 8 in []. It is not possible to predict the malign potential of a pheochromocytoma from the histopathology, but a PASS score > 4 indicates potential for aggressive clinical behavior. Thus, the patient will be followed with annually blood tests (3-metthoxyadrenalin, 3-metthoxynoradrenalin) lifelong. [].
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Pheochromocytoma induced cardiomyopathy in a young man: a case report
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Your role is to provide a brief, accurate title of this medical case report
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A 73-year-old male patient from Aleppo city in Syria referred to a dermatology private clinic and oral medicine clinic in Aleppo University.\nThe patient complains of bullous lesions on gingiva, oral mucosa first, then on scalp, trunk, and face (Figures –). The patient indicates no history of medication. I have followed up the patient to detect bullous lesions if it develops on the skin. Crusted plaques were identified on the scalp, trunk, and face. In oral medicine clinic, clinical intraoral examination indicated to erosions and erythematous on gingiva and buccal mucosa. The patient indicated in the medical history that the oral erosion lesions started few months before the presentation of bullous lesions on his skin. I have referred the patient to a dermatology clinic for evaluation as well. Clinical examination of his skin indicates that the hyperpigmented circular patches were identified over the chest and abdomen as well as a sequel of rupture of bullae. Biopsy of skin lesions from fresh vesicles showed a suprabasal cleft formation and a row of “tomb-stone” appearance of basal cells. Direct immunofluorescence showed deposition of IgG in epidermis (). The diagnosis confirmed as pemphigus vulgaris ().\nThe patient received oral prednisolone (80 mg/kg/day) and azathioprine. The consent form was signed by the patient, and ethical approval was taken from Aleppo University. The dose of prednisolone was slowly tapered down to 40 mg/day (then decrease to 5 mg every three weeks). Specialists in dermatology and oral medicine follow the lesions on his skin and mouth, respectively. All lesions show complete recovery. The patient had received the high doses of prednisolone in hospital at the beginning of treatment. The daily evaluation for this case by specialists in dermatology, oral medicine, and internal medicine is very strict. The patient has complication such as diabetic, fasting blood sugar showing 160 mg/dL, depression, and osteoporosis. The patient remained under the treatment of 5 mg/day and 100 mg/day of prednisolone and azathioprine, respectively. The patient shows complete remission achieved three years from diagnosis. The patient shows side effects such as osteoporosis hyperglycemia and hypertension.
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Pemphigus Vulgaris in Old Patient
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You need to condense this case report into a succinct title
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A 28 year old male presented 18 hrs after sustaining multiple long bone fractures. He sustained fractures to his right femur, both bones of right lower limb and lateral malleolus. Patient arrived in emergency room with respiratory distress for which he was intubated and electively ventilated.\nPatient had no history of loss of consciousness, vomiting or ENT bleed. His vital parameters revealed heart rate of 120 /min, blood pressure of 106/90 mm Hg , respiratory rate of 30/min and Glasgow coma scale(GCS) of 9 (E3M5V1). Computed tomographic (CT) study of the head and CT angiography revealed normal study. Fat globules were not seen in either the urine or broncho alveolar lavage. Fundus examination revealed blurring of right disc margin and left papilloedema. MRI brain done on third day of ICU admission revealed multiple punctuate scattered nonconfluent (T2 flair hyperintense and T1 hypointense) lesions in bilateral cerebral hemispheres (predominantly in subcortical white matter), basal ganglia, thalamus, pons and cerebellum which are suggestive of CFE.\nTracheostomy was done on third day of ICU admission in view of expected long duration of mechanical ventilation. On fourth day of ICU stay, patient had focal seizures and GCS decreased to 8. Phenytoin therapy was initiated for control of siezures. Supportive treatment was continued and early fracture stabilization was achieved once patient improved. Patient was weaned from ventilator and tracheostomy was decannulated 28 days post trauma. There was complete regression of lesions on MRI and the patients recovered completely.
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Cerebral Fat Embolism: A diagnostic challenge
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Your job is to distill the important information into a title from this case report
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A 64-year-old woman was admitted to hospital with painless jaundice later confirmed. Laboratory test revealed elevation of bilirubin (8 mg/dl) and serum tumor marker CA 19-9 and CEA. Further work up by computer tomography (CT) identified a 2 cm hypodense mass within the pancreas head consistent with a pancreatic neoplasm. In absence of vascular involvement and distant metastases, the tumor was assessed as resectable in the multidisciplinary board and the patient was scheduled for surgery. At this point, the preoperative imaging evaluation already identified a replaced right hepatic artery (RHA) arising directly from the gastroduodenal artery (GDA) ().\nThis variant was intraoperatively verified. When the proper hepatic artery (PHA) was dissected out, it became evident that the PHA merged in a single left hepatic artery (LHA) supplying exclusively the left lobe. Further dissection toward the pancreatic mass revealed that the RHA had its origin 1 cm below the bifurcation of the GDA from the common hepatic artery (CHA) (). However, the LHA and PHA were identified as expected. The ‘real’ GDA was assumed to be encased by the tumor, as the distal aspect of the artery was extremely close to the upper border of the mass. After careful dissection, the GDA was distally divided from the RHA () and the mass was removed with correct oncologic margins, following a classical duodenopancreatectomy and Child reconstruction. shows the replaced RHA after removal of the specimen and division of the GDA. The postoperative course was uneventful and was discharged on the postoperative day 11.
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Replaced right hepatic artery arising from the gastroduodenal artery: a rare and challenging anatomical variant of the Whipple procedure
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Your role is to provide a brief, accurate title of this medical case report
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A 25- year old female was presented with complex partial seizure for three months. She had bifrontal headache for last two months which was moderate in intensity and aggravated in the early morning hours. Headache was often associated with vomiting, however vomiting did not relieve headache.\nThe patient was conscious and oriented with time, place, and person. There was no sensory or motor deficit. All cranial nerves were normal. There was bilateral early papilloedema. Enhanced computed tomography (CT) scan of head showed- left temporal cystic mass without any enhancing area with perifocal oedema. The cyst had attenuation value of 7 hounsefield unit [].\nLeft temporal craniotomy was done. After corticectomy, the dilated left temporal horn was opened, which led the clear fluid to come out under pressure. There was a well defined whitish cyst of 2.5cm × 2 cm size present at trigone and was removed in without rupture [].
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Intraventricular hydatid cyst causing entrapped temporal horn syndrome: Case report and review of literature
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You are to provide a brief yet comprehensive title of this case report
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An 80-year-old man had a surgical history of open radical cystectomy with ileal neobladder reconstruction for bladder cancer (pTisN0M0 Stage0is) 5 years prior and an incisional hernia repair using a Ventrio™ Hernia Patch (C.R. Bard; Davol Inc., Warwick, RI) with intraperitoneal implantation technique 3 years prior. He had no other medical history and no family history to mention. He presented to a medical institution with fever and abdominal pain. Computed tomography (CT) scan showed that the mesh that had been used to repair the abdominal wall hernia migrated into the neobladder and ileum. He was diagnosed with entero-neobladder fistula caused by the mesh migration, and conservative treatment with antibiotics (TAZ/PIPC) was started. However, this conservative treatment did not improve the patient's condition, and he was referred to our hospital one month later. A fistula was found on the skin of the lower abdomen (). Urine drainage from the fistula was also observed. Urinalysis was positive for occult blood and bacterial contamination, and the urine culture showed enteric bacteria. Hematological examination revealed a white blood cell count of 8530/μL, which was within the normal range, but C-reactive protein was elevated at 3.81 mg/dL. Cystography showed the neobladder without fistula formation, and cystoscopy showed fecal matter and calcified mesh in the bladder. Abdominal CT scan showed a migrated mesh into the neobladder and ileum (). The patient was therefore diagnosed with mesh migration into the neobladder and ileum with entero-neobladder and entero-cutaneous fistulas related to mesh infection. Mesh removal and partial resection of the neobladder and small intestine were performed (Figures and ). The mesh was tightly adherent to the neobladder and ileum, with fistula formation. The mesh was completely removed, and the neobladder and ileum were partially resected. The defect in the neobladder wall was closed in a straightforward manner, and the resected ileum was only about 20 cm (). The incisional hernia of the abdominal wall was repaired by simple suturing of the fascia (). On the 13th postoperative day, the patient complained of mild lower abdominal pain, and a transurethral (neobladder) cystography was performed, suspecting leakage from the closed site of the neobladder. And it was confirmed that there was no leakage (). On postoperative day 14, the CT scan showed subcutaneous fluid accumulation in the abdomen (). Drainage was required for 10 days, and antibiotics (PIPC) were administered, but after drain removal, the patient was discharged without any complications on postoperative day 40 (). The patient was almost incontinent before surgery and required diapers. Postoperatively, the patient was completely incontinent, and blood tests showed renal dysfunction with an elevated serum creatinine level of 1.5. Since he was unable to perform intermittent catheter drainage by himself, we decided to introduce an indwelling urethral catheter postoperatively. This case was a postradical cystectomy with neobladder reconstruction in an elderly patient, and urinary function could not be preserved. One year has passed since the surgery and he has not had any recurrence, but his urinary catheter is now permanently in place.
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Mesh Migration into the Neobladder and Ileum with Complicated Fistula Formation following Incisional Hernia Repair
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As a medical summarizer, your job is to condense this case report into its key points
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A 44-year-old female was admitted due to abdominal distension and persistent lower limbs edema for over 2 months. Other right-heart-failure-like symptoms caused by systemic congestion were also observed. Transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) found a giant phyllodes mass completely occupies right ventricle (RV, Fig. a) and causes right ventricular outflow tract (RVOT) obstruction (Fig. b). Contrast-enhanced computed tomography showed an irregular and slightly hypodense shadow (6.2 cm × 3.9 cm) with clear border (Fig. ) in RV. MRI calculated ejection fraction of RV has sharply decreased compared with that of the left ventricle (24.1% vs. 55.3%) (Additional File ).\nThe patient underwent a surgery through a median sternotomy with cardiopulmonary bypass and a longitudinal right atriotomy was used to open the heart. A wide base mass originated from the right ventricle free wall and occupies most of the right ventricular cavity. No adhesion to the septal leaflet or chordae tendineae of the tricuspid valve. The tumor was completely excised from its base. The fundus was then cauterized and rinsed. The 9.5 * 5.0 cm neoplasm was a soft, pedicled and well-defined kermesinus mass (Fig. a). Microscopically, stellate cells can be seen scattered in a loose myxoid stroma (Fig. b). The diagnosis of right ventricular cardiac myxoma was hence confirmed. The patient recovered uneventfully and the pre-discharge echocardiogram showed no mass (Fig. ). The patient was followed up for one year, no recurrence was found and the general condition was good.
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Giant right ventricular myxoma presenting as right heart failure with systemic congestion: a rare case report
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Your task is to provide an accurate and brief title of this case report
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A 57-year-old man, with a previous history of uncomplicated type 2 diabetes, was admitted to the ECU on 26 March 2020, for dyspnoea and fever.\nUpon admission, his temperature was 37.2°C, blood pressure was 132/87 mmHg, and heart rate was 107 b.p.m. BMI 27.8 kg/m2. Oxygen saturation was 86% (room air) and respiratory rate was 20/per min. Lung auscultation was normal.\nLaboratory results showed: elevated CRP (52.4 mg/L) and lymphocytopenia. Results for the reverse transcription polymerase chain reaction (RT-PCR) for COVID-19 were positive. Chest CT showed ground-glass opacities and peripheral condensations in both lungs with severe extension (over 50%), typical of COVID-19.\nOn Day 1, the patient was provided with oxygen therapy at 4 L/min, anti-viral treatment with hydroxychloroquine and antibiotic therapy, given the suspicion of a concomitant bacterial infection, and a prophylactic dose of low-molecular-weight heparin (LMWH). On Day 2, respiratory parameters declined and oxygen therapy was increased at 9 L/min. I.V Tocilizumab was administered off-label at 800 mg, allowing stabilization of the respiratory state. On April 30, the patient complained of a pain in the right leg, associated with a cyanotic appearance. The arterial Doppler ultrasound revealed features of acute ischaemia of the right leg, with occlusion of the right superficial femoral artery. The CTA of the abdominal aorta and lower limbs showed multiple intra-aortic thrombi, occlusion of the distal superior mesenteric artery, splenic and renal ischaemic lesions, occlusion of the right superficial femoral artery at the canal of Hunter and occlusion of the left supra-articular popliteal artery (). EKG was normal.\nThe patient was given low-dose aspirin and IV UFH. Thrombectomy or thrombolysis could not be performed, as his respiratory state did not allow general anaesthesia.\nTTE showed physiological mitral regurgitation. Immunoglobulin (IgM) M anti-cardiolipin antibodies (aCls) were slightly positive at 21 Units Isotype M Phospholipid (UMPL, RR <20 UMPL), IgG aCl were negative, as well as anti-β2GP1 antibodies.\nThe patient’s ischaemic manifestations improved under anticoagulation first by IV UFH and then VKA, repeat investigations by CTA and new assessment of aCl were scheduled a month later to discuss a revascularization surgery. The patient was transferred to a rehabilitation unit on April 10.
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Clinical spectrum of ischaemic arterial diseases associated with COVID-19: a series of four illustrative cases
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You need to condense this case report into a succinct title
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A 65-year-old male was referred to the gastroenterology department with obstructive icterus. His medical history was remarkable for arterial hypertension, gastric ulcer, and chronic gastritis, diverticulosis of the colon and sideropenic anemia. He presented with epigastric abdominal pain, nausea, and heartburn. His physical examination revealed icterus of the skin and conjunctiva. His bilirubin was found to be elevated (107 μmol/l). AST and ALT were 114 IU/l and 217 IU/l, respectively. The WBC count was 10.42 × 103/mm [], and segments were 24.7%.\nUltrasound revealed an elongated gallbladder (10.5 cm) filled with sludge and tiny concrements, and the common bile duct was normal in diameter, without visible intraluminal substrate. The liver was slightly enlarged with hyperechogenic parenchyma diffusely. Computed tomography (CT) of the abdomen showed normal liver structure and an enlarged gallbladder without signs of pathological changes in the wall or lumen. MRCP showed choledocholithiasis, no signs of common bile duct dilation, and normal intrahepatic bile ducts ().\nHe underwent ERCP for choledocholithiasis. Access to the major papilla next to a periampullar diverticulum was obtained, and a widened common bile duct was shown with small concrements prepapillary. A sphincterotomy and concrement extraction with a balloon was performed. The procedure passed without complications.\nWhile waking up from the sedation, the patient immediately complained about abdominal pain. The gastroenterologist found the abdomen to be distended and referred the patient to an urgent CT of the abdomen. The WBC was 10.42 × 103/mm []. On CT, free air was found around the duodenum in level of the papilla in the retroperitoneum and around the liver equaling pneumoperitoneum and pneumoretroperitoneum (). Postprocedural pneumobilia in the gallbladder, cystic duct, common bile duct, and intrahepatic bile ducts was found. Free contrast was found around the gastric fundus (), paracolical, and pelvis, and the radiologist suspected duodenal perforation.\nThe patient was referred urgently to the general surgery department. The patient's abdomen was found to be distended with signs of peritonitis, no audible peristalsis. The patient was rushed to an emergency laparotomy. Intraoperative biliary peritonitis was found. After thorough exploration of the upper abdomen and kocherization of the duodenum and head of the pancreas, no perforation of the duodenum or common bile duct was found. Hence, retroperitoneal perforation as the source of the intraperitoneal biliary collection could be excluded. Only when removing the liver retractor on the anterior side of the III, liver segment ruptured, but otherwise, normally appearing bile duct was found with bile secretion into the peritoneal cavity (). The defect was closed with sutures. A choledochotomy was performed, and a T-drainage positioned to facilitate the biliary drainage. Cholecystectomy, lymphadenectomy, and omentectomy were performed too. Since the site of the intrahepatic bile duct rupture was clearly seen, no indication for an intraoperative cholangiography was found; hence, the rupture of the intrahepatic bile duct was not confirmed radiologically during surgery. The procedure ran without complications.\nThe postoperative recovery was uneventful. A cholangiography was performed which excluded the presence of any aberrant intrahepatic bile ducts (). The patient did not develop jaundice postoperatively. The patient was discharged on POD 15.
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A Novel Cause of Biliary Peritonitis after Endoscopic Retrograde Cholangiopancreatography: Case Report and Literature Review
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Your objective is to distill this medical case report into a succinct title
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A 75-year-old female with a past medical history of gastroesophageal reflux disease and Barrett's esophagus status post multiple upper endoscopies and colonoscopies presented with progressive weakness, fatigue, diminished appetite, and diffuse abdominal pain for 3 weeks. The patient stated that she was actively undergoing acupuncture treatments, which relieved her symptoms of gastroesophageal reflux disease over the last 3–5 years until her symptoms returned 1 month prior to admission. She denied any family history of gastrointestinal malignancy. She admitted having occasional dysphagia for solid food, recent weight loss of approximately 5 lbs during the past month, progressive generalized weakness, and a fall. On admission, her vitals were unremarkable except for tachycardia with a heart rate of 123 beats/min. On physical examination, she was alert and responsive. Her abdomen was soft with no guarding, but she had mild epigastric tenderness. Given her tachycardia, a CT angiography of her lungs was done to rule out pulmonary embolism. On this CT angiography, gastric thickening, celiac adenopathy, and multiple large liver masses were incidentally found. This was followed by a CT of her abdomen and pelvis with and without intravenous or oral contrast (Fig. ).\nThe patient's labs revealed markedly elevated CEA of 742 ng/mL (normal ≤3 ng/mL), an AFP of 46,135 ng/mL (normal <12 ng/mL), and a CA19-9 of 6,842 U/mL (normal 0–37 U/mL). Then an upper endoscopy revealed a large mass in the distal esophagus that was not fully obstructing the lumen, but the mass did extend into the stomach (Fig. ).\nBiopsies of the mass and immunohistochemistry stains were performed to confirm EAC. The patient's tumor markers did not confirm any findings of Barrett's epithelium or any mucosal changes to reflect reflux esophagitis. The tissue was negative for HER-2, which can be seen in up to 20% of gastroesophageal adenocarcinomas, and immunohistochemical stains were positive for CDX2, CK7, and Heppar1 and negative for CK20, further confirming that the tumor was less likely due to metastasis from HCC in the liver based on the histochemical properties (Fig. ). Needle aspiration biopsy of one of the large lesions in her liver with staining for AFP revealed EAC with metastasis to the liver (Fig. , ). A Port-A-Cath was placed by General Surgery and the patient was discharged from the hospital and scheduled for outpatient follow-up.\nIn the outpatient office, she was treated with palliative chemotherapy-FOLFOX regimen. She experienced weakness, fatigue, nausea, decrease in appetite, and weight loss and stated that these symptoms occurred around 3–4 days after starting treatment. A repeat CT scan showed significant decrease in size of the known liver metastasis.\nThe patient presented again to the hospital after several months for a blood transfusion for symptomatic anemia of neoplastic disease. The patient stated that she began to have a slowly worsening progression of exertional dyspnea over the 3 months since the prior hospitalization. A CT of the chest and abdomen was obtained to evaluate her symptoms of dyspnea and showed progression of metastatic disease in the liver with an increase in the size of the largest focus although her metastatic lymphadenopathy remained unchanged.
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An Extremely Rare Presentation of an Alpha-Fetoprotein-Producing Esophageal Adenocarcinoma
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Your task is to provide a clear and precise title of this case report
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A 25-year-old gentleman presented to our clinic with a complaint of recurrent pain and swelling on his right cheek of three-month duration. He visited a general practitioner each time, and the condition was resolved with analgesic and antibiotics. However, his symptoms got worse and he attended our Oral Surgery Clinic for consultation.\nThe patient is a fit and healthy young man with no relevant medical history and no known history of allergy. Past surgical history revealed that he had underwent bimaxillary orthognathic surgery one and half year earlier in a local hospital. Although the postoperative period was uneventful, the surgical team informed him that there was a dislodged orthodontic appliance in his right cheek that must have occurred during the operation. The team explained to the patient that this accident was realized later on the next day after the surgery when the molar tube from the right maxillary second molar was found missing, and its presence was confirmed high up in the right maxillary-zygomatic buttress area shown in the postoperative X-ray image taken on the next day following the surgery. A series of further postoperative radiographs confirmed its location, lying outside the right maxillary antrum. Due to the pronounced postoperative facial oedema at that time, no attempt was made to remove the appliance. The absence of sign and symptoms during further follow-up sessions confirmed the decision to leave it in-situ with continuous clinical observation.\nOn examination, there was no extraoral swelling noted. The mandible and maxilla seemed firm indicating good healing following previous mandibular saggital split and maxillary Le Fort I osteotomy sites and a stable class I dental occlusion. Intraorally, there was a sinus with slight pus discharge on the upper right buccal sulcus region adjacent to the upper right first premolar. All teeth in that quadrant were firm and vital. Tenderness was elicited upon palpation on the upper right vestibular region. We suspected the sinus track may originate from the dislodged appliance embedded in the cheek soft tissue. A periapical view was then taken with gutta-percha inserted into the sinus for foreign body localization purpose. The radiograph revealed the gutta-percha pointed towards the site of titanium plate and screws placed used for rigid fixation, and with the molar orthodontic tube appliance in its vicinity (). A cone beam CT was performed to provide a 3D detailed location of the appliance (Figures and ) and confirmed it to be located outside the maxillary antrum.\nThe presence of the molar orthodontic tube foreign body reaction was suspected as the most probable cause of the recurrent right cheek pain and swelling associated with an intraoral discharging sinus. Exploration of the site was performed through the sulcular incision under general anesthesia. The dislodged molar tube was identified lying on the zygomatic bone just beneath the raised flap. It was removed by dividing some surrounding fibrous tissue strands. Just below it, one titanium straight bone plate with four screws used for fixing the previous Le Fort I osteotomy site was inspected and found to be rigidly embedded in normal bone. However, a decision was made to remove them based on the fact that they are present in an infected area. (). The Le Fort I osteotomy site showed good healing with new bone formation. Patient had an uneventful recovery thereafter, and the orthognathic surgical team who attended him previously was informed of his progress.
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Dislodged Bonded Molar Tube into Wound during Orthognathic Surgery
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Your objective is to distill this medical case report into a succinct title
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A 71-year-old man with anorexia and weight loss visited our hospital in December 2018. Laboratory findings showed elevated levels of inflammatory markers and tumor markers including carcinoembryonic antigen [17.8 ng/ml (reference range: 0.0–4.9 ng/ml)], carbohydrate antigen 19–9 [765.9 U/ml (reference range: 0.0–36.9 U/ml)], and squamous cell carcinoma antigen [105 ng/ml (reference range: 0.0–1.4 ng/ml)]. Abdominal computed tomography (CT) revealed enlargement of the gallbladder, which was 80 mm in diameter and involved the S5 segment of the liver and the hepatic flexure of the transverse colon (Fig. a). Abdominal CT detected a nodule in the transverse mesocolon, suggesting peritoneal dissemination or lymph node swelling due to metastasis or inflammation. Colonoscopy revealed an elevated lesion on the transverse colon. Biopsy identified no malignant cells, indicating that the elevation was caused by compression from the tumor (Fig. b). Percutaneous liver biopsy for the diagnosis of the tumor revealed poorly differentiated adenocarcinoma.\nAlthough gallbladder cancer with direct invasion to the liver and the transverse colon was suspected, it was difficult to confirm the diagnosis of the nodule in the transverse mesocolon and the possible diagnoses included peritoneal dissemination, lymph node metastasis, and inflammatory lymph node swelling. Therefore, the clinical stage of the gallbladder cancer was diagnosed as T4N1M1 Stage IV-B (in case of peritoneal dissemination or lymph node metastasis) or T4N1M0 Stage IV-A (in case of inflammatory lymph node swelling) according to the TNM classification of malignant tumors (eighth edition) edited by the Union for International Cancer Control []. Although the tumor was highly advanced, general condition of the patient was favorable and there was a possibility to achieve R0 resection. Therefore, we scheduled surgical resection including right hepatectomy, transverse colon resection, and lymph node dissection after exploring laparotomy confirmed the absence of peritoneal dissemination or remote metastasis.\nThe surgery was performed in January 2019. No ascites or peritoneal dissemination (Fig. a) was observed on exploring laparotomy. Intraoperative ultrasonography revealed no other intrahepatic metastases. Furthermore, there was no para-aortic lymph node swelling by macroscopic and ultrasonographic findings, and therefore, we did not conduct the sampling of para-aortic lymph nodes. The nodule detected in the transverse mesocolon was not a peritoneal dissemination, but a lymph node swelling. Thus, we proceeded with resection of the tumor. Initially, right hemicolectomy was performed and the nodule in the transverse mesocolon was simultaneously removed. Subsequently, right hemihepatectomy was performed with the clamp crushing method using the Pringle’s maneuver. The lymph nodes in the hepatoduodenal ligament were also removed. The operative time was 6 h 18 min and the estimated blood loss was 507 ml. Two units each of red blood cells and fresh frozen plasma were transfused during the operation.\nMacroscopic findings of the specimen revealed a whitish mass, 8.5 × 7.5 cm in diameter, involving the transverse colon (Fig. b, c). Pathological analysis of the tumor demonstrated glandular structures and a tendency toward keratinization in hematoxylin–eosin staining, indicating an adenocarcinoma component and a squamous cell carcinoma component, respectively (Fig. d). Liver was confirmed as the origin of the tumor, since the main tumor lesion was located in the liver and there was no intraepithelial lesion in the gallbladder. The tumor invaded into the mucosal surface of the transverse colon through vascular invasion. Lymph node metastasis was identified in the hepatoduodenal ligament (2/10) and transverse mesocolon (1/3). In terms of lympho-vascular invasion, there were microscopically obvious venous invasion (v3+) and slight lymphatic invasion (ly+) in the infiltrated transverse mesocolon. The surgical margins were negative. Immunostaining of the liver tumor revealed that the tumor was cytokeratin (CK) 7 (+) and CK 20 (−), suggesting adenocarcinoma of the biliary system []. The tumor was CK 5/6 (+) and p 40 (+), indicating that it contained squamous epithelium [, ] (Fig. e). Consequently, the final diagnosis was adenosquamous carcinoma (ASC) of the liver [vp1, vv1, va0, sm (−), T3N1M1, Stage IV-B].\nThe postoperative course was uneventful except slight elevation in the level of hepatic enzymes immediately after the surgery. The patient was discharged 14 days after the surgery without major complications. Although adjuvant chemotherapy using gemcitabine (1000 mg/m2) and cisplatin (25 mg/m2) was administered, follow-up CT at 4 months after the surgery detected metastases to the lung. Although systemic chemotherapy using gemcitabine (1000 mg/m2) and S-1 (120 mg/day) was initiated, the tumor progressed gradually. The patient died 12 months after the operation.
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Transverse colon invasion from intrahepatic cholangiocarcinoma with lymph node metastasis in the regional mesocolon: a case report
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Your role is to extract the core information from this case report
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A 25-year-old man accidentally fell from a cliff and hit his right flank on the ground while camping. Initially, he was able to barely walk, but he ultimately became unable to walk at all due to severe flank pain. His colleague called an ambulance. He had no remarkable personal or family history and was a social drinker.\nInitially, he was transported to a local hospital, but computed tomography (CT) revealed right renal injury with massive retroperitoneal hematoma, so he was transported to our hospital by a physician-staffed helicopter 2 hours after the accident. Upon arrival, he showed clear consciousness but was in a hemorrhagic shock state. His vital signs were as follows: blood pressure, 84/50 mmHg; heart rate, 140 beats per minute; respiratory rate, 30 breaths per minute; percutaneous saturation; and 98% under 10 L/minute of oxygen via mask. He had marked right flank pain. A focused assessment with sonography in trauma was positive at Morrison's pouch. He urgently received 6 units of different-type blood transfusion, and his blood pressure temporarily increased. Enhanced CT revealed extravasation of contrast medium from the injured right kidney with massive retroperitoneal hematoma, which had pushed the visceral organs up into the ventral side (). Blood test findings on arrival are shown in . On returning to the emergency room, he suffered hemorrhagic shock again and subsequently underwent repeated massive blood transfusion, including red blood cells, cryoprecipitate, fresh-frozen plasma, and platelets, and also received tracheal intubation and an indwelling intra-aortic balloon occlusion catheter (IABP) at zone I as a prophylactic measure against cardiac arrest. He was moved to the angio suite for interventional radiology and underwent transarterial selective renal artery embolization, after which he was admitted to the intensive care unit. His vital signs stabilized on hospital day 2. The IABP was removed without inflation. He received 12 units of red blood cell and fresh-frozen plasma, 20 units of platelets, and 4 units of cryoprecipitate within 24 hours. He was extubated on day 3 after initiating diuresis. CT on the same day revealed renal partial infarction without pseudoaneurysmal formation or urinoma. On days 4 and 5, a blood examination revealed increased levels of amylase (360 and 904 IU/L, respectively) with new additional epigastralgia. Enhanced CT on day 5 did not show exudative inflammation around the pancreas, which was still shifted upward by the retroperitoneal hematoma (). Amylase isozyme patterns on day 5 identified the pancreas types, and the lipase level was 3061 IU/L. After receiving a diagnosis of mild-grade acute pancreatitis based on CT findings [], he abstained from food on days 5 and 6. As the severity of acute pancreatitis was mild, he began to eat again from day 7. The maximum amylase level was 1041 IU/L on day 6 and decreased day by day without deterioration of the severity of his acute pancreatitis (). Magnetic resonance cholangiopancreatography on day 12 showed no injury to the main pancreatic duct. As he was able to eat and walk, he was discharged on day 14.
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Posttraumatic Pancreatitis Four Days after Renal Injury with Massive Retroperitoneal Hematoma
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Your task is to provide a clear and precise title of this case report
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A 30-year-old man with a 2-month history of hoarseness, weight loss, and fever received multiples courses of antibiotics and corticosteroids with partial response, developing dyspnea. The patient was hospitalized for further study. A contrast-enhanced computer tomography (CT) of the head and neck showed edema of the larynx without compromising other structures or adenopathies. Direct laryngoscopy exploration showed necrotic tissue and ulcers at the larynx and glottic region, with loss of the normal anatomy of the larynx. A first biopsy described chronic laryngitis with ulcers and unspecific granulation tissue. A microbiologic study, including TB, and the autoimmune study were negative. The patient received antibiotics and corticosteroids to be readmitted to the hospital 1 month later because of fever and dyspnea, requiring a tracheostomy.\nA new CT scan showed edema of the larynx with obliteration of the airway. A laryngoscopic examination showed necrotic tissue in the glottis and larynx, and the biopsy informed necrotic tissue with ulcers and granulation in these structures. The immunologic and microbiologic study was negative again, and the patient received cyclofosfamide and corticosteroids. Later on, the patient was hospitalized a few more times for tracheobronchitis, developing severe supraglottic edema and a swallowing disorder.\nThe patient was finally admitted to our hospital 4 months later. Laboratory exams showed normal white blood cells, erythrocyte sedimentation rate (16), C reactive protein (64, N < 10), procalcitonin (<0.05), lactate dehydrogenase, renal and hepatic function, and negative microbiologic study (blood, urine, and tracheal secretion cultures, and; markers of hepatitis B virus, hepatitis C virus, human immunodeficiency virus, and syphilis). Immunologic tests such as antinuclear antibody, extractable nuclear antibodies, Anti double stranded DNA, anti-myeloperoxidase, anti-PR3, and C3 and C4 complement were all negative or normal. A direct laryngoscopy examination identified ulcerative and necrotic lesions at the epiglottis and larynx, with loss of the larynx's structure (Fig. A). Biopsy specimen and microscopic examination revealed chronic, necrotizing laryngitis, with no granulomas, vasculitis, or atypical cells. Koch culture and TB polymerase chain reaction of tissue samples were negative. Magnetic resonance image (MRI) of the neck demonstrated inflammatory compromise of the glottis and epiglottis partially obliterating the airway (Fig. B-D). Therefore, the patient received 3 boluses of 1 gram of methylprednisolone and started Rituximab (1 gram). A week later, before discharged from the hospital, the patient had normalized inflammatory parameters, and at laryngoscopy, the inflammation and necrotic ulcers at the larynx were in regression.\nA month later, the patient presented with a new episode of tracheobronchitis, fever, erythema, and diffuse enlargement of the right arm. MRI showed myositis of the biceps and brachial muscles (Fig. A-B). Abiopsy of the affected biceps was performed. Infection was rule out, and direct microscopy showed an extensive muscle infiltration by mononuclear cells and abundant mitosis. Immunohistochemistry was positive for CD3, CD8, Ki 67 (90%), and CD56 compatible with extranodal Natural killer / T cell lymphoma (Fig. C). The previous tracheal biopsy was revised and showed the same results described for muscle biopsy.\nThe patient received chemotherapy, 6 cycles of cyclophosphamide, hydroxydaunorubicin, oncovine (vincristine), prednisone protocol followed by radiotherapy. Unfortunately, however, the disease was chemoradiotherapy resistant, and he died 9 months after the final diagnosis.
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An unusual extranodal natural killer/T-cell lymphoma presenting as chronic laryngitis
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Your job is to distill the important information into a title from this case report
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A 1-day-old term male baby, weighing 2800 g, presented with excessive salivation from the mouth. IFT went up to 20 cm and remained coiled up in the long upper pouch. Radiographs with red rubber catheter showed the presence of obstruction at T6/T7 vertebral level []. Operative findings were similar to Case 1 except there was absence of fibromuscular strands between the segments []. Outcome was favorable.
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Kluth Type IIIb6 Esophageal Atresia: Diagnostic Dilemma and Pitfalls of Using Infant Feeding Tube
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You are to provide a brief yet comprehensive title of this case report
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Case 2: The second patient was an 89-year-old male individual with a history of hypertension and delirium. Before surgery, his blood pressure was well controlled, and although he was taking dementia medicine, the patient was able to follow commands well. His pulmonary function test results indicated an obstructive pattern. Total hip arthroplasty was performed using the same anesthetic regimen used for the first patient. While ventilating at an FiO2 of 0.4, the patient showed an onset of hypoxia, with O2 saturation level dropping from 100% to 80% and PaO2 dropping from 129 to 53.0. This patient also showed an improvement of O2 saturation level from 81% to 88% after recovering spontaneous respiration by administering a muscle relaxant-reversing agent. His O2 saturation level improved to 90% with continuous positive airway pressure. Similar to the first patient, the second patient’s O2 saturation level improved to 98% after surgery.\nNeither patient developed any respiratory complications after surgery. The first patient had no notable findings on the postoperative chest X-ray, whereas the second patient showed subsegmental atelectasis on the right middle lobe compared with the preoperative findings ().
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Causes and Treatment of Hypoxia during Total Hip Arthroplasty in Elderly Patients: A Case Report
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Your objective is to distill this medical case report into a succinct title
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A 65-year-old man was referred by the otolaryngology department to our outpatient clinic due to sudden swelling and mild pain around the right eye. On examination, the patient exhibited what appeared to be severe edema encompassing the upper and lower lids of the right eye (). Crepitus was clearly audible on palpation of the eyelids. An attempt to open the lids was unsuccessful. Visual acuity and intraocular pressure could not be measured due to extreme lid swelling. The patient reported that he had undergone transnasal endoscopic nasal polypectomy through the right nostril 2 days earlier. He said he had been instructed not to cough or strain after the endoscopic nasal surgery and the sudden swelling occurred immediately after severe coughing and straining. We suspected that the sinus wall was weakened due to his endoscopic surgery and the increased pressure caused by straining had forced air in the nose into the periorbital area. B-mode ultrasonography showed trapped air in the periorbital area ().\nConsidering the patient’s anxiety, the severity of periorbital emphysema, inability to conduct a full ophthalmologic examination, and the risk of complications such as compressive optic neuropathy, the patient was re-evaluated for a surgical intervention. After consultation, it was decided to evacuate the air using a 21 gauge needle inserted in the subcutaneous tissue of the upper and lower lids. In sterile conditions, the eye area was cleaned with 10% povidone-iodine. A 21-gauge needle was passed through the skin and subcutaneous tissue of the upper and lower lids parallel to the tarsus about 1.5 cm from the lid margin. Evacuation of subcutaneous air was evident from a significant reduction in lid swelling during the procedure (). The patient’s vital signs were stable and the procedure was concluded. He was discharged with systemic antibiotics (cefuroxime axetil 500 mg twice daily) and moxifloxacin drops four times daily.\nOn follow-up examination the next day, the periorbital emphysema was substantially reduced and the globe could be examined (, ). He had full visual acuity in both eyes; intraocular pressure was 17 mmHg in the right eye and 16 mmHg in the left eye. Dilated fundus examination was normal. No restriction in eye movements was observed. Follow-up examinations at 1 week and 1 month revealed no pathological findings.
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Periorbital Emphysema After Endoscopic Nasal Polyp Surgery
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Your task is to summarize this medical case report into a title
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A 75-year-old male underwent a subtotal gastrectomy at 62 years of age. He was diagnosed as a well-differentiated adenocarcinoma confined to the gastric mucosa. He remained in good health until 3 years ago, at which time he noticed a 2 cm asymptomatic mass on the chest wall. The mass was situated 10 cm apart from the previous surgical scar. One week before hospital admission, he experienced pain at the site of the mass and was referred for further evaluation.\nThe clinical condition of the patient was good. Physical examination revealed a firm, smooth, round mass on the anterior chest wall. The size of the mass had not changed since initial presentation. The mass was initially presumed to be a lipoma or epidermal inclusion cyst on physical palpation. However FNA was necessary to rule out a metastatic adenocarcinoma originating from the stomach.\nThe FNA cytology showed low cellular smears containing a few cohesive sheets of polygonal pleomorphic cells with vesicular chromatin, prominent nucleoli, abundant dense cytoplasm, and cytoplasmic vacuoles. Scattered individual polygonal cells were also present in a hemorrhagic background (). Some fibrins were intermingled, and some of the cells showed long cytoplasmic processes suggestive of spindling. Pleomorphic polygonal cells were arranged in alveolar or glandular patterns that were suspected to be metastatic adenocarcinoma.\nThe pathologic findings of the excised mass showed a well-demarcated vascular lesion within the skeletal muscle associated with a hematoma. There was an anastomosing papillary core lined by plump endothelial cells. The papillae contained fibrin-like materials and the endothelial cells were pleomorphic with vesicular nuclei and prominent nucleoli (). Mitotic figures were not observed. The overall cellular features were similar to those observed in the aspirate smears. The cells showed diffuse strong cytoplasmic immunoreactivity for CD34 and factor VIII-related antigen, and were negative for cytokeratin, confirming the diagnosis of intravascular papillary endothelial hyperplasia.
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Intravascular Papillary Endothelial Hyperplasia of the Chest Wall Misdiagnosed as a Malignancy on Fine Needle Aspiration
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You are to provide a brief yet comprehensive title of this case report
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A 21-year-old man was referred to hospital due to recent dyspnea and chest pain for 2 weeks. He had a previous history of atopic dermatitis during infancy, but did not take any recent medications. He denied ingestion of any raw meat, freshwater fish, or liver. He was acute looking, and had bilateral crackles and jugular venous engorgement. Blood pressure (BP) was 84/53 mmHg, pulse rate (PR) was 104/min, respiratory rate (RR) was 16-22/min, body temperature (BT) was 37.2℃. Initial blood tests revealed elevated cardiac enzymes (creatine kinase-myoglobin [CK-MB], 10.5 g/mL [normal range, 0-2.8 ng/mL], and troponin I, 0.09 ng/mL [normal range, 0-0.045 ng/mL]) and brain natriuretic peptide (BNP, 2,824 pg/mL [normal range, 0-88 pg/mL]). Initial emergent complete blood count (CBC) showed blood eosinophil count was within normal range (495/µL) with marked leukocytosis (21,500/µL). However, revealed persistent eosinophilia (810/µL on day 3; 1,485/µL on day 5; 1,960/µL on day 6). Coronary angiography was unremarkable, and transthoracic echocardiography revealed biventricular dysfunction with decreased ejection fraction (EF) of 35%-40%, increased left ventricle (LV) wall thickness, and dilated LV (LV end diastolic diameter, 58 mm). Then initial presumptive diagnosis was made as acute viral myocarditis. However, as blood hypereosinophilia was detected, eosinophilic myocarditis was suspected. Endomyocardial biopsy confirmed the diagnosis, demonstrating myocardial disarray, and diffuse eosinophilic infiltration in myocardial tissues (). Serum total IgE was 214 U/mL (normal range, 0-100 U/mL) and eosinophil cationic protein (ECP) levels were >200 µg/L (normal range, 2-18 µg/L). Antineutrophilic cytoplasmic antibody was negative (). PDGFRβ(5q33) and CHIC2 del(4)(q12q12) fluorescence in situ hybridization were negative. Thus, intravenous prednisolone 60 mg was started, and blood eosinophil counts and dyspnea began to improve. In a month, he discharged with full recovery in LV functions.
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Eosinophilic myocarditis: case series and literature review
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As a medical summarizer, your job is to condense this case report into its key points
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A 69-year-old male underwent combined EGD and colonoscopy performed in the medical intensive care unit for hematochezia. The patient had type 2 diabetes, an ASA score of 4, and no history of ocular disease nor symptoms of corneal injury prior to the procedure. The patient was sedated with 1 mg midazolam and propofol under monitored anesthesia care; supplemental oxygen was administered via nasal cannula at 4 L/min. The procedure time was 2 h and 18 min and no other interventions were performed or complications noted. Upon waking from sedation, the patient complained of discomfort in his right eye with no visual difficulties. On inspection the right eye presented conjunctival injection. Wood’s lamp examination revealed a corneal abrasion. The patient was treated with a topical anesthetic ointment. At a follow-up appointment the next day, the patient reported that the eye redness had resolved and that the pain was much improved.
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Corneal injury after routine gastrointestinal endoscopy with moderate sedation
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Your task is to provide a clear and precise title of this case report
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An 89-year-old lady presented with a one-day history of acute shortness of breath, as well as a cough productive of brown sputum. Her past medical history was significant for chronic obstructive pulmonary disease, ischaemic heart disease, hypertension, hypothyroidism, and previous breast cancer in 2012, for which she remained on hormonal treatment. She lived with her daughter in a house with a full package of care. However her exercise tolerance was limited to only ten yards with a walking frame, which meant she was confined to downstairs living. She denied ever smoking and drank alcohol within the recommended limits. There was no history within the family of any particular illnesses.\nOn arrival to accident and emergency she was clearly in respiratory distress. Her observations were as follows: respiratory rate 40, oxygen saturation of 80% on room air, heart rate 130, blood pressure 200/90, and temperature 39.1 degrees Celsius.\nOn examination there was bronchial breathing with widespread crepitations and wheeze with nil else of significance noted on the initial examination.\nAn arterial blood gas revealed severe type one respiratory failure and blood tests were indicative of an acute inflammatory response with associated acute kidney injury. This lady was initially treated with intravenous benzylpenicillin and clarithromycin as per trust policy for an exacerbation of chronic obstructive pulmonary disease, as well as being supported with oxygen, intravenous fluids, steroids, and nebulisers. She was acutely unwell and had shown little response after 24 hours. As a result, it was felt that she was unlikely to survive this episode—both the patient and family were informed and the patient was placed on the supportive care pathway with a decision being made not to attempt cardiopulmonary resuscitation and for ward based management only. In the meantime her antibiotics were continued but switched to piperacillin/tazobactam (Tazocin).\nShe slowly began to respond to treatment and her oxygen requirements were reducing. During the second day of admission the ward received a call from the microbiology consultant stating that the blood cultures grew Pasteurella multocida within 24 hours, a common commensal organism in the oropharynx of domesticated animals. This triggered the medical team to enquire about any recent animal contact or injuries. The patient then revealed that she had one dog and two cats at home and had been bitten on her hand by her dog the day previous to admission. This information was new and had not been known previously and it was then noted on examination that there was a healing wound on the dorsum of the left hand. Interestingly the family reported that the dog had been increasingly unwell and aggressive for the previous week, with the vet explaining to the family that the dog had a “brain infection” and needed to be “put down.” Cats are more common carriers of Pasteurella multocida than dogs; however she did not provide any history of being recently scratched or licked by her cats [, ].\nThe patient remarkably improved on piperacillin/tazobactam antibiotics, leading to the supportive care pathway being revoked. She was discharged from hospital after receiving ten days of intravenous antibiotics and was sent home with a five-day course of oral coamoxiclav. This lady unfortunately died six months later after a readmission with pleuritic chest pain and acute type one respiratory failure. This was on a background of a recent fall and subsequent fibula fracture. She was too unwell to be investigated extensively but it was felt that the cause of death was likely to be secondary to a pulmonary embolism.
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Infective Exacerbation of Pasteurella multocida
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Your role is to provide a brief, accurate title of this medical case report
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A 46-year-old premenopausal woman had a past medical history of 1-cm papillary thyroid cancer (pT1a) diagnosed at the age of 40 and treated with total thyroidectomy, uterine fibromatosis treated with hysterectomy and bilateral breast augmentation. She was diagnosed in August 2018 with metastatic bilateral infiltrating lobular carcinoma of the breast. In June 2018, she presented with general fatigue. Blood tests performed in August 2018 revealed severe anemia (hemoglobin level, 7.5 g/dl), which required red blood cell transfusions, and a reduction in white blood cell and platelet counts (white blood cell count 2,900/μl; platelet count, 110,000/μl). Other laboratory studies showed elevated alkaline phosphatase. A bone marrow biopsy was performed; pathology revealed that poorly differentiated lobular carcinoma with strong immunohistochemical (IHC) expression of ER (80%) had infiltrated the bone marrow, with reduced numbers of the three hemopoietic cell lines (myeloid, erythroid, and megakaryocytic). An 18-fluorodeoxyglucose-positron emission tomography computed tomography (FDG-PET/CT) showed uptake with activation of the bone marrow in all bone segments, a nuanced uptake in bilateral breast and a pelvic ascitic effusion (, ). Mammography, ultrasonography, and magnetic resonance imaging of the breast found a bilateral multicentric and multifocal disease, consistent with the lobular histotype, with bilateral axillary enlarged lymph nodes. She underwent fine needle biopsy of a suspicious nodule in the right breast, which revealed a moderately differentiated invasive lobular carcinoma. The IHC test proved positive for ER (80%) and PR (80%) and negative for HER2 (1+). The Ki67 labeling index was low (10%). Serum levels of CA15.3 were elevated (46 U/ml).\nThe patient had been suggested to start chemotherapy. However, she was concerned about alopecia and chemotherapy-related side effects in general. Thus, the patient had approached our center for a second opinion. We kept in mind the risks that chemotherapy carried due to the low blood cell count. On the other hand, we were not confident enough to start endocrine monotherapy. We considered the encouraging survival results, together with the not relevant hematologic toxicity, of the combination of ET with the CDK4/6 inhibitor palbociclib. We shared with the patient the possibility of undertaking enhanced ET, adding a new drug recently available in clinical practice, palbociclib, specifying that no data were available on the efficacy and safety of the proposed combination in similar clinical situations. Therefore, we agreed with the patient to start ET with a combination of an AI, letrozole, and a CDK4/6 inhibitor, palbociclib, switching to chemotherapy in case of worsened signs and symptoms of the metastatic disease. We also added ovarian suppression with a luteinizing hormone-releasing hormone agonist (LH-RHa) as the patient was premenopausal.\nIn September 2018, she started palbociclib 125 mg orally daily 3 weeks on and 1 week off, letrozole 2.5 mg orally daily continuously and leuprorelin 3.75 mg intramuscular injections every 28 days. The patient tolerated treatment well, except for grade 1 fatigue, arthralgia, and hot flashes. After the first two weeks of therapy with palbociclib, the patient also had grade 4 neutropenia without fever, which resolved with discontinuation of palbociclib for 3 weeks. Then, the CDK4/6 inhibitor was restarted at the reduced dose of 100 mg daily, with subsequent persistent asymptomatic grade 2 neutropenia.\nAfter 4 months of treatment, her red blood cells and platelet count was restored to within the normal range (hemoglobin level 12 g/dl, platelet count 239,000/μl) with grade 2 neutropenia being treated with palbociclib. Serum levels of Ca15.3 decreased to 18 U/ml. In February 2019, follow-up PET/CT scan showed the resolution of the hypermetabolic breast tumors and bone metastatic foci with the disappearance of the ascitic effusion (). Patient’s subsequent PET/CT imaging every 6 months confirmed complete response to ongoing treatment with last PET/CT performed in June 2020. Last tumor markers over the past 20 months were negative until September 2020. So far, the patient is clinically asymptomatic for metastatic BC and she remains in a durable complete remission for 26 months on this treatment regimen. Timeline of relevant clinical data and therapies are presented in .
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The Therapeutic Challenge of Disseminated Bone Marrow Metastasis From HR-Positive HER2-Negative Breast Cancer: Case Report and Review of the Literature
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Please create a concise title of this case report, focusing on critical details
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A 35 year old female patient presented to the ENT out patient department of the Lok Nayak Hospital, Delhi, with chronic nasal obstruction, excessive sneezing, nasal discharge and frontal headache since several months. Nasal obstruction was of gradual onset, non progressive, more on the left side than right. Nasal obstruction did not respond to standard medical treatment and was of recurrent nature. The nasal discharge was intermittent, purulent and nonfoul smelling. There was no history of hemifacial pain, ear discharge, ear ache, nasal trauma or previous nasal surgery. No history of any allergies to drugs or food products was present. Systemic history was uneventful.\nOn examination the nose showed external parrot beak deformity and there was mild external deviation of the nose to the right. Nasal septum was deviated to right inferiorly, and towards left superiorly. There was Candal deviation to left. Nasal patency was decreased on the right side and Cottle's test was positive. No sinus tenderness could be elicited.\nDifferential leukocyte count of the patient showed eosinophilia suggesting an allergic etiology and the Non Contrast CT PNS revealed a deviated nasal septum towards right, bilateral concha bullosa, mucosal thickening in left frontal recess, left anterior ethmoidal air cells and right sphenoidal sinus and bilateral inferior turbinates. Near total opacification in both maxillary sinuses with blocked osteomeatal units were seen (). There was no bony erosion or invasion on CT scan. The major CT feature of allergic sinusitis is the presence of a soft tissue mass within the involved sinus, seen on unenhanced studies (). Failing any improvement on medical therapy, bilateral fibreoptic endoscopic sinus surgery with septoplasty was planned under GA and the biopsy was excised and sent for fungal culture.\nBoth Gram staining of the impression smears of the tissue crushed between two sterile slides and 10% KOH preparation showed the presence of fungal hyphae. Biopsy material was inoculated on a set of Sabouraud dextrose agar with and without antibiotics and one tube of each set was incubated at 22°C and 37°C respectively. On the 5th day of incubation, a black colored wooly growth was seen in all four tubes. The LPCB preparation of the growth showed phaeoid septate hyphae with internodal branching and macroconidia with alternate septations similar in morphology to Alternaria, but the presence of verrucose, muriform macroconidia borne from short geniculate conidiophores showing 2-3 transverse septa and 1-2 longitudinal and/ or oblique septation indicated towards Ulocladium spp. A slide culture was done and the absence of chains of macroconidia ruled out Alternaria spp. and confirmed the fungi to be Ulocladium botrytis morphologically ().
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An unusual phaeoid fungi: Ulocladium, as a cause of chronic allergic fungal sinusitis
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As a clinical title specialist, your goal is to synthesize the key elements of this case report
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The patient was a 62-year-old man who was previously a smoker and had a medical history of hypertension. During a routine health check, a complete blood count was performed, revealing a severe leukocytosis (white blood cell (WBC): 62 × 109/L). During hospitalization, he did not show any discomfort or signs of illness. The only constitutional symptom was light sweating during night over the previous 3 months, which had possibly worsened over the last week. His vital signs were normal. Clinical examination revealed a palpable spleen and three fingerbreadths below the costal margin. Chest radiography was normal. The spleen was 17.3 cm in length by ultrasonographic measurement, and no hepatomegaly was noted. The results of the blood tests at time of hospitalization are demonstrated in .\nThe blood smear revealed neutrophils at all stages of differentiation, mostly mature neutrophils without any clear signs of dysplasia (71% neutrophils, 10% band forms, 8% metamyelocytes, and 5% myelocytes). There were 1% blasts and no basophils or monocytes ().\nBased on the results of the blood investigations, the patient was suspected to be suffering from CML. A bone marrow examination was performed, which confirmed expanded myelopoiesis without significant dysplasia and presence of 1% blasts. As expected, mutation analyses for JAK2, CALR, and MPL were negative. Moreover, fluorescence in situ hybridization (FISH) analysis for the Philadelphia chromosome, t(9,22), and real-time polymerase chain reaction (RT-PCR) for BCR–ABL1 fusion transcripts, which was initiated before the results of FISH analysis due to high clinical suspicion of CML, also turned out negative. Furthermore, G-banding demonstrated a normal male karyotype (46,XY), and FISH analysis for PDGFRA, PDGFRB, PCM1-JAK2, and FGFR1 rearrangements was negative. Bone marrow biopsy confirmed signs of MDS/MPN, with dominant mature granulocytopoiesis and an increased number of individually spread atypical megakaryocytes ().\nTo further confirm the diagnosis, analysis of a myeloid mutation panel (TruSight Myeloid Sequencing Panel, Illuminas, USA) was performed on the bone marrow aspirate. The panel confirmed clonal hematopoiesis in the presence of EZH2 (variant allele frequency (VAF) 93.5%), CUX1 (VAF 83.5%), TET2 (VAF 53.9%), and BCOR (VAF 12.6%) mutations. These gene mutations are commonly observed in MDS/MPN overlap syndrome, but they are not specific for any entity within the syndrome. According to the 2016 WHO classification system for myeloid malignancies, we classified the patient as having MDS/MPN-U.\nThe patient’s leukocytosis and thrombocytosis (a myeloproliferative feature of the disease) expanded over the next few weeks, and he had light constitutional symptoms. Treatment with hydroxyurea was initiated, and gradually increased to a dose of 1500 mg/day; the treatment was well tolerated. Pegylated interferon-α was added to the treatment and gradually increased to a dose of 100 mg once weekly. Consequently, while the leukocytosis improved, precursors still comprised >10% of nucleated cells. illustrates the blood parameters over time ().\nReduced intensity conditioning (RIC) allo-HSCT with a matched sibling donor was performed 6 months after initial diagnosis, and the disease was stable during this period. The conditioning regimen consisted of fludarabine and treosulfan. Graft-versus-host disease (GvHD) prophylaxis was as follows: methotrexate at days +1, +3, +6, and +11, and cyclosporin A from day −1 with a target serum concentration of 200–300 µg/L. Engraftment occurred with platelets >20 × 109/L on day +15, >50 × 109/L on day +20, and neutrophils >0.2 × 109/L on day +16. The patient developed acute skin and intestinal GvHD (grade I and IV, respectively) on day +60, which was successfully treated with steroids and addition of alpha-1-proteinase inhibitor. The therapeutic range of cyclosporin A was raised. Due to a rise in cytomegalovirus (CMV) DNA transcript levels without signs of CMV-related disease, pre-emptive intravenous ganciclovir was administered from day +90 until CMV DNA transcripts were no longer detected. Evaluation at 3, 6, 9, 12 months, and 2 years confirmed complete remission (CR) with normal blood and bone marrow smears, and donor chimerism >99%.
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Favorable outcome of a patient with an unclassifiable myelodysplastic syndrome/myeloproliferative neoplasm treated with allogeneic hematopoietic stem cell transplantation
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As a medical summarizer, your job is to condense this case report into its key points
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An 18-year-old girl with mild learning disability and poor vision was referred to the vision clinic in a tertiary care hospital. She had been born with no complications at 40-weeks gestation by spontaneous vaginal delivery. The pregnancy was uneventful. At two weeks of age, she had an apneic attack at home, possibly due to choking, and was resuscitated by the ambulance service after 10 minutes of cyanosis. Subsequently, she developed “congenital” nystagmus and maintained good health. She wore glasses for astigmatism. She was studying in mainstream school with the use of magnifiers, as she was having difficulty reading. At secondary school, she was given additional educational support on account of her visual difficulties. Her difficulties not only related to vision but also to her interpretation of the visual environment and this caused embarrassment and lack of confidence.\nOn examination, her visual acuities were right eye 20/80 and left eye 20/60, and 20/40 binocularly for single letters (Snellen's test type). For crowded letters, her binocular visual acuity was 20/80 and N18 for reading material. Extraocular movements were full. There was uniplanar (horizontal) manifest nystagmus with a diminished amplitude (or null point) on slight left gaze. Examination of the eyes was normal. Visual field examination proved difficult unless the patient was prompted, because peripheral visual inattention was evident. No colour vision deficit was identified.\nHer mother described that, as a child, the patient bumped into obstacles and was not able to judge when the pavement ended and the road began. She was unable to identify distant targets. She did not like it when the furniture in the house was moved, as she then bumped into it. She had problems finding objects on a patterned background, that is, she could rarely find her clothes on a patterned bedspread. She hated shopping as she could not cope with the crowds. She explained that it was difficult to recognize faces, especially when concentrating on other things. She found it very difficult to identify the family car from among other parked cars. (a) summarizes the features elicited.\nBinocular VEP to reversing black and white checkerboards (120′ element size) showed delayed P100 recordings (150 ms; upper limit of normal 110 ms). Monocular pattern-onset VEPs showed delayed C1 at 160 ms and 164 ms for the right and left eyes, respectively (upper limit of normal 115 ms). The hemispheric VEP distribution was in keeping with normal chiasmal crossing. Binocular ERGs were normal for photopic and scotopic conditions. These findings render albinism or retinal disorders very unlikely as causes of her nystagmus.\nMRI of the brain showed major structures to be present and intact (). The optic nerves, chiasm, and optic tracts showed no abnormality. The corpus callosum and posterior pituitary gland were normal. There was no significant ventricular dilation or asymmetry in the posterior horns of the lateral ventricles and no gross asymmetry of the cerebral hemispheres. The white matter thickness around this region was normal but the grey matter thickness in both occipital poles was diminished and poorly defined, consistent with a cortical atrophy. Brain folding and myelination, apart from the occipital poles, were normal.
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Uniplanar Nystagmus Associated with Perceptual and Cognitive Visual Dysfunction due to Presumed Focal Ischemic Occipital Cortical Atrophy: A Missed Diagnosis and New Observation
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Your task is to summarize this medical case report into a title
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An 84-year-old woman was found lying on the floor with impaired awareness and transported to our hospital by ambulance. At presentation, the neurological examination by a stroke specialist demonstrated slight right-side upper and lower limb palsy, buccofacial apraxia, and motor aphasia. Palatoplegia or deviation of the tongue was not obvious. Sensory disturbance, including of the face and oral cavity, was not obvious. We did not perform a mental test in detail because of motor aphasia. Diffusion-weighted MRI revealed a new localized lesion in the left primary motor cortex (Fig. a). On the sixth day after onset, VF demonstrated swallowing hesitation with a typical repetitive rippling movement of the tongue (Video 1). The OPT + PFAT was 6.4 s for water and 12.0 s for jelly. From the day after VF, she started to eat softened food for dysphagia. She maintained adequate oral intake and good swallowing function while in our hospital without any obvious aspiration pneumonia. On the 20th day from onset, she left our hospital and was admitted to another hospital for further rehabilitation.
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Clinical Characteristics and Lesions Responsible for Swallowing Hesitation After Acute Cerebral Infarction
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Your objective is to distill this medical case report into a succinct title
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A 46-year-old man with a 6-year history of mild blurring of vision in the right eye was diagnosed with MacTel type 1 (). Visual acuity was 20/20 in his right eye. Photocoagulation scar was observed temporal to the fovea. The OCT scan showed intraretinal cystoid spaces[,]. AO-SLO video was successfully registered, and the constructed capillary image showed microaneurysm. Capillary was visualized more clearly and sharply in images constructed with elastic registration than in images without elastic registration.
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Image Quality Improvement in Adaptive Optics Scanning Laser Ophthalmoscopy Assisted Capillary Visualization Using B-spline-based Elastic Image Registration
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You are to provide a brief yet comprehensive title of this case report
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A 14-month-old boy with hearing loss visited the otolaryngology unit of the department of surgery; the electrocardiogram showed a prolonged QT interval with a QTc of 530 msec. He never experienced syncopal episodes, but his brother had a history of syncope while running in play. Otherwise, no other specific family history of LQTS was found. A Holter study showed neither T wave interruption nor Torsade de points. Treatment was immediately started with atenolol (β-adrenergic blocker), and genetic studies were performed on the patient and his family members (father, mother, and brother). The patient's father and mother showed normal echocardiograms with QTc values of 425 msec and 418 msec, respectively. However, the QT interval of the patient's brother was prolonged (QTc of 547 msec), but hearing loss was not observed.\nAfter obtaining informed consent, we collected peripheral blood samples from the patient and his family. Whole blood was collected in standard EDTA tubes, and DNA was extracted by using the GentraPureGene blood kit (Gentra Systems, Minneapolis, MN, USA) according to the manufacturer's instructions. PCR was performed by using primers specific for 16 coding exons of KCNQ1. The amplified products were sequenced on an ABI 3730 analyzer (Applied Biosystems, Foster City, CA, USA) by using BigDye Terminator v3.1 Cycle sequencing kits (Applied Biosystems). Gross deletions and duplications in KCNQ1 were screened by the MLPA method, using the SALSA MLPA P114 Long-QT probe mix kit (MRC-Holland, Amsterdam, Netherlands).\nThe study was performed in accordance with the Declaration of Helsinki and approved by the institutional ethics review board of the Seoul National University Hospital.\nGenetic analysis revealed compound heterozygous mutations in KCNQ1 consisting of a large deletion (exons 7-10, c.922-?_c.1393+?del, reference sequence: NM_000218.2) and a frameshift mutation (c.1893dup; p.Arg632Glnfs*20) in the proband and his brother. The proband's father was heterozygous for the large deletion (exons 7-10) but did not carry the frameshift mutation, whereas the proband's mother was heterozygous for the frameshift mutation (c.1893dup; p.Arg632Glnfs*20) but neither exon deletions nor duplications were detected ( and ).
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Large Deletion in KCNQ1 Identified in a Family with Jervell and Lange-Nielsen Syndrome
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Your objective is to distill this medical case report into a succinct title
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A 64-year-old woman was admitted to our hospital with a pulsatile mass swelling over the left cervical region and right hemiparesis after cough for 1 day. She had a history of fibromatosis, but no previous history of trauma, operation or inflammation in this region. On physical examination, a 5-cm large pulsatile swelling with blowing bruit was found over the left cervical region and multiple fibromas were found in regions of face, neck, and trunk. Neurological examination revealed muscular strength of grade IV according to the ‘manual muscle test (MMT)' grading system and hypoesthesia of right limbs, including touch and pain sensation. Computed tomography angiography (CTA) and DSA revealed a left high-flow internal carotid-jugular fistula at the first cervical level and twisted left internal carotid artery (ICA) (Figures ). Blood flow from the vertebrobasilar artery and right ICA via the circle of Willis supplied the left anterior cerebral artery and middle cerebral artery and drained backwards into the petrosal segment of left ICA (Figures ).\nWe chose embolization of both the fistula and parental artery, because no appropriate covered stent could be used to pack the fistula in the condition of reservation of left ICA. The purpose of first endovascular treatment was to isolate the fistula, by blocking both the backward blood flow from right ICA and the forward blood flow from left ICA. A Headway-21 stent catheter was selectively inserted into the distal part of fistula in the segment of carotid cavernous sinus, meanwhile an Echelon-10 microcatheter was placed in the distal part of stent catheter. One LVIS 5.5*30 mm stent, with its characteristic relatively compact mesh, was used to cover the distal part of fistula to avoid coils being pushed into internal jugular vein and heart (Figure ). However, the 3.5 cm fistula could not be covered by the LVIS stent. Therefore, 10 coils were additionally used one by one, to block the fistula from the distal to proximal part through an Echelon-10 microcatheter (Figure ). When considering the fast-backward blood flow from the right ICA after embolization, we could not guarantee the safety of blocking by Onyx. We chose one detachable balloon to block the ICA near the proximal part of fistula to stop the forward blood flow, and the backward blood flow would be stopped in the second treatment (Figures ).\nThe blowing bruit was reduced significantly after the first treatment, but became worse after 2 months later. The patient was admitted to our hospital again, and DSA revealed residual blood flow in the fistula from the left ICA and premature balloon deflation (Figures ). It was fortunate that LVIS stent blocked the balloon into the internal jugular vein. An additional 13 coils were used to pack the fistula with double-microcatheter techniques, under the multi-angle DSA projection, to avoid the coil protruding into the internal jugular vein (Figures ). Afterwards, two detachable balloons were used to block the proximal part of left ICA again (Figure ). DSA revealed the forward blood flow disappeared, the low-flow backward blood from right ICA still supplied the fistula, and a normal ipsilateral jugular vein (Figure ). Because the fistula was mostly blocked, and the low-flow backward blood may promote the formation of thrombosis in the distal part of fistula, we stopped the second endovascular treatment and planed a DSA examination to evaluate the effect of embolization and to determine further treatment. After this treatment, the patient did not feel the blowing bruit or any other discomfort.\nHowever, the patient complained of swelling and pain in the left occipitocervical region 2 days later. Physical examination revealed a large subcutaneous mass, with volatility and severe tenderness. Emergent CT revealed a subcutaneous hematoma in left occipitocervical region, without abnormalities in brain (Figures ). DSA in the hybrid operation room showed the coils in the fistula were stable without no forward blood flow in the proximal part of fistula. However, there was still a little backward blood flow through the right ICA and vertebrobasilar artery into right internal jugular vein, via the distal part of fistula. The lower part of fistula was not shown, because the blood drained into the right internal jugular vein through the sigmoid and transverse sinus reversely (Figures ). It was suggested that the occipitocervical subcutaneous hemorrhage was caused by poor ipsilateral jugular drainage, which was the result of the formation of thrombosis in fistula extending to the left internal jugular vein, thus blocking forward and backward reflow. We inserted an Echelon microcatheter through the left vertebrobasilar artery-posterior communicating artery, then selectively to petrosal segment of the left ICA, where 3 coils were put in, and then a 1.2 ml Onyx-18 was injected slowly. DSA examination after this procedure revealed that the backward blood flow distal to the fistula disappeared (Figures ). An open operation to remove the hematoma was preformed after the interventional operation. Multiple capillary hemorrhages were found from behind the sternocleidomastoid muscle after removing clots. The operation to stop bleeding was successful, and the postoperative course was uneventful. A 6-month follow-up DSA demonstrated a totally occluded fistula allowing the patient to engage in light manual labor with normal neurological functioning after the operation (Figures ).
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Endovascular Treatment of Congenital Internal Carotid-Jugular Fistula
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As a medical summarizer, your job is to condense this case report into its key points
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A 57-year-old man presented to Jinhua Central Hospital affiliated with Zhejiang University (Jinhua, China) with a complaint of frequent cough with bloody sputum for 4 days. He denied any history of skin, mucous membrane or eye surgeries; electric cauterisation; or any family history of cancer. Physical examination at the outpatient clinic revealed diminished breath sounds over the lower lobe of the right lung, and no abnormal lesions were detected in other sites of the body, including the skin, head, neck, scalp, anogenital region and eyes. Chest radiography showed a high-density shadow. Subsequent CT plain and contrast-enhanced scan showed a space-occupying lesion in the lower lobe of the right lung adjacent to the pleura with a clear boundary. A right lower lobectomy for the space-occupying lesion was performed and further diagnosed by pathological examination. Before the excision, whole body positron emission tomography–CT (PET-CT) was performed, showing a malignant space-occupying lesion in the lower lobe of the right lung with liver metastasis (Fig. ).\nGrossly, a solitary mass measuring 3.5 cm × 3.0 cm × 3.0 cm was located in the lower lobe of the right lung, appearing as a round, darkly pigmented, solid neoplasm with significant necrosis. Hematoxylin and eosin staining demonstrated that the tumour was located in the lung tissue, comprising malignant epithelial tumour cells with large amounts of acidophilic cytoplasm and prominent nuclei. Melanin pigmentation could also sometimes be noticed, and there were junctional changes with characteristic tumour cells invading the bronchial subepithelial area from the basement membrane. All of these findings were suggestive of MM (Fig. ). Immunohistochemical staining demonstrated that the cytoplasm of the malignant cells was positive for human melanoma black 45 (HMB-45), Melan-A, and S-100 and negative for cytokeratin (CK), CK7, Napsin A, transcription termination factor 1 (TTF1), P40 and P63, confirming the diagnosis of MM (Fig. ).\nBased on the clinical characteristics, CT and PET-CT findings and pathological evaluation, a final diagnosis of PMML was made. After surgery, the patient received one cycle of chemotherapy. However, as his general condition was very poor, the patient died of pulmonary infection 27 days later.
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Primary malignant melanoma of the lung: a case report and literature review
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You are to provide a brief yet comprehensive title of this case report
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A 65-year-old female with a body mass index of 29 presented with a 7-month history of left shoulder pain and weakness. Physical exam and diagnostic imaging were consistent with a symptomatic full thickness rotator cuff tear of the supraspinatus and a partial tear of the subscapularis tendon (Fig. ). She was indicated for an elective arthroscopic surgical repair. She was otherwise healthy with her only medical comorbidity consisting of hyperlipidemia. She had no prior surgical history including no prior shoulder procedures.\nAnesthesia evaluation on the day of surgery was performed and her neck was recorded as “unremarkable.” She was assigned an American Society of Anesthesiologists (ASA) score of 2. On the day of surgery, she was easily intubated with an endotracheal tube in the supine position and then placed in the standard lateral decubitus position for arthroscopic shoulder surgery. Exam under anesthesia was performed followed by a diagnostic shoulder arthroscopy. Normal saline was fed into a Stryker CrossFlow® Integrated Arthroscopy Pump (Stryker Endoscopy, San Jose, CA, USA) set at 25 mmHg initially. Epinephrine was not added to the irrigation fluid. Shortly after beginning the case, the arthroscopic fluid pressure was raised to 35 mmHg to aid in visualization where it remained for the duration of the case. No lavage cycles were utilized. Standard posterior, anterosuperior and anteroinferior portals were placed as well as a lateral working portal. She was found to have a type 1 superior labrum anterior to posterior (SLAP) tear, degenerative changes in the anterior, inferior and posterior labrum, a subscapularis tear in the upper one third which was retracted medially, and a complete supraspinatus tear. A biceps tenotomy was performed followed by rotator cuff repair of the subscapularis and supraspinatus tears utilizing suture anchors. Bone quality was remarkably poor with pull-out of multiple suture anchors during the rotator cuff repair adding to surgical complexity and time. Total operative time was 3 h and 53 min. Upon completion of the case and removal of the surgical drapes, significant unilateral face and neck swelling was noted on the side of the operative shoulder (the non-gravity dependent side). Upon consultation with the anesthesia providers the decision was made to obtain a computed tomography (CT) scan for visualization of the soft tissues surrounding the airway, with a plan to leave the patient intubated overnight. The CT demonstrated diffuse soft tissue edema in the subcutaneous tissues of the neck, chest and face. The airway was deviated at the level of the trachea due to the paratracheal edema. There was no focal collection or extravasated contrast indicative of a hematoma or vascular injury (Fig. ).\nThe patient was monitored overnight in the Intensive Care Unit (ICU). After resolution of the edema, she met standard ICU extubation criteria, and was extubated on the morning of postoperative day one. Postoperatively, the patient has done well without any airway or pulmonary complications, complete resolution of preoperative symptoms, and return to baseline shoulder function (Fig. ).
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Extravasation of fluid in arthroscopic shoulder surgery requiring prolonged intubation: a case report
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Your task is to provide a clear and precise title of this case report
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A previously well 44-year-old female presented with acute lower limb numbness and weakness of 1-day duration. Prior to this, she suffered from back pain for 2 weeks that gradually progressed to pain in both hips as well. There were no complaints of urinary or bowel incontinence. She did not experience any abdominal pain, distension, vomiting or constipation.\nOn examination, the patient had decreased sensation and power in the bilateral lower limbs and up-going plantar reflexes. Abdominal examination revealed no mass or distension. Bowel sounds were active. Anal tone was intact on digital rectal examination.\nMagnetic resonance imaging of her thoracic and lumbar spine with 10 ml intravenous Magnevist showed abnormal marrow replacement affecting the 11th thoracic vertebral body associated with enhancement causing compression of the spinal cord (Fig. ). The initial impression was spine metastases from unknown primary causing spinal cord compression. The patient underwent excision of thoracic spine tumour, decompression laminectomy and fixation the following day. A computed tomography (CT) scan of her thorax and abdomen with 80 ml intravenous Omnipaque 350 was performed 2 days after surgery to look for a primary malignancy. A 2-cm liver lesion (Fig. ) was detected along with an indeterminate 0.3-cm left pulmonary nodule and a single enlarged 1.3-cm para-aortic lymph node. The small and large bowels were normal (Fig. ). Immunohistology of the vertebral tumour revealed epidural Ewing sarcoma. Molecular testing detected presence of t(11;22)(q24;q12) translocation further confirming the diagnosis of Ewing sarcoma.\nThe patient was planned for chemotherapy but, 3 weeks after her spine surgery, she developed symptoms of intestinal obstruction with persistent vomiting, intermittent upper abdominal pain and distension. A repeat CT scan showed multiple new lytic lesions in the vertebrae, right iliac bone and right femur, increase in size and number of liver nodules (Fig. ) and para-aortic lymphadenopathy. It also showed new findings of small bowel dilatation secondary to an entero-enteric intussusception (Fig. ). An emergent laparotomy was performed and jejunal-jejunal intussusception was found (Fig. ) with a 5-cm tumour forming the lead point (Fig. ). There were no other lesions in the small bowel and colon. The affected segment of the small bowel was resected with primary anastomosis. Histopathological examination of the resected small bowel tumour confirmed metastatic Ewing sarcoma, morphologically similar to the spinal tumour (Figs. and ).The entire panel of immunochemical stains including CD99, synaptophysin, chromogranin, MNF-116, AE1/AE3, epithelial membrane antigen (EMA), CD34, HMB-45,desmin and S100 showed similar results in both the vertebral as well as the small bowel tumour (Figs. , , and ).\nThe patient made an uneventful recovery from surgery and was started on palliative chemotherapy. She eventually succumbed to progressive metastatic disease 16 months after her initial diagnosis.\nThe Ewing sarcoma family of tumors (ESFT) consists of Ewing sarcoma, peripheral primitive neuroectodermal tumor (PNET), extraosseous Ewing sarcoma (EES), and Askin’s tumor (Ewing sarcoma of the chest wall). ESFT tumours are of neural crest derivation that differentiate along a neuroendocrine lineage and are described as small round cell tumours. All ESFT tumours are characterized by a balanced chromosomal translocation between the 5ʹ half of the EWS gene (22q12) and the 3ʹ half of members of the ETS family of transcription factors, leading to the understanding that ESFT represents a single neoplastic entity [].\nEwing sarcoma predominantly affects children and young adults with a peak incidence between 10 and 20 years of age. About 30 % occur in adults over the age of 20 and fewer than 5 % occur in adults over the age of 40 []. Ewing sarcoma most often arises in the mid-shaft or diaphysis of the long bones of the extremities with the spine making up only 8 % of primary sites of Ewing sarcoma []. Our patient, being a 44-year-old female adult, did not fit the typical profile of an Ewing sarcoma patient and was initially treated as spinal metastases from a yet undetermined primary. It was only on histopathological examination of the spinal tumour that the diagnosis of Ewing sarcoma was reached.\nThe presence of metastasis is the single most important factor in determining survival in ESFT patients. Patients with metastatic disease at diagnosis have a dismal 5-year survival rate varying from 0–25 %, compared with 40–79 % for those with localized disease [, ]. Chemotherapy is essential in the treatment of Ewing sarcoma because although approximately 80 % of patients present with clinically localized disease, subclinical metastatic disease is presumed to be present in almost all patients due to a 80–90 % relapse rate noted in patients who underwent local therapy alone []. It is possible that our patient had occult metastases that continued to rapidly progress after excision of the primary tumour before commencement of systemic chemotherapy. Metastases are mostly found in the lungs (50 %), bone (25 %) and bone marrow (20 %) []. Only eight cases of primary Ewing sarcoma of the small bowel have been reported [–, , ], and metastasis of Ewing sarcoma to the small bowel is even rarer with Capitini reporting a case of a 26-year-old male with metastasis of left femur Ewing sarcoma to the small bowel and brain following allogenic stem cell transplantation.\nIntussusception is the invagination of a bowel loop with its mesenteric fold (intussusceptum) into the lumen of a contiguous portion of the bowel (intussuscipiens) as a result of peristalsis. Intussusception is rare in adults, accounting for 1–5 % of all cases of intestinal obstruction and 5 % of all intussusceptions []. Most cases of intussusception in adults are due to a pathologic lead point within the bowel and are malignant in over 50 % of cases [], thereby necessitating surgery and resection of the affected bowel segment. In the small intestine, an intussusception can be secondary to the presence of intra- or extra-luminal lesions which include inflammatory lesions, Meckel’s diverticulum, postoperative adhesions, lipoma, adenomatous polyps, lymphoma and metastases or iatrogenic (the presence of an intestinal tube, in patients with a gastrojejunostomy, etc.). Malignancy (adenocarcinoma) accounts for up to 30 % of cases of intussusception occurring in the small bowel []. In 2003, Boehm [] described a case of ileoileal intussusception in an 18-year-old male who presented with a protracted course of abdominal pain and vomiting for several weeks. The intussusception was eventually discovered on laparotomy and histopathology of the resected bowel revealed primary Ewing sarcoma. Our patient suffered from intussusception as well, although the cause was due to a large jejunal intraluminal metastasis from her primary spinal ES. No bowel mass was evident on her initial CT scan (Figs. and ), but her subsequent CT performed after development of intestinal obstructive symptoms showed not only new development of small bowel intussusception but also progression of metastatic disease (Figs. , and ). The resected jejunal metastatic tumour, possibly a result of haematogenous spread, displayed the same histomorphological and immunohistochemical characteristics as the vertebral primary tumour (Figs. , , , , and ).
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A case of small bowel metastasis from spinal Ewing sarcoma causing intussusception in an adult female
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You are tasked with extracting and summarizing the essential information from this case report
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A 28-year-old female gravida 3 para 2, who was 28 weeks pregnant, presented to a county hospital with complaints of auditory hallucinations (AH), visual hallucinations (VH), and paranoia. The patient had no known psychiatric history with the onset of psychotic symptoms beginning one week prior to presentation. It was later confirmed by collateral contact that the patient was suffering from three months of depressed mood, anhedonia, crying spells, decreased sleep, energy, and appetite. On presentation, the physical exam was benign, vitals, complete blood count (CBC), comprehensive metabolic panel (CMP) were within normal limits (WNL). The patient was not taking medications, herbal supplements, or illicit drugs and urine drug screen (UDS) was negative. CT and noncontrast MRI were both unremarkable. The patient was diagnosed with major depressive disorder (MDD), severe with psychotic features, and was started on sertraline (SRT) and olanzapine (OLZ). SRT was titrated up to 50 mg per day and OLZ to 20 mg per day.\nConcurrently, the patient admitted to four weeks of nausea, vomiting, and limited oral intake resulting in a 10-pound weight loss. She was diagnosed with hyperemesis gravidarum (HG) and started on the combination of IV famotidine 20 mg twice a day (BID), doxylamine succinate 12.5 mg four times per day (QID), and pyridoxine 25 mg QID. Despite this treatment, her nausea and vomiting continued resulting in the addition of ODSN to be utilized on an as-needed basis (PRN). The first administration of ODSN was one day after admission with the majority of doses given three to eight days after admission. The total daily doses never exceeded 12 mg.\nFive days following admission, LFTs were assessed with the AST measuring at 73 units/liter (U/L) and ALT at 113 U/L. On the next day, the AST and ALT continued to rise to 111 and 176 U/L respectively. A comprehensive workup was performed to identify the cause of her hypertransaminasemia. Laboratory tests assessing for hepatitis A, B, and C were all negative, anti-smooth muscle antibody was negative and antinuclear antibodies, alpha-1 antitrypsin, ceruloplasmin, total bilirubin, and alkaline phosphatase levels were all normal. The right upper quadrant ultrasound showed no abnormalities. Pre-eclampsia and the associated hemolysis, elevated liver enzymes, and a low platelet count (HELLP) syndrome were ruled out due to normal measurements of blood pressure, urine protein to creatinine ratio via 24-hour urine collection, platelet count, and hemoglobin level. With most causes ruled out, drug-induced liver injury became the leading explanation for her elevated transaminases. As such, her medication regimen was reviewed and OLZ was identified as a possible causal agent due to the known association of OLZ and hepatotoxicity []. The patient was switched to haloperidol (HDL) and titrated up to a total daily dosage of 20 mg. Despite this switch, her LFTs continued to rise. Eight days after her admission, the patient’s nausea and vomiting improved, resulting in tolerance of oral intake and requiring only two doses of 4 mg ODSN for the remaining six days of her hospitalization. Some 10 days following her admission, her transaminases plateaued with AST measured at 267 U/L and ALT at 605 U/L. Her transaminases down trended for the remainder of her hospitalization approaching normal limits by the time of discharge. With her psychosis and nausea significantly improved and transaminases approaching normal range, she was discharged after 14 days in the hospital. She was instructed to take HDL 20 mg per day, SRT 50 mg per day, famotidine 20 mg BID, pyridoxine 25 mg QID, ODSN 4 mg PRN, and doxylamine 12.5 mg PRN.\nIn the following month, the patient was admitted on two additional instances to the psychiatric emergency room (PER) for psychosis prior to delivery. On both occasions, it was determined, with the assistance of collateral information that her decompensation was due to medication noncompliance. On the first admission, her CBC and CMP were WNL and UDS was negative. She quickly reconstituted when she was restarted on HDL and was discharged home in two days. Some 19 days following this discharge, the patient presented resulting in her third admission. Similar to her previous encounter, no abnormalities were found on laboratory testing or UDS and she quickly reconstituted once she restarted HDL. After carefully weighing the risks and benefits, it was determined she would benefit from a long-acting injectable form of HDL, Haldol Decanoate. The patient received a 100 mg intramuscular injection of Haldol Decanoate, continued on oral HDL and SRT, and discharged home.\nSeventy-two days following her initial admission, the patient presented for delivery. Upon admission, the patient was linear, organized, and showed no signs of psychosis. She claimed to be adherent to HDL 10 mg, SRT 50 mg, and utilized ODSN 4 mg PRN. She denied the continuation of famotidine, pyridoxine, and doxylamine succinate. It is unclear how frequently she self-administered ODSN. On admission, the patient was nauseous with a low appetite. Her AST and ALT were measured at 348 and 575 U/L, respectively. The patient received a dose of 4 mg ODSN on the first day of admission and was continued on SRT and HDL. She received another dose of 4 mg ODSN on her third day of hospitalization and her transaminases continued to rise. Later that night, she delivered via planned cesarean section. Following her delivery, she experienced a rapid resolution of her nausea and did not receive additional ODSN. Over the next three days, she recovered from her delivery and her transaminases significantly down trended resulting in discharge.
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A Rise in Aspartate Transaminase and Alanine Transaminase Associated With Ondansetron Administration in a Pregnant Female
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As a medical summarizer, your job is to condense this case report into its key points
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A 53-year-old man was referred to our hospital in 2014 for investigation of biliary enzyme elevation. In 1999, at the age of 38 years, he suffered from severe hepatitis due to acute hepatitis A accompanied by chronic hepatitis B. He underwent LDLT with a right lobe graft donated by his younger brother at a transplant center. The donor was HBsAg positive, but there was no other eligible donor. Therefore, LDLT from the HBsAg-positive donor was performed after approval by the institutional review board of the transplant center. After LDLT, the patient continued to be HBsAg and hepatitis B virus (HBV) DNA positive despite the use of anti-HBV immunoglobulin and nucleoside analogues (lamivudine and adefovir) because of appearing lamivudine-resistant HBV strain. He received tacrolimus as an immunosuppression after LDLT. He did not experience any acute cellular rejection. He had an iodinated contrast medium allergy.\nPhysical examination was normal except for the operation scar of LDLT. Laboratory investigations showed a hemoglobin level of 13.3 g/dL and a white blood cell count of 3,480/µL. The serum C-reactive protein level was slightly elevated to 0.49 mg/dL (normal range, <0.14). The results of biochemical analysis of the blood were total bilirubin 1.2 mg/dL (normal range, 0.4–1.5), aspartate aminotransferase 55 IU/L (normal range, 12–31), alanine aminotransferase 81 IU/L (normal range, 8–40), alkaline phosphatase 2,355 IU/L (normal range, 100–330), γ-glutamyl transpeptidase 1,413 IU/L (normal range, 11–73), carcinoembryonic antigen 6.0 ng/mL (normal range, <3.4), carbohydrate antigen 19-9 39 U/mL (normal range, <37.0), alpha-fetoprotein 1.9 ng/mL (normal range, <7.0), and des-γ-carboxy prothrombin 20 mAU/mL (normal range, <40.0). HBsAg, hepatitis B core antibody, and hepatitis B e-antigen were all positive. Hepatitis C antibody was negative. Liver biopsy from the background liver showed mild inflammation and fibrosis probably due to chronic hepatitis B and did not suggest rejection. Abdominal ultrasound (US) showed a low-echoic nodule at segment 5/6 (Fig. ). Biliary dilatation was not observed. Contrast-enhanced real-time ultrasound imaging with Sonazoid® (Daiichisankyo, Tokyo, Japan) showed that this nodule was hypervascular in the arterial phase (Fig. ), followed by a defect in the postvascular phase (Fig. ). These US findings suggested this tumor to be a solid tumor but not liver abscess, and the enhancement pattern was heavily suggestive of malignancy such as HCC. Magnetic resonance imaging (MRI) examination showed a 15-mm mass in segment 5/6 of the right lobe of the liver, with low intensity on T1-weighted image and high intensity on T2-weighted as well as diffusion-weighted image. Dynamic contrast-enhanced MRI with gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (EOB-MRI) also showed hypervascularity in the arterial phase (Fig. ). In the hepatobiliary phase of EOB-MRI, the tumor showed low intensity, similar to findings in HCC (Fig. ). Although the tumor markers alpha-fetoprotein and des-γ-carboxy prothrombin were not elevated, the mass was clinically diagnosed as HCC because the patient had chronic HBV infection. 18F fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) was performed to exclude the possibility of metastatic liver tumor from other organ malignancy. It revealed abnormal uptake in the liver tumor but no abnormal uptake in other lesions (Fig. ), supporting the diagnosis of hepatic malignancy including HCC.\nWe referred the patient to the transplant center where his LDLT had been done to treat the tumor surgically. However, the tumor became unclear on EOB-MRI after 1 month (Fig. ). A structure showing high intensity on T1-weighted MRI image was found at the roots of the right hepatic biliary duct (Fig. ). A similar lesion was also retrospectively found on the initial MRI images (data not shown). Therefore, the patient was treated by percutaneous transhepatic cholangiodrainage and then biliary sludge was removed (Fig. ). We then followed him carefully. Six months after the first examination, the tumor had completely disappeared on EOB-MRI (Fig. ) and biliary sludge was not detected (Fig. ). We therefore considered the tumor as an IPT secondary to biliary tract infection due to biliary-jejunum reconstruction. The patient's clinical course was good and no recurrence was found for 3 years.
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Vanishing Tumor in a Liver Graft from a Hepatitis B Virus Surface Antigen-Positive Donor
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As a medical summarizer, your job is to condense this case report into its key points
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Case 3: A 76-year-old male patient presented to the hospital with diarrhea and coughing and a history of one-week common cold. Chest CT showed minor pulmonary changes in favor of involvement with coronavirus, and the PCR test was positive. After 5 days of admission, he could not move his legs and could not stand or walk. Therefore, electrodiagnostic tests to evaluate lower limb weakness were performed. During the EDX examination, the patient was absolutely conscious under nasal auxiliary oxygen without intubation or respiratory distress. EMG/NCS showed the mixed type axonal and demyelinating sensorimotor peripheral neuropathy, which could be related to early stages of GBS or one of its axonal variants because only 5 days passed and the findings of electrodiagnostic criteria for typical GBS was not completely fulfilled yet (). IVIG 20 g per day for 5 days concomitant anti- COVID treatment was started for the patient, and after 2 weeks of admission, he was discharged to home with good recovery.
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Electrophysiologic findings in patients with COVID-19 and quadriparesia in the northwest of Iran, A case series study and literature review
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Your role is to provide a brief, accurate title of this medical case report
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A 60-year-old woman with known NF1 displaying the classical features including multiple neurofibromas was admitted with signs of acute appendicitis. She presented lower right-sided abdominal pain, distended abdomen, and elevated infection parameters and underwent laparoscopic appendectomy. She was in good health until the appendicitis and had never experienced any carcinoid symptoms. Besides an inflammatory affected appendix the pathology report showed a tumor with multiple infiltrating microglandular elements of goblet cells with signet ring cell features appearing as a goblet cell carcinoid subtype B (). The diagnosis of a goblet cell carcinoid was confirmed by positive immunostaining for the neuroendocrine markers chromogranin A (CgA) () and synaptophysin (). Further, mucin was seen in Alcian blue-stained slides (). Proliferation index showed a Ki67 index of 30–40%. There was no sign of extension throughout the appendix wall but the resection margins were positive. Therefore, a right-sided hemicolectomy was performed with free margins and no lymph node metastases. Serologically, tumor markers serotonin and CgA were slightly increased while urinary 5-HIAA, carcinoembryonic antigen (CEA), cancer antigen 19-9 (CA 19-9), and cancer antigen 125 (CA 125) were all normal after surgery. Computer tomography (CT) scan showed no signs of metastases in the abdomen or thorax, which indicates the cancer has been radically resected. The somatostatin receptor scintigraphy was negative as expected [].
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Goblet Cell Carcinoid in a Patient with Neurofibromatosis Type 1: A Rare Combination
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Please create a concise title of this case report, focusing on critical details
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A 29-year-old African American lady was brought into the emergency department with abdominal pain and recurrent headaches for four weeks, dizziness for a week, and an episode of syncope. She had crampy abdominal pain that was mild and progressive, associated with constipation but no nausea, vomiting, or abdominal distension. Headaches were mainly frontal, lasting a few hours, and transiently relieved with Tylenol. She denied any visual changes, photosensitivity, or eye pain. She developed dizziness about a week prior, which was worsened on standing, and improved on lying down. She fell a few times. She had a syncopal event lasting a few minutes with altered mental status following awakening, hence she was brought for further evaluation. The review of systems was significant for a 10-pound weight loss in a month, palpitations, fatigue polydipsia, and polyuria.\nOn presentation, her vital signs were within normal limits, except for mild tachypnea. Physical examination showed an obese lady, who was alert and fully oriented, with dry oral mucosa, pale conjunctiva, and an enlarged neck mass.\nLaboratory investigations showed moderate microcystic anemia, creatinine of 1.7 mg/dL (normal range 0.6-1.2 mg/dL), calcium of 21 mg/dL (normal range 8.5-10.5 mg/dL), phosphate of 2.2 mg/dL (normal range 2.5-4.5 mg/dL), and lipase of 450 U/L (normal range 5-55 U/L). Other investigations included parathyroid hormone (PTH) of 4.36 pg/mL (normal range 12-88 pg/L), 25 hydroxy vitamin D of <7 ng/mL (normal range 30-100 ng/mL), 1, 25 dihydroxy vitamin D of 18 ng/mL (normal range 18-72 ng/mL), PTHrP of 33 pg/mL (normal range 14-27 pg/mL), and TSH of 0.20 uIU/mL (normal range 0.34-5.60 uIU/mL)\nMagnetic resonance imaging (MRI) of the brain showed a 3.6 cm dural-based left frontal lobe mass invading the inner table of the left frontal calvarium and extending into the left frontal sinus (Figure ). A computed tomography (CT) scan of the neck showed marked heterogeneous enlargement of the right thyroid gland measuring approximately 8.7 x 5.2 x 11 cm (Figure ). CT of the abdomen and pelvis showed an enlarged uterus with heterogeneous attenuation and enlarged endometrial canal, approximately 9.8 x 13.4 x 17.3 cm (Figure ).\nFurther imaging revealed generalized lymphadenopathy, multiple hypodense liver lesions, infiltrations, and edema of the pancreatic head, and mixed lytic and sclerotic osseous lesions in the pelvis, with pathologic fracture of the right pubic ramus. An assessment of symptomatic severe hypercalcemia likely from metastatic neoplasm, acute interstitial pancreatitis, acute kidney injury, and brain lesion with mass effect was made and she was admitted into the intensive care unit for management. She received high-flow intravenous (IV) fluids, IV pamidronate, IV dexamethasone, and IV levetiracetam. Her calcium down-trended rapidly from 21 to 10.8 in three days of management, and she showed corresponding clinical improvement.\nMultiple pathological results from biopsies of uterine, liver, thyroid, and brain masses showed high-grade neuroendocrine neoplasms of an unknown primary site.
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Severe Hypercalcemia as the Initial Presentation of a Neuroendocrine Carcinoma of Unknown Primary Site: A Case Report
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Summarize this medical case report, ensuring to cover the initial presentation
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Our patient was a 21-year-old Chinese man with a history of congenital idiopathic pectus excavatum without a history of documented cardiac or pulmonary compromise. He was initially seen by the authors reporting of a marked reduction in physical ability whenever he put on a loaded body vest and backpack for training. The attire was a new requirement that arose as a result of a new vocation. At the time of consult, our patient was forthcoming in the description of his symptoms. He had experienced marked dyspnea on exertion, central chest tightness and easy fatigability, which resolved upon removal of the heavy load followed by a few minutes of rest. As a result, he was never able to actively participate in proper training when in full gear, and was never able to keep up with the rest of his colleagues. Prior to this vocation, he was an active sportsman with an outstanding physical condition despite the pectus excavatum defect. His exercise routine included running of more than 30 minutes three or more times per week. His records revealed that he was able to complete a 2.4 km run in 10 minutes whilst in singlet and shorts only. A routine resting pulmonary function test, echocardiography and electrocardiography performed prior to his vocational change did not demonstrate any significant abnormalities (Table ).\nUpon physical examination, the caved-in appearance of his anterior chest was clearly observed (Figure ). Compensatory anterior flaring of his lower ribs at the costal margins was noted. The apex beat was undisplaced and his heart sounds were normal. No murmurs or other additional sounds were heard. His lung sounds were clear and of equal intensity bilaterally. Plain chest radiographs with anteroposterior and lateral views were subsequently taken, along with computed thoracic tomography (Figure ). Interestingly, a Haller index of 2.5 was obtained, which is considered to be of mild severity based on such anatomical considerations only. Due to the nature of the precipitating factors (that is, the body vest and backpack) leading to his symptoms, it was highly possible that his chest wall defect compromised his pulmonary function upon load-stress. In order to provide objective evidence to support his symptoms, he agreed to undergo static pulmonary function testing while putting on a body vest and backpack weighing 30% of his body weight. The test was performed on a spirometer (Microlab ML 3500) under close supervision, with the best effort amongst three results recorded. The amount of air which can be forcibly exhaled in the first second (forced expiratory volume in one second, FEV1) and the total amount of air which can be forcibly exhaled after maximal inspiration (forced vital capacity, FVC), were measured. Interestingly, the results showed that, although his pulmonary function at rest was normal when he was in normal work dress (FEV1 94.3%, FVC 92.2%, FEV1/FVC: 86.7), there was a significant deterioration with a restrictive pattern when wearing the body vest and backpack (FEV1 75.5%, FVC 69.3%, FEV1/FVC 92.3). On the other hand, a physically-matched healthy control who voluntarily agreed to undergo the same test did not demonstrate such a drastic deterioration in lung function (Figure ). Throughout the tests, physical examination and vital signs were otherwise generally unremarkable. A definitive diagnosis of restrictive lung function triggered by load-stress was made in this patient with idiopathic pectus excavatum, and he was subsequently referred to a cardiothoracic surgeon for follow-up.
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Objective effect manifestation of pectus excavatum on load-stressed pulmonary function testing: a case report
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You are required to deliver a compact title of this case report, outlining the significant findings
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A 43-year-old woman visited the Emergency Department (ED) of our University with bilateral sudden hearing impairment. The hearing loss had occurred suddenly with fever and vomiting a day before the visit to the ED and associated symptoms were: tinnitus that seemed like a machine humming, mild dizziness, fever peaking at up to 40°C, a painful rash (on the right upper eyelid, chest, back, forearms, and lower extremities), arthralgia in both the hip and knee joints, and vision loss in the right eye. The patient had no history of autoimmune diseases or surgery.\nUpon physical examination, both tympanic membranes were normal, and examination with a tuning fork showed left lateralization for the Weber test, and both ears were positive for the Rinne test. A rash could be seen all over her body, and her eyesight was measured to be 0.2 in the right eye, and 0.9 in the left eye (Fig. ).\nLaboratory test results were: high-sensitivity C-reactive protein (hsCRP) 160.12 mg/L, erythrocyte sedimentation rate (ESR) 79 mm/hr, and Seg neutrophil 84.10%. Pure tone audiometry (PTA) was performed on the second day after hearing loss had occurred (Fig. A), and showed bilateral sensorineural hearing loss. For a diagnosis of SS, clinical symptoms must satisfy both of 2 major criteria, and more than 2 of 4 minor criteria (Table ). Our patient had abrupt onset of painful erythematous plaques which met the major criteria, with pyrexia (>38°C) and abnormal laboratory values (3/4; erythrocyte sedimentation rate >20 mm/h, positive C-reactive protein, >8000 leukocytes, and >70% neutrophils) that satisfied the minor criteria. For a definitive diagnosis, we performed a skin biopsy with samples from the skin on her back; the results were consistent with acute febrile neutrophilic dermatosis (Fig. ). Intravenous prednisolone was given, and topical steroids were applied to the skin lesions.\nThere were no remarkable findings from brain magnetic resonance imaging and magnetic resonance angiography, but right orbital cellulitis, as shown by the diffuse soft tissue swelling and enhancement in the right upper and lower eyelids, was found on facial computed tomography (CT). After a week of treatment, there was no change in vision but skin lesions had improved. Follow-up on the hearing test showed an improvement of up to 20 dB in both ears. The patient was discharged after a week of treatment, with follow-up at the outpatient clinic after 1 month. Vision examination performed at the outpatient clinic showed a vast improvement to 1.2 in the right eye, and 1.2 in the left eye. After 3 months, the hearing test showed full recovery: 11 dB in the right ear, and 8 dB in the left ear (Fig. B).
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Bilateral sudden sensorineural hearing loss with Sweet syndrome
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As a medical summarizer, your job is to condense this case report into its key points
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A 48-year-old man came to our hospital for sudden effort dyspnea. The patient underwent seven years ago to aortic valve replacement (AVR) with 25 mm On-X (On-X Life Technology Inc., Austin, TX, USA) mechanical prosthesis for severe aortic valve regurgitation and ascending aorta replacement with a tube graft n 28 for ascending aorta aneurysm. The AVR was performed using three semicontinuous (2-0 Prolene, Ethicon, Somerville, NJ, USA) suture technique. The surgeon used three similar sutures with knots tied among them, hence the term semicontinuous. According to a "parachute technique" the sutures were suspended (left loose) to enable an easier suturing of the aortic annulus and sewing ring of the artificial valve prior to lower the prosthesis. Then a gentle alternate traction on the three semicontinuous sutures, usually with the help of a surgical nerve hook, is applied to pull up the redundant suture. This could weaken the suture and lead to its failure at a later date.\nA yearly transthoracic echocardiography (TTE) follow-up didn't show any pathological findings. The TTE, performed as soon as the patient was admitted to Emergency Room (ER), revealed a severe aortic regurgitation due to a PVL. The ejection fraction was normal but the left ventricle was dilated: indexed end diastolic volume (iEDV) 107 ml, indexed end systolic volume (iESV) 45 ml. The transesophageal echocardiogram (TEE) confirmed the severe aortic regurgitation, showing an aortic non coronary sinus PVL with a partial detachment of aortic prosthesis. Figure clearly documents the PVL.\nPreoperative 3 D, 24 slices, Computed Tomography Scan (CT-scan) showed perfect patency of coronary arteries and severe retrosternal adhesions.\nAfter the sternum reopening and adhesions dissection, the ascending aorta tube graft was opened. The surgical findings confirmed a partial prosthesis detachment at the level of the non coronary aortic sinus, due to the semicontinuous suture breaking (Figure ). The other two sutures of the left and right coronary sinuses were intact. After the prosthesis explant, a new aortic mechanical prosthesis was implanted (23 mm S. Jude, S. Jude Medical, St. Paul, MN, USA), using interrupted suture technique with 2-0 Ethibond (Ethicon) polytetrafluoroethylene (Teflon)-buttressed stitches. The Teflon buttresses were positioned in the ventricular aspect of the annulus. The postoperative TEE showed normal position and function of the prosthesis The postoperative course was uneventful and the patient was shortly discharged.
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Non infective severe aortic paravalvular leakage 7 years after surgery: the role of suture technique
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