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ashy dermatosis is a hypermelanotic disorder of the idiopathic variety characterized by bluish - grey macules in healthy individuals . it is a controversial entity and is sometimes considered as a variant of lichen planus . etiology of ashy dermatosis is mostly unknown and it usually affects the face , arms , neck , and trunk . ashy dermatosis usually has a symmetrical distribution but cases with unilateral presentation have also been observed . lichen planus pigmentosus , occupational dermatosis with hyperpigmentation , drug - related dermatoses , universal acquired melanosis , and familial progressive hyperpigmentation are the common entities confounding diagnosis . our case was a 20 year - old indian male who presented with slowly progressive , diffuse darkening of the face , arms , neck , and trunk seen over the last two years [ figures 1 and 2 ] . he had no previous history of skin diseases and was not on any kind of medication during this two - year period . laboratory investigations suggested normal blood counts , blood glucose level , normal liver and kidney function test and normal acth stimulation ( sensitive ) test results . bluish black discoloration of face , chest , and upper extrimity bluish black discoloration of neck and back oral mucous membrane and palate are not involved it has been a controversial topic that has showed a tendency to appear mostly in dark colored individuals and also in asians . confusion also arises because the disease is also known by many different names like erythema dyschromicum perstans and lichen planus pigmentosus . others have suggested that ashy dermatosis presents clear clinical characteristics but that histopathological findings are not specific . our differential diagnoses revolved around lichen planus pigmentosus , occupational dermatosis with hyperpigmentation , drug - related dermatoses , universal acquired melanosis , allgrove 's syndrome , dermatomyositis , and familial progressive hyperpigmentation syndrome . absence of occupational exposure ruled out occupational dermatosis with hyperpigmentation ; dermatomyositis is a condition of muscle weakness , and allgrove syndrome is characterized by alacrima , achalasia , and acth insensitivity . but the patient did not show any of these symptoms and signs . a normal creatinine phosphokinase ( cpk ) level ruled out the chances of dermatomyositis , and a normal barium meal x - ray and acth sensitivity test ruled out allgrove syndrome . the patient had not taken any drugs in this period.so drug - related dermatosis was ruled out . the histopathological study was not conclusive enough to differentiate from lichen planus pigmentosus but the absence of pruritus , the lack of involvement of the oral mucosa , and the bluish - black discoloration in our patient , a dark colored indian in his second decade of life support our diagnosis in favor of ashy dermatosis of the idiopathic variety . the only treatment in this condition resulting in considerable improvement in pigmentation is clofazimine at a dose of 100 mg three times per week for three to five months .

we present here the case of a young indian male with slowly progressive , diffuse darkening of the face , arms , neck , and trunk . the patient was not taking any medication and there was no history of any previous skin disease and the mucous membrane was not involved . these findings are consistent with a diagnosis for ashy dermatosis of unknown etiology .

according to the eau guidelines nephron - sparing surgery ( nss ) has a similar oncological outcome to that of radical surgery . however , nss is not suitable in some patients with localized renal cell carcinoma ( rcc ) because : 1 ) of locally advanced tumor growth , 2 ) partial resection is not technically feasible because the tumor is in an unfavorable location , 3 ) and/or significant deterioration of the patient 's general health . in these situations the gold standard curative therapy remains radical nephrectomy , which includes radical removal of the tumor - bearing kidney . acute pancreatitis has not yet been described in the published literature as a complication of radical nephrectomy . a 56-year - old patient was referred to the department of urology at the medical university of graz for right renal tumor ( ct scan verified a 12 cm renal mass ) to perform a radical nephrectomy . the preoperative anesthetic screening of our patient showed asa ii according to the american association of anesthesiology and well - controlled hypertension with normal laboratory blood tests . there were no co - existing infections the histological examination of the right kidney revealed a renal cell carcinoma ( rcc ) . the operation was uneventful . however , one day later the patient complained of gradually increasing , serious abdominal and back pain , including jaundice and fever . on physical examination , the patient had neither a history of biliary lithiasis nor chronic alcohol consumption or infections . laboratory data ( blood ) demonstrated urea 61 mg / dl ( n : 10 - 45 ) , uric acid 8.5 mg / dl ( n : 3.4 - 7 ) , potassium 4.3 mmol/ ( n : 3.5 - 5 ) , calcium 1.99 mmol / l ( n : 2.202.65 ) , aspartate aminotransferase 216 iu / l ( n : 0 - 35 ) , alanine aminotransferase 134 iu / l ( n:0 - 45 ) , lactate dehydrogenase 404 iu / l ( n:120 - 240 ) and amylase 989 iu / l ( n : 13 - 53 ) , lipase 2154 ( 0 - 60 ) , and procalcitonin 3.45 ( n:0 - 0.5 ) . white blood cell count was also raised ( 13000 ) , as well as crp 268 mg / l ( n:0 - 8 ) , bilirubin 1.43 ( n:0.1 - 1.2 mg / dl ) , and creatinine 2.78 mg / dl ( 0.6 - 1.3 ) . an abdominal ct scan was performed and demonstrated parenchymal edema of the pancreas ( figs . 1 and 2 ) . the patient was referred to the intensive care unit and treated conservatively for 15 days his medical condition improved and he was referred to the department of gastroenterology , where mr cholangiopancreatography showed no biliary stones , and a normal liver . the international symposium on acute pancreatitis in 1992 defined pancreatic necrosis as the presence of one or more diffuse or focal areas of non - viable pancreatic parenchyma . so , based on the patient 's clinical presentation and ct scan findings , the diagnosis of acute pancreatitis as a complication of radical nephrectomy was considered . the patient was referred to the intensive care unit ( icu ) and oral intake was prohibited . a nasogastric tube was inserted for decompression and parenteral nutrition was started from a central vein . ten days later , serum pancreatic enzyme levels and white blood cell count returned to normal ranges bowel movements became normal , and the patient passed stool . on the same day , the nasogastric tube was removed and restricted oral intake was permitted . on day 16 transperitoneal radical open nephrectomy is a generally accepted treatment for a renal mass greater than 10 cm in size . in the published literature according to burkey retroperitoneal dissection and ischemia could be risk factors for postoperative pancreatitis . however , this was not the case in our patient and trauma to the head of pancreas was avoided . according to milian et al the mortality rate of pancreatitis was 8.3% for conservative medical treatment versus 26.5% for surgical treatment . physicians should consider pancreatitis as a potentially life - threatening adverse event associated with propofol [ 6 , 7 ] , which may be due to failure of free fatty acid metabolism secondary to inhibition of free fatty acid entry into the mitochondria . we hypothesize that propofol could have played a role in the pathophysiology in this condition , because no biliary stone was demonstrated on preoperative or postoperative radiologic studies in the presented case . additionally , no other predisposing factors ( e.g. alcohol , infection , addiction or hypercalcemia as well as history of chronic pancreatitis ) for pancreatitis were present in our patient .

radical open nephrectomy is considered the standard treatment for kidney tumors or masses greater than 10 cm . we present a rare case of acute pancreatitis that occurred after right radical transperitoneal nephrectomy , which was treated by nonsurgical conservative interventions.the incidence of acute pancreatitis after renal surgery is not known in the literature.a 56-year - old man developed acute pancreatitis postoperatively after radical transperitoneal nephrectomy . an initial ct scan showed an enlarged pancreas with hypodense , heterogeneous consistency and with peripancreatic , perihepatic , mesenteric , and pelvic fluid collections . this complication was managed conservatively .

a 44-year - old , para 2 , female with chronic pelvic pain was admitted for microlaparoscopic conscious pain mapping to evaluate the cause of her pain . the patient had undergone a cesarean hysterectomy in 1979 during her last delivery secondary to having multiple large leiomyomata . over the next decade , she suffered from chronic right - sided pelvic pain that was unrelieved with conservative medical therapy including hormonal therapy , nonsteroidal anti - inflammatory drugs , and narcotic medications . a laparotomy with bilateral salpingo - oophorectomy and appendectomy were performed , which revealed endometriosis . , the patient underwent 14 laparoscopic surgeries at various centers with minimal to no improvement . although many of the operative reports describe fulguration of endometriosis and lysis of adhesions , others reported normal findings . after an extensive history and physical examination were obtained and a review of the available medical records and videotape of her most recent laparoscopy was conducted , she was offered the option of undergoing micro - laparoscopic conscious pain mapping . prior to surgery , the patient was familiarized with the conscious pain mapping procedure and pain scoring system . she was asked to rate her pain on a scale of 0 , no pain , to 4 , severe pain . the procedure was conducted in the outpatient surgery center of a private community hospital . with the patient in the supine position , conscious sedation ( atropine 0.2 mg , ondansetron hydrochloride 4 mg , midazolam hydrochloride 1 mg , and fentanyl citrate 350 g given slowly and titrated at 50 g increments to effect ) was administered intravenously . periumbilical and suprapubic blocks were administered at operative sites of 10 ml of 1% lidocaine with epinephrine 1:100,000 buffered with sodium bicarbonate ( 10:1 dilution ) . a pneumoperitoneum was created with carbon dioxide using the insuflow device ( georgia biomedical inc . , macon , ga ) after inserting a veress needle and 2-mm cannula . after advancing a 2-mm microlaparoscope ( minisite , us surgical corp . , norwalk , ct ) into the peritoneal cavity , a second 2-mm cannula was placed in the suprapubic region and a 2-mm manipulating probe directed into the pelvic cavity . diagnostic microlaparoscopy and conscious pain mapping were performed by systematic probing of the pelvic cavity and obtaining intraoperative patient feedback regarding the presence or absence of pain . inspection of the pelvis confirmed a previous hysterectomy , bilateral salpingo - oophorectomy and appendectomy . the posterior cul - de - sac had a few small powder - burn endometriosis lesions that produced a minimal pain score of 1 ( out of 4 ) . however , the patient had old sutures with granulation tissue ( figure 1 ) over the right pelvic brim with a pain mapping score of 4 ( figure 2 ) . this exquisitely painful area was probed a second time to authenticate its role as the pain focus . fulguration of the site was performed with 2-mm monopolar cautery scissors at a power setting of 40 w spray coagulation ( figure 3 ) . she tolerated both the diagnostic and operative components of her surgery under local anesthesia with conscious sedation . at the scheduled 2-week and 6-month postoperative visits , she reported being completely pain - free without the use of analgesics . chronic pelvic pain accounts for approximately 10% to 15% of a woman 's visits to the gynecologist , up to 50% of diagnostic laparoscopies , and many hysterectomies each year . interestingly , a variable percentage of patients have no pathologic findings with the traditional laparoscopic approach under general anesthesia . physical examination sometimes provides confusing and minimally useful data for evaluating chronic pelvic pain . in a large study of 1194 patients with chronic pelvic pain , normal pelvic examinations were found in 749 patients . not surprisingly , in 479 patients with chronic pelvic pain and a normal examination , 63% had abnormal findings during diagnostic laparoscopy . however , 17.5% of the study patients with an abnormal pelvic examination had a normal diagnostic laparoscopy . it is for this latter subgroup of patients that conscious pain mapping may provide more clinical information than with traditional laparoscopy under general anesthesia . she subsequently underwent a bilateral salpingo - oophorectomy and appendectomy without symptom relief . over a period of 12 years , she underwent 14 laparoscopies , all performed under general anesthesia . although some of these operative reports describe the presence of endometriosis , adhesions , or both of these , none addressed the sutures in the right pelvic brim . further confusing the patient 's clinical picture is the fact that no consistent relationship existed between the severity of endometriosis and pelvic pain . the burned out endometriosis lesions seen during conscious pain mapping produced a low pain score of 1 . once electrosurgery to fulgurate the lesion over the right pelvic brim was performed , the patient 's pain score dropped from a severe 4 ( out of 4 ) to an insignificant score of 1 . it is critical to perform conscious pain mapping in patients with chronic pelvic pain who have undergone unsuccessful surgical attempts to resolve their pain .

chronic pelvic pain is a debilitating , life - altering syndrome that negatively affects a woman 's quality of life and personal relationships . many women continue to suffer with pelvic pain despite having undergone multiple medical and surgical treatments . unfortunately , some women are incorrectly labeled as having psychological illness when organic disease may be present . i report a case of a woman who underwent multiple pelvic and abdominal surgeries before the cause of her pain was identified through microlaparoscopic conscious pain mapping .

primary ovarian failure ( pof ) is a syndrome composed of amenorrhea , estrogen deficiency and follicular stimulating hormone ( fsh ) of menopausal ranges in young women . in this article a 29-year old woman with a history of primary amenorrhea attended hospital with full term pregnancy . she had experienced a few episodes of withdrawal bleeding on hormonal treatment initially and she had conceived spontaneously . this case was presented to emphasize the real chances of spontaneous conceptions due to intermittent and unpredictable ovarian function in patients with poi . nevertheless , egg donation is still considered the best option for infertility in such women . fuller albright first described a condition he termed primary ovarian insufficiency ( poi ) in 1942 when he reported a syndrome of amenorrhea , estrogen deficiency and menopausal follicular stimulating hormone ( fsh ) levels in young women ( 1 ) . herein , we report such a case that had primary amenorrhea and presented with full term pregnancy . a 29-year - old woman attended antenatal out - patient department of north eastern indira gandhi regional institute of health and medical sciences ( neigrihms ) , shillong , meghalaya , india with full term pregnancy in october 2009 . she gave a very interesting history of primary amenorrhea with a few episodes of withdrawal bleeding upon hormonal treatment in the past . for the past 3 4 years she had not been receiving any treatment and had remained amenorrhoeic . after 4 years of marriage , she went to a local doctor for nausea and vomiting and , to her surprise , her urine pregnancy test was positive . her expected date of delivery ( edd ) was calculated from the first trimester ultrasound , which confirmed the gestational maturity . on examination , , uterus was found to be in the form of a full - term pregnancy . the fetus was in cephalic presentation and fetal heart rate ( fhr ) was 136 beats per minute and regular . per vaginal examination revealed a closed internal os with soft , short and central cervix . caesarean section was performed on maternal request and a healthy male baby weighing 2.5 kg was delivered . primary ovarian insufficiency has varied manifestations of amenorrhea , oligomenorrhea or dysfunctional uterine bleeding . overall , approximately 10% of women with poi present with primary amenorrhea ( 2 , 3 ) . a similar case of spontaneous pregnancy has been reported in a 27-year old woman with hypergonadotropic ovarian failure ( 4 ) . we suspected her to be a case of primary ovarian insufficiency on the basis of history alone and in the absence of any laboratory test of increased fsh , since we admitted her for the first time in full term pregnancy . this case was reported to emphasize the real chances for a spontaneous conception because of the intermittent and unpredictable ovarian function in these patients . primary ovarian insufficiency occurs in only 1% of women it can still result in spontaneous pregnancy in 5 - 10% of the cases . women with poi should be educated on the nature of the disease and the current research efforts . it is important to be aware of the condition and the options for future treatment .

introductionprimary ovarian failure ( pof ) is a syndrome composed of amenorrhea , estrogen deficiency and follicular stimulating hormone ( fsh ) of menopausal ranges in young women . in this article , we report a case of primary amenorrhea that presented with full term pregnancy.case presentationa 29-year old woman with a history of primary amenorrhea attended hospital with full term pregnancy . she had experienced a few episodes of withdrawal bleeding on hormonal treatment initially and she had conceived spontaneously . subsequently , she had uneventful pregnancy and caesarean delivery on maternal request.conclusionthis case was presented to emphasize the real chances of spontaneous conceptions due to intermittent and unpredictable ovarian function in patients with poi . nevertheless , egg donation is still considered the best option for infertility in such women .

neuropsychiatric manifestations are included : p0 eripheral neuropathy , myeloneuropathy , cerebellar ataxia , optic atrophy , mood disorders , psychosis , personality changes , loss of memory , depression , dementia , confusion and more rarely reversible manic and schizoferniform status and obsessive compulsive disorder ( ocd).[18 ] psychiatric manifestations of b12 deficiency seldom precede anemia.[68 ] we present a case of b12 deficiency in which ocd precedes anemia . a 29-year - old female came with anxiety and history of ocd since 11 years ago . general blood chemistries including thyroid function tests , liver function tests , renal function tests , cbc diff , hemoglobin level and iron profile had been performed 5 months ago and all were in normal ranges [ table 1 ] , but further investigations in recent visit showed mild anemia ( hb=11.8 g / dl , mcv=89 fl ) and markedly diminished serum cobalamine level to < 30 pg / ml and also iron deficiency with significant decreased ferritin level to 1.28 ng / ml [ table 2 ] . laboratory findings of first visit laboratory findings of the recent visit the association between b12 deficiency and iron deficiency in this case was our explanation to her normocytic anemia . diagnosis of b12 deficiency with ocd manifestation and concurrent iron deficiency was made and parenteral b12 and oral iron replacement therapy initiated . in this 29-year - old female , ocd was the early manifestation of b12 deficiency . although , it was rarely reported , but psychiatric and mood disorders may be the first manifestation of b12 deficiency and precede anemia.[68 ] we recommend checking serum b12 and folate level in any case with psychiatric disorder such as ocd , even in the absence of anemia and other hematologic manifestations of b12 and/or folate deficiencies . b12 replacement therapy can resolve symptoms of psychiatric disorders in patients with b12 deficiency.literature review shows that patients with ocd have dysregulation in serotoninergic system and efficacy of serotonin reuptake inhibitors ( sris ) in the treatment of ocd was demonstrated.[912 ] neurotransmitters ( dopamine , serotonin and melatonin ) are necessary for a normal balanced mood , emotions and also sleeping . folic acid and vitamin b12 act as cofactors in synthesis of neurotransmitters such as serotonin and norepinephrine . although it is rare but psychiatric manifestations of b12 deficiency may precede anemia as we saw in this case .

b12 acts as a cofactor in synthesis of neurotransmitters such as serotonin and dopamine , thus b12 deficiency affects mood , emotions and sleeping and can lead to psychiatric disorders . psychiatric manifestations of b12 deficiency are varied . they seldom precede anemia . we want to present a case of b12 deficiency which was presented with obsessive compulsive disorder .

the birth of a baby with a tail can cause tremendous psychological disturbance to the parents . isolated case reports of various types of human tails have been described in the literature . the main features and imaging findings of six patients have been summarised in table 1 . the plain radiographs showed spina bifida in three patients at l 5 and s 1 . summary of main features and imaging findings of all patients other than patient number 5 ( lumbar lipomeningomyelocele ) , all other patients underwent surgical excision . the parents of patient number 5 refused to give consent for the operation and the patient was lost to follow - up . on histopathological examination , the specimen of sacrococcygeal teratoma showed mature tissues that included bones , cartilage , fat and neural tissues , whereas other tails showed mature adipose tissue , blood vessels and nerves . a vestigial tail describes a remnant of a structure found in embryonic life or in ancestral forms . during the 5 to 6 week of intrauterine life it contains adipose tissue , connective tissue , central bundles of striated muscle , blood vessels and nerves and is covered by skin . it can move and contract and occurs twice as often in males as in females . none of our patients showed any movement of the tail . unlike the tail of other vertebrates , human tails do not contain vertebral structures . the additional lesions found with pseudo tails are lipomas , teratomas , chondromegaly and gliomas , and there may be elongated parasitic fetus . human tail usually occurs in the lumbosacral region , but it has also been reported in the cervical region . teratoma in the human tail has also been reported . in a review series of 48 skin - covered lumbosacral masses the preoperative assessment includes a complete clinical examination including neurology , plain radiographs of the spine and computed tomography or magnetic resonance imaging . an occult spinal lesion has been reported in around 50% of the cases . in another review by lu , tail in the midline of lumbar region tail in the left side of the buttock , away from the midline tail in the midline of lumbar region tail in the midline of lumbar region tail in the midline of lumbar region ( lipomyelomeningocele ) sacrococcygeal teratoma with tail , away from the midline

human tail is a curiosity , a cosmetic stigma and presents as an appendage in the lumbosacral region . six patients of tail in the lumbosacral region are presented here to discuss the spectrum of presentation of human tails . the embryology , pathology and treatment of this entity are discussed along with a brief review of the literature .

this genus comprises of gram - negative , strictly - aerobic , non - fermenting , non - fastidious , non - motile , catalase - positive , oxidase - negative bacteria with dna g + c content of 39.0% to 47.0% . according to euzeby 's list of prokaryotic names with standing in nomenclature ( http://www.bacterio.cict.fr/a/acinetobacter.html ) acinetobacter guillouiae proposed by nemec et al . was isolated from sewage - containing gas - work effluent and shares characteristics corresponding to those of the genus acinetobacter . a. guillouiae strain msp 4 - 18 , isolated from a mangrove soil sample from parangipettai ( 1130n , 7947e ) , tamil nadu , india , was grown on tryptic soya agar medium ( tsa ; himedia ) at 30 c . genomic dna was extracted from 36 hour old culture using zr fungal / bacterial dna miniprep as per manufacturer 's instructions . amplification and sequencing of 16s rrna was performed as described by mayilraj et al . . identification was confirmed using 16s rrna sequencing . to determine the phylogenetic relationship of strain msp4 - 18 , the 16s rrna sequence consisting of 1502 bp was compared with those of type strains of species of related genera and identification of phylogenetic neighbors and the calculation of pairwise 16s rrna gene sequence similarities were achieved using the eztaxon server and aligned using mega version 5.0 . bootstrap analysis was performed to assess the confidence limits of the branching ( fig . 1 ) . the genome of a. guillouiae msp 4 - 18 was sequenced using the illumina - hiseq 1000 technology . sequencing resulted in 26,685,818 paired - end reads ( insert size of 350 bp ) with a length of 101 bp . a total of 26,465,246 high - quality reads with approximately 550 coverage were assembled with clcbio wb6 ( word size 40 and bubble size 60 ) to obtain 94 contigs ( n50 , 128,068 bp ) of 4,848,959 bp and average g + c content of 38.0% . the functional annotation was carried out by rast ( rapid annotation using subsystem technology ) , fig . 2 shows the subsystem distribution of a. guillouiae strain msp 4 - 18 , trna was predicted by trnascan - se 1.23 and rrna genes by rnammer 1.2 . the genome contains 3 rrna genes ( 5s-23s-16s ) and 69 aminoacyl - trna synthetase genes . a total of 4543 coding regions ( 2294 genes transcribed from the positive strand and 2249 from the negative strand ) were found in the genome , of which 3052 ( 67% ) could be functionally annotated . the genome coding density is 83% with an average gene length of 883 bp . the annotated genome has 106 genes responsible for resistance to antibiotic and toxic compounds including 13 genes for mdr efflux pumps . sixty five genes are involved in oxidative stress , 12 in osmotic stress , 15 for heat shock and several others for response to various other stresses , to make a total of 107 genes responsible for stress response in this organism . the functional comparison of the genome sequences available on the rast server revealed the closest neighbors of a. guillouiae msp 4 - 18 as acinetobacter baumanii ab0057 ( score 502 ) followed by a. baumanii aye ( score 500 ) , acinetobacter johnsonii sh046 ( score 494 ) and a. baumanii acicu ( score 494 ) . the a. guillouiae msp 4 - 18 whole genome shot gun ( wgs ) project which has been deposited at ddbj / embl / genbank under the project accession asqg00000000 of the project ( 01 ) has the accession number asqg01000000 and consists of sequences asqg01000001asqg01000094 . the authors declare that there is no conflict of interest on any work published in this paper .

the genus acinetobacter consists of 31 validly published species ubiquitously distributed in nature and primarily associated with nosocomial infection . we report the 4.8 mb genome of acinetobacter guillouiae msp 4 - 18 , isolated from a mangrove soil sample from parangipettai ( 1130n , 7947e ) , tamil nadu , india . the draft genome of a. guillouiae msp 4 - 18 has a g + c content of 38.0% and includes 3 rrna genes ( 5s , 23s , 16s ) and 69 aminoacyl - trna synthetase genes .

most cases of hematuria can be diagnosed by urinalysis , urine culture , urinary cytology , computed tomography , and rigid and flexible cysto - ureteroscopy . we present a rare cause of hematuria that was challenging both to diagnose and to treat . a 50-year - old woman presented with a 1-month history of painless gross hematuria without clots . she was a known diabetic , hypertensive and ischemic heart disease patient and on regular treatment but not on any anticoagulants . on examination , she was hemodynamically stable . urinalysis revealed significant hematuria . bleeding time , clotting time , liver function tests , urine culture and urine cytology were unremarkable . cystoscopy with retrograde pyelogram revealed efflux of blood from the right ureteric orifice and a filling defect in the renal pelvis [ figure 1 ] . biopsy of the floating brownish lesion with attachment to the renal pelvis using a semi - rigid ureteroscope was reported as fibrocollagenous material with no evidence of malignancy . however , the semi - rigid ureterorenoscope was unable to definitively rule out malignancy and flexible ureteroscope was planned . the patient continued to have hematuria and received eight units of packed red blood cells and eight units of fresh frozen plasma . however , she developed swelling and ecchymosis at the right thigh ( puncture site ) , which was confirmed to be a pseudoaneurysm in the duplex scan . during anamnesis , it was revealed that the patient had bruises 2 weeks ago following insulin injection . filling defect rgp retrograde pyelogram at this juncture , her activated partial thromboplastin time ( aptt ) was raised but d dimer , fibrinogen and fibrin degradation product were normal . the bethesda test confirmed acquired factor viii inhibitor syndrome with a value of 1.6 bethesda unit . flexible ureteroscopy showed hyperemic patches and brownish floating material in the right renal pelvis that was completely removed using a dormia basket . the patient was subsequently managed jointly with a hematologist and treated with prednisolone and factor viii inhibitor bypass activity ( feiba ) , and hematuria settled . isolated presentation of hematuria is even rarer as these bleeding disorders are accompanied by bleeding at other sites . acquired factor viii inhibitor syndrome is one such condition with an incidence of about one case per million per year . in this condition , autoantibodies are formed against factor viii . acquired hemophilia is different from the congenital type as it has no genetic inheritance pattern and hemarthroses are seldom present . it could cause significant morbidity with bleeding tendencies , and the mortality rate is 8 - 22% . acquired hemophilia is associated with autoimmune disorders , malignancy ( solid , lymphoproliferative ) , skin diseases ( pemphigus , epidermolysisbullosa ) , infections , drugs and post - partum state , but these are mostly idiopathic . the diagnosis is based on isolated prolongation of activated partial thromboplastin time not corrected by ptt correction study and confirmation by nijmegen modification of the bethesda assay showing reduced factor viii levels with evidence of factor viii inhibitor activity . treatment is aimed at ( 1 ) controlling bleeding and its complications and ( 2 ) eradication of the inhibitor . fresh frozen plasma and cryoprecipitate will not control bleeding as they do not contain sufficient factor viii to overcome the inhibitor . if the plasma levels of factor viii are raised to 30 - 50% in an acquired hemophilic patient , hemostasis could be generally achieved if the inhibitor assay is less than 5 bu ( bethesda unit ) . 1-deamino-8-d - arginine vasopressin ( ddavp ) or infusion of factor viii ( either human or porcine ) is used to achieve the higher levels . however , if high - titer antibodies are present ( more than 5 bethesda unit ) to obtain hemostasis , bypassing agents like either activated prothrombin complex concentrate ( apcc ) ( feiba ) or recombinant activated factor 7(rfvii ) ( novaseven ) is needed . corticosteroids , cytotoxic drugs such as cyclophosamide , azathioprine , vincristine , cyclosporine and rituximab , and high - dose intravenous immunoglobulins are used alone or in combination to eradicate the autoantibodies . the possibility of acquired hemophilia should be considered if elderly individuals present with severe hematuria , isolated aptt elevation , and when all other urological investigations were not contributory . this case is presented in view of the rarity of acquired factor viii inhibitor syndrome , with only hematuria as the main symptom mimicking urological malignancy .

a 50-year - old woman presented with gross hematuria for 1 month . clinical examinations , laboratory investigations , ultrasound and contrast computed tomography were normal , except anemia . cystoscopy revealed bloody efflux from the right side . retrograde pyelogram showed filling defect in the renal pelvis and biopsy was inconclusive . renal angiogram was normal . she developed ecchymosis on the right thigh and arm with elevated activated partial thromboplastin time . the partial thromboplastin time correction study and bethesda study confirmed the presence of acquired factor viii inhibitor ( acquired hemophilia ) . with flexible ureterorenoscopy , the mass in the renal pelvis was removed and its histopathology revealed clotted blood . the patient was subsequently managed with steroids and factor eight inhibitor bypass activity .

the authors present a case of giant ureteric calculus highlighting the importance of plain film radiograph in the assessment of children with suspected renal tract calculi . ultrasonography demonstrated left hydronephrosis and a 2 cm echogenic area with acoustic shadow in the proximal ureter , consistent with a ureteric calculus . plain radiography astonishingly revealed a large 7 cm radio - opaque shadow in the line of the left ureter extending from the left pelvi - ureteric junction to the mid - ureter , and a second 4 cm opacity in the left distal ureter ( fig 1 ) . plain abdominal radiograph demonstrating large opacity extending from the left pelvi - ureteric junction to the mid ureter , and a smaller opacity in the distal ureter . a dmsa scan showed split renal function of 30% on the left side and 70% on the right . the left distal ureter was identified using an extraperitoneal approach through a left iliac fossa incision . the distal calculus was extracted through a longitudinal ureteric incision . as it was not possible to retrieve the proximal stone through this incision the proximal ureteric calculus measured 6.5 x 1.8 cm and weighed 7991 milligrams ( fig 2 ) . ureteric calculi removed from the proximal ( left ) and distal ( right ) ureter . it was composed of 85% magnesium ammonium phosphate ( struvite ) and 15% carbonate apatite . the uk incidence of urolithiasis in children has been estimated to be two per million per annum ( 1 ) . giant. renal tract calculi commonly present with renal colic , haematuria , urinary tract infections or lower urinary tract symptoms . giant ureteric calculi have been reported to present with urinary tract infection and retention of urine ( 2,3 ) . they can however be asymptomatic and progress silently , as was characterised by our case , where the giant calculus was discovered incidentally . current practice reflects evidence that ultrasonography is more sensitive than plain radiography in detecting renal tract calculi in children ( 4,5 ) . however , ultrasonography is less sensitive in detecting and characterising ureteric stones than plain radiography . a combination of ultrasonography and plain radiography has therefore been recommended as the standard assessment . ultrasonography does not always accurately characterise ureteric calculi and if a plain radiograph had not been performed , the extent of the calculus would not have been appreciated and a different course of management may have been undertaken . the management of giant ureteric calculi entails removal of the calculus or nephroureterectomy depending on kidney function . the authors wish to emphasise the importance of including a plain abdominal radiography in the pre - operative assessment of ureteric calculus in children .

giant ureteric calculi are extremely rare in children . we present a case of a child who was originally admitted for observation following non - accidental injury and had an episode of painless haematuria as an inpatient . ultrasonography demonstrated left hydronephrosis and a 2 cm echogenic area in the proximal ureter . a plain abdominal radiograph surprisingly revealed two left ureteric calculi , one 7 cm and the other 4 cm in length . stone extraction was achieved using an open left ureterolithotomy and pyelolithotomy .

a 4-year - old female child presented with her third episode of fever , headache , and vomiting . her first such episode was at 3 years and 2 months of age for which she was treated elsewhere as pyogenic meningitis with antibiotics after a cerebrospinal fluid ( csf ) study which was culture negative . since she had recurrent meningitis , computed tomography ( ct ) of the head with contrast was done which was initially reported as her complement levels ( c3 and c4 ) and immunoglobulin ( including igg subclass ) assays were normal and her retroviral status and vasculitis workup were negative . she was given pneumococcal vaccine and was discharged after which her third similar episode occurred . csf leak was thought of and ct myelocisternography was done which did not reveal any bony defect . reevaluation of the old ct showed a hypodense ( 2 - 20 hounsfield unit ) cyst seen in front of the brain stem , with minimal flattening of the anterior surface of medulla which was initially missed [ figure 1 ] . magnetic resonance imaging ( mri ) with spectroscopy confirmed the presence of an epidermoid cyst in the premedullary cistern [ figure 2 ] with a prominent lipid peak . she underwent a near - total excision of the lesion and histopathology confirmed an epidermoid cyst . computed tomography shows a hypodense ( 2 - 20 hounsfield unit ) cyst seen in front of the brain stem in the premedullary cistern lifting the basilar artery ( arrow ) , with flattening of the anterior surface of medulla ( arrow head ) ( a ) a 30 23 39 mm well - defined t1 hypointense lesion ( white arrow ) , with flattening of the anterior surface of medulla ( arrow head ) . ( b ) its t2 hyperintense occupying the premedullary and prepontine cistern displacing medulla oblongata and inferior part of pons posteriorly . ( c ) flair images differentiate epidermoids from arachnoid cysts demonstrating lesion to be hyperintense to csf . ( d ) diffusion - weighted imaging show high signal intensity suggesting restricted diffusion with corresponding . recurrent meningitis is defined as two or more episodes of meningitis separated by a period of complete resolution of signs , symptoms , and laboratory findings . aseptic meningitis can be recurrent and is characterized by noninfective serous inflammation of the meninges . it presents as recurring bouts of fever , meningism , pleocytosis , and a failure to culture organisms from the csf . the reaction is sudden and striking but of short duration , and is often preceded and followed by symptom free intervals . epidermoid and dermoid cysts can cause recurrent , episodic aseptic meningitis by rupturing cyst contents into the subarachnoid space , which is thought to result in chemical irritation . epidermoid cysts originate from the inclusion of epidermal components within the neuraxis during the embryonic stage and can be located intracranially or intraspinally and present in the third or fourth decade of life . dermoids are midline often accompanied by persistent defects in the closure of the overlying bone and skin , while epidermoids are found more often in lateral positions , such as the cerebellopontine angles . the pathological reaction to the irritants ranges from mild leptomeningitis to widespread granulomatous meningitis , ependymitis , and posterior radiculitis . since chemical and bacterial meningitis may coexist , it is safer to start antibiotic therapy initially since the spinal fluid profiles in bacterial and chemical meningitis are similar . the exceptions are a csf white blood cell count > 7500/l and a glucose level of < 10mg / dl that are not found in any case of chemical meningitis . patients with chemical meningitis usually do not present with coma , new focal neurological findings , or new onset of seizures and they rarely have temperatures > 39.4c bacterial meningitis in association with these tumors is most commonly related to a coexisting dermal sinus tract and the most common organism is staphylococcus aureus . the literature search identified 24 cases of recurrent meningitis associated with dermoid and epidermoid cysts . our case was unique because of its relatively early and rare presentation with aseptic meningitis and to highlight the fact that these lesions can be missed in cursory ct reading unless specifically looked for . identification of these lesions is important since patients can be spared expensive workup for recurrent meningitis and they can lead a symptom - free life once total excision is performed .

aseptic meningitis is characterized by noninfective serous inflammation of the meninges . it can occur in a recurrent fashion when associated with dermoid and epidermoid cysts due to rupture of cyst contents into subarachnoid space resulting in aseptic chemical meningitis . bacterial meningitis in association with these tumors is commonly related to a coexisting dermal sinus tract and the most common organism is staphylococcus aureus .

tarantula is a large spider which usually be found in tropical and subtropical areas , but recently has become as pets in worldwide ( 1 ) . consequently , it is more likely that emergency physicians encounter with patients that hurt with these spiders . they are nonaggressive arthropods that if to be forced to defend themselves , flick their needle - like abdominal hair at the target and may rarely bite ( 2 ) . though tarantulas may look scary , most of their species are relatively harmless , just a few cases may be dangerous to humans ( 1 ) . their attacks generally do not cause general manifestation , however there are some case reports in this regard ( 3 , 4 ) . here , an unusual presentation of tarantula bite was reported . a 40-year - old man referred to the emergency department ( ed ) with severe colicky periumbilical pain , which was non - positional and radiated to both legs . the patient did not have recent trauma history , except heavy lifting , and also any positive past medical history . on admission time , tachycardia of 110/minute revealed a sinus tachycardia on 12 lead electrocardiogram ( ecg ) and hypertension of 220/110 mmhg in the right arm and 190/100 mmhg in the left arm . on physical examination , straight leg raising ( slr ) test did not aggravate the pain and all other systems were normal too . with suspicion of large vessel insult abdominal sonography , chest radiography ( cxr ) and double contrast enhanced computed tomography ( ct ) were performed , all reported as normal . after ruling out above - mentioned critical impressions , with attention to the history of heavy lifting , herniated disk was suspected so that magnetic resonance imaging ( mri ) was requested in which no abnormalities were found . during all these examinations , despite palliative treatments , the patient had severe pain without improvement . unfortunately , the patient was discharged against medical advice and admitted again after 24 hours with right leg swelling and erythema . in this time , the patient was exposed and several bite - like sites were surprisingly found on his right leg . tarantulas usually flick their hair at the target , so the most clinical presentations of biting are local allergic reactions including irritation , pruritus , edema , and erythema . if the flicked hair takes place in eye , can result in redness and keratitis . their bite usually sense as mild pain similar to a pinprick , but can cause severe pain , muscle spasms , local swelling , and numbness or even arthritis ( 3 , 4 ) . in spite of all above - mentioned , there is no properly documented case of permanent deficit or death following the tarantula bite ( 5 ) . such severe symptoms almost always belong to other spiders like black widow spider ( 6 ) . surprisingly , our case had some of these symptoms in spite of being bitten by tarantula . therefore , we would consider that tarantula bite can mimic symptoms of black widow spider envenomation . laboratory tests and imaging studies are not helpful for evaluation and management ( 7 ) . in the case of tarantula bite , washing the site with soap and water and applying a cool compress or even an ice cube can reduce the local symptoms . treatment in the ed is usually conservative and involves administration of antihistamines , corticosteroids , and analgesics ( 8) . although no specific treatment exists , it has been suggested that calcium supplements may be beneficial to relieve the muscle spasms ( 4 ) . there is no report of recurrent or delayed reaction yet , so except for rare cases of anaphylaxis , all patients can be discharged after symptom resolution . all authors passed four criteria for authorship contribution based on recommendations of the international committee of medical journal editors .

tarantulas have recently become as pets in most parts of the world that increased the probability of encountering emergency physicians with patients hurt with these spiders . their attacks usually do not cause general manifestation , however there are some case reports in this regard . here , a 40-year - old man was reported who was referred to the emergency department with severe periumbilical pain that radiated to both legs and diagnosed as a victim of tarantula bite . such symptoms usually are belonging to other spiders like black widow spider , but it seems that tarantula can mimic them in some cases , too .

pyometra is a rare complication of in vitro fertilization and embryo transfer . in this paper a 30-year - old female , married for 7 years presented to our clinic with primary subfertility . she had a history of recurrent ovarian cyst on the left ovary for which both laparoscopic cystectomy and laparotomy had been done . a day 2 transvaginal ultrasound showed an antral follicle count of seven on the right side . six fertilized and three 8 cell embryos were transferred on the 3 day after egg collection . the sonologist reported a cystic mass in the left adnexa , which was suggestive of hydrosalpinx . eight eggs were retrieved , seven fertilized and three 8 celled embryos were transferred ( day 3 ) . twelve days after embryo transfer ( et ) she complained of pain in the lower abdomen and orange colored , odorless discharge per vaginum . on transvaginal ultrasound scan , the uterine cavity appeared to be distended with fluid and the endometrium was bright and echogeneic . the total white blood cell count was 4000 and the differential count was also within normal limits . a single intrauterine gestation was seen 5 days later and the fetal heart was documented a week later . the catheter was removed at this stage as there was minimal pus in the drain . the patient was discharged from the hospital and resumed antenatal care on the outpatient basis . she underwent regular first trimester screening for down 's syndrome , which was reported as low risk . she had impaired glucose tolerance at 20 weeks and was advised a diabetic diet , which she followed throughout her pregnancy . she had an elective cesarian at 39 weeks and delivered a healthy boy baby weighing 3.2 kg . it has been reported previously in patients after egg collection . at the time of diagnosis , the endometrium seemed bright and echogenic and the beta hcg was positive . a conservative approach was considered to be the patient was otherwise asymptomatic and there were no systemic features of infection ( the blood counts were normal and blood culture was negative ) . the source of the collection was unknown . whether the recurrent cyst aspiration was contributory or was it due to fresh inoculation during et remained a mystery . there was a plan to perform a laparoscopy to identify the source and perform corrective surgery if there was no spontaneous reduction within a week or if systemic features were to manifest earlier . in view of the early viable pregnancy , however , as the pus was sterile and the patient parameters were stable a conservative approach was considered acceptable . there were suggestions to terminate the pregnancy as there were concerns if the pyometra could adversely affect the fetus and the mother . as the pregnancy was progressing well as assessed by serial ultrasound , no active interventions were thought necessary . however , orange colored vaginal discharge seemed out of place and she was called in for examination and ultrasound scan . this case also tells us those patients concerns however strange should not be summarily dismissed without proper evaluation . specific signs should be looked for , such as fever and masses with fluid levels on ultrasound in the uterus , adnexa or pelvis . the mechanism of post - ivf / et infection apart from direct inoculation of vaginal microorganisms by puncture through the nonsterile vagina , could also be due to reactivation of an old pelvic inflammatory disease , or through inadvertent direct puncture of the bowel with spillage . the most probable source of pus in this case was drainage of the hydrosalpinx and therefore an iatrogenic problem . if drainage of the pus is not adequate to eradicate the focus of infection , removal of the affected organ ( salphingooopherectomy or hysterectomy ) might be necessary . review of published literature showed case reports of pyometra in postmenopausal women ; and there are only two case reports of nontuberculous pyometra in the reproductive age group after ovum retrieval for ivf . biopsy in one of the cases revealed endometritis , while the other was negative for it . it has also been reported that early and reliable diagnosis of genital tuberculosis involving state of the art technology , such as dna polymerase chain reaction ( pcr ) and/or mrna - based reverse transcription - pcr ( rt - pcr ) ; and treatment before development of the fulminant genital tuberculosis has resulted in higher pregnancy rates . genital tuberculosis should thus be considered for differential diagnosis of pyometra in young infertile patients as it may aggravate the disease ; and resultant peritonitis , which may be life - threatening . a rare case of tuberculous pyometra in a young infertile female confirmed by mrna - based rt - pcr they concluded that a combination of high degree of clinical suspicion and high precision gene detection methods ( e.g. mrna ) in culture - negative cases may be useful in diagnosis of genital tuberculosis . most cases described in the literature are associated with failed ivf , and even if the procedure is successful , the rate of pregnancy loss is high . therefore if the condition is detected prior to et , consideration should be given to cryopreserving the embryos and treating the infection first , followed by a frozen et cycle . successful pregnancies have been reported following treatment cycles complicated by infection , even when surgical drainage has been required for resolution . the couple should be adequately counseled about the condition and should be involved in the decision making process . the fact that successful term pregnancy is possible after diagnosis of pyometra tells us that there is a role for conservative management in pregnancy as long as the maternal condition is stable .

a 30 year old woman presented 12 days after embryo transfer with lower abdominal pain and orange vaginal discharge . she was diagnosed to have pyometra . a conservative management with drainage of the pyometra was followed by an uneventful pregnancy and term delivery . conservative management in a case of pregnancy with pyometra needs close supervision to ensure maternal and fetal well being .

using dental implants for prosthetic rehabilitation of the edentulous maxilla has become a routine dental procedure . however , low quality of the posterior maxillary bone and a highly pneumatised maxillary sinus can compromise an implant 's survival12 . implant migration into the maxillary sinus can be caused by inexperienced practitioners , unexpected perforations during sinus floor elevation , application of heavy force during implant insertion , and dental implant placement without sinus floor elevation of an excessively pneumatised maxillary sinus3 . if this condition is inadequately treated , the implants can displace to deeper craniofacial cavities , causing infection , tissue necrosis , and adverse reactions to foreign bodies4 . treatment of implant migration into the maxillary sinus includes the classic caldwell - luc operation and the endoscopic approach via the nose5 . in this case report , we will discuss a dental implant that disappeared following its migration into the left maxillary sinus . a 53-year - old male patient was referred to us for retrieval of a displaced dental implant that had migrated into his left maxillary sinus . three months before his referral , the patient underwent a surgical procedure where eight dental implants were inserted to rehabilitate his fully edentulous maxilla . 1 ) using sinus floor elevation , implants placed in the left and right first molar areas were inserted simultaneously . three months postoperatively , the patient 's dentist administered a panoramic radiograph and discovered that one of the implants had migrated into the patient 's left antrum.(fig . 2 ) the patient 's medical and family history was not remarkable , and intraoral examination showed no signs or symptoms of oroantral fistula . after administering computed tomography imaging to localize the implant , we discovered no foreign body in the maxillary sinus.(fig . 3 ) due to the small size of the migrated implant ( 3.4 mm in diameter and 8 mm in length ) and the absence of oroantral fistula , we believe that the implant left the maxillary sinus via the ostium . thoracic and abdominal radiographs were taken for aspiration risk of the implant but no radiopaque objects within the patient 's body were detected . similarly , a six - month follow - up of the patient proved to also be uneventful.(fig . although complications are uncommon , dental implant migration into the maxillary sinus can occur due to inexperienced operators , high pneumatisation of the sinus , and low bone density in the posterior maxilla6 . although implant migration into the maxillary sinus is usually symptomless , it can cause infections that affect the paranasal sinuses and oroantral communications . implants that have migrated into the paranasal sinuses may also cause sinusitis and adverse reactions to foreign bodies7 . migrated dental implants can primarily be diagnosed using three - dimensional computed tomography but can also be observed on panoramic radiographs and lateral or frontal cephalograms . retrieval of migrated implants can be achieved via standard caldwell - luc operations , transoral functional endoscopic sinus surgeries ( fess ) , and transnasal fess4 . some advantages of endoscopic removal of foreign bodies from the atrium include low morbidity , rapid recovery periods , and possible treatment of the affected paranasal cavities4 . for instance , kitamura and zeredo6 describe a case report where a migrated dental implant was removed endoscopically via semilunar hiatus . in their report , access to the maxillary sinus via semilunar hiatus was cited to be undemanding . to our knowledge , this is the first report of a dental implant that migrated into the maxillary sinus and left the sinus cavity without further treatment . because the patient claimed to have experienced no sensation of swallowing the implant , we believe that the dental implant may have left the antrum via the ostium while the patient was sleeping . therefore , this complication may create the risk of foreign body aspiration and life - threatening conditions . in conclusion , foreign bodies in the maxillary sinus should be retrieved as soon as possible to avoid infections , maxillary sinusitis , and the potential risk of foreign body aspiration .

migration of dental implants into the maxillary sinus is uncommon . however , poor bone quality and quantity in the posterior maxilla can increase the potential for this complication to arise during implant placement procedures . the aim of this report is to present a dental implant that migrated into the maxillary sinus and disappeared . a 53-year - old male patient was referred to us by his dentist after a dental implant migrated into his maxillary sinus . the displaced implant was discovered on a panoramic radiograph taken five days before his referral . using computed tomography , we determined that the displaced dental implant was not in the antrum . there was also no sign of oroantral fistula . because of the small size of the displaced implant , we think that the implant may have left the maxillary sinus via the ostium .

woolly hair nevus is a rare condition , characterized by unruly and tightly coiled hair , which is not genetically determined . a 5-year - old girl child presented with abnormal patch of hair since 2 years of age . her parents noticed a single patch of curling and coiling of hair along with altered texture over the left side of scalp . her parents felt the patch to be unruly and unsightly and hence attempted repeated tonsuring . in spite of this , we noticed a solitary circumscribed patch of size 64 cm located over the left frontoparietal region of scalp . the hair over the patch had an altered texture , was lighter in color , thinner , tightly coiled , and curled giving an unkempt appearance [ figure 1 ] . based on the above findings , we arrived at a diagnosis of localized woolly hair nevus . a well - circumscribed patch of tightly coiled woolly hair hpe of scalp showing normal hair follicle and appendages woolly hair is characterized by tightly coiled hair occurring over the entire scalp or part of it in an individual of non - african origin . it is a nevoid condition characterized by a circumscribed patch of unruly and curled hair with an altered texture . this condition may be associated with melanocytic or epidermal nevi , mongolian spots elsewhere on the skin . ocular defects like persistent pupillary membrane , retinal defects , and precocious puberty have also been associated . woolly hair nevus is not associated with cardiac abnormalities as in carvajal or naxos disease in which desmoplakin and plakoglobin mutations are known to occur , respectively . our patient presented with an isolated woolly hair nevus without any associations , which has been reported very rarely . however , this patient must be followed up regularly to detect any cardiac defects which may present later .

woolly hair nevus is a rare non - hereditary focal condition characterized by unruly and tightly coiled hair . it can appear in childhood or adolescence and may be associated with epidermal or melanocytic nevus . patients presenting with woolly hair must be examined completely to rule out cardiofaciocutaneous and noonan syndrome .

hypertensive disease , in which there is persistent pathologic elevation of arterial pressure and increased total peripheral resistance , is associated with vascular lesions in the brain , heart , kidneys , and eyes . elevation of systemic blood pressure causes both focal and generalized retinal arteriolar constriction , presumably mediated by autoregulation . a prolonged duration of particularly high blood pressure can be associated with a breakdown of the inner blood - retinal barrier , with extravasation of plasma and red blood cells . retinal hemorrhages , cottonwool spots , intraretinal lipid , and , in severe cases , the development of a macular star configuration of intraretinal lipid can be seen [ 13 ] . when the choroidal vessels are severely affected by elevated blood pressure , as in acute hypertension , fibrinoid necrosis of choroidal arterioles can cause occlusion of areas of choriocapillaris , with a subsequent breakdown of the outer blood - retinal barrier . in severe cases the optic nerve can be involved . although the retinal vascular changes and optic neuropathy are well known , hypertensive choroidopathy usually does not receive as much attention . hypertensive choroidopathy has been reported in toxemia of pregnancy , renal disease , pheochromocytoma , and malignant hypertension . a 50-year - old man presented with a painless loss of vision in his both eyes and dull , pressure - like frontal headache . the best - corrected visual acuity ( bcva ) was 20/200 and 20/50 in the right and left eyes , respectively . he had a history of anterior ischemic optic neuropathy in the right eye 30 years ago . slit - lamp examination showed serous retinal detachment in both eyes and optic disc swelling in the left eye ( figures 1 and 2 ) . retinal arteriolar narrowing , vascular tortuosity , and arteriovenous nicking were identified in both eyes . fundus fluorescein angiography ( fa ) showed window defect associated with the macular cystoid change . indocyanine green angiography ( ia ) showed decreased perfusion of the choroid at the macula in both eyes . he had a history of hypertension 1 year ago , but had no medical treatment . on posttreatment day 30 , the serous retinal detachment disappeared in both eyes ( figures 3 and 4 ) . his bcva was recovered to 20/500 and 20/16 in the right and left eyes , respectively . the optic disc in the right eye remained pale due to anterior ischemic optic neuropathy 30 years ago . severe systemic hypertension is associated with significant damage of end organs , such as eyes , heart , central nervous system , and kidneys . the ophthalmic artery branch of the internal carotid artery supplies the optic nerve and retina , extraocular muscles , and eyelids . branches of ophthalmic artery include the central retinal artery and short and long posterior ciliary arteries . the central retinal artery and vein supply the inner ( anterior ) two thirds of the retina . the choroidal circulation receives blood primarily from the short and long posterior ciliary arteries and delivers blood to the retinal pigment epithelium , optic nerve , and outer ( posterior ) one third of the retina . the retinal photoreceptors and pigment epithelium are nourished by an inner layer of the choroid which is called the choriocapillaris . accelerated hypertension and/or ophthalmic / ciliary artery occlusion may result in choroidal ischemia . with complete ophthalmic artery occlusion , both compromise of ciliary arteries may occur without retinal artery involvement , leading to choroidal ischemia , which causes hypertensive choroidopathy . the rpe becomes necrotic ; this may result in serous retinal detachment and/or localized pigment epithelial detachment . some of these are attributed to a breakdown of the inner blood - retinal barrier with retinal endothelial cell decompensation . it is notable that no active leakage is observed in the area with serous retinal detachment in our patient . ia shows hypofluorescence along the retinal artery . although it is unclear that this finding is cause or effect , it may play a role in the pathogenesis of this case . the narrowed arterioles , vascular tortuosity , and arteriolovenous nicking in the retinal vessels were also observed . it seems that the patient had a history of longstanding chronic hypertension , and a sudden bp elevation triggered it off and formed this condition . after antihypertension treatment , the serous retinal detachment disappeared , and his bcva was recovered . in most cases with hypertensive choroidopathy , visual acuity returns to normal by controlling their bp . however , there is a case reporting that the visual acuity was not recovered in spite of being controlled the bp . a patient with those findings should be considered as hypertensive choroidopathy and treated with antihypertension therapy as soon as possible .

purpose . we report a case of hypertensive choroidopathy with bilateral serous retinal detachments . patient . a 50-year - old man underwent bilateral serous retinal detachments . retinal arteriolar narrowing , vascular tortuosity , and arteriovenous nicking were identified in both eyes . the blood pressure was 206/125 mmhg . the patient was diagnosed with bilateral hypertensive choroidopathy and treated with oral antihypertensive treatment . results and discussion . one month after antihypertensive treatment , the serous retinal detachments resolved and the visual acuity improved . a patient with those findings should be considered as having hypertensive choroidopathy and treated as soon as possible .

sodium bromate and potassium bromate are strong oxidants that are widely used in hair permanent wave neutralizers , reagents of printing or dyeing and other chemical processes . hair wave permanent neutralizing solutions typically contain 2 - 10% sodium or potassium bromate , which are colorless , odorless and tasteless . clinical manifestations of bromate intoxication include vomiting , diarrhea , central nervous system symptoms , oliguric or non - oliguric acute renal failure , hemolytic anemia , and deafness . hearing impairment is rather common and is usually rapidly progressive , bilateral , and of severe to profound sensorineural type of hearing loss ( snhl ) . although many investigators have studied the characteristics of hearing impairment , cochlear implantation ( ci ) after bromate intoxication has been rarely documented . we hereby present a case of successful ci in bromate - induced bilateral sudden total deafness . she had accidentally ingested a cold wave neutralizer . within one hour after the ingestion , she developed nausea , vomiting , and diffuse abdominal pain . her past history included hypertension , left hemiparesis due to previous brain hemorrhage and infarction and depressive disorder . upon arrival in the emergency room of a local hospital , she received intravenous hydration and furosemide injection . one day later , she was referred to our hospital with decreased urinary output and reduced mental state . four days after admission , her kidney function was normalized and mentality was recovered to an alert state . 1b ) and v - wave was not detectable at 90 db in the auditory brainstem response . she was diagnosed as having bromate - induced sudden deafness and steroid was administered systematically for a week with tapering for another week . nucleus 24re was implanted without any intra - operative problems and the neural response telemetry showed satisfactory values . six months after the implant , ci - aided pta showed a threshold of 30 db ( fig . , she comprehended 70% of the sentences , 85% of the words and 68% in the korean version of the central institute for the deaf test . hearing problems may be diagnosed with a delay after bromate intoxication due to other life - threatening symptoms such as acute renal failure which generally occurs within 1 hour after the ingestion . however , the onset of bromate - induced hearing loss is actually rapid , occurring within 4 - 16 hours of ingestion . like many other ototoxins , the degree of hearing impairment is severe to profound , and is irreversible in most cases . since they are usually transient , loop diuretics including furosemide are ototoxic in themselves . in the present case , the patient received furosemide during the primary treatment , which may have aggravated the ototoxic effects of bromate . previous studies using guinea pigs and sodium bromate demonstrated severe collapse of the reissner 's membrane , hair cell degeneration and damage of the stria vascularis . the ototoxicity may be ascribed to a decrease in enzyme activities which leads to damage of the stria vascularis with degenerative changes in outer hair cells on the other hand , dizziness associated with bromated - induced vestibulotoxicity is not common . the dizziness could be secondary to other systemic toxicities such as lightheadedness or general malaise . to our knowledge , there has only been one report in the english literature of ci performed in patients deafened due to bromated - ingestion . in this case , the diagnosis of hearing loss was delayed for at least 6 months after bromate ingestion . in our case , deafness was diagnosed right after the recovery of consciousness and the intervention with ci was done 3 months after the diagnosis . in both cases , the outcome of ci was good . other potential drugs with ototoxicity should be avoided and early monitoring of hearing level is needed .

despite the well - established nature of bromate - induced ototoxicity , cochlear implantation after bromate intoxication has been rarely documented . we hereby present a case of a 51-year - old female deafened completely after bromate ingestion . her hearing was not restored by systemic steroid treatment and hearing aids were of no use . a cochlear implantation was performed on her right ear 3 months after the bromate ingestion . in bromate intoxication cases , early monitoring of hearing level is necessary and other drugs with potential ototoxicity should be avoided . the outcome of cochlear implantation was excellent in this case of bromate - induced deafness .

the comprehensive aortic root and valve repair ( carvar ) procedure is , basically , one of the valve sparing surgical techniques for aortic valve or aortic root disease . three basic surgical procedures of this technique are annular reduction , reduction of sinotubular junction ( stj ) and leaflet correction.1)2 ) for reduction of the annulus or stj , a commercially available sizing device , strip or ring and template ( sciencity co , seoul , korea ) are used.3 ) carvar procedure and devices , named and designed by dr . mg song , are under evaluation for list up process as new health technology by the health insurance review and assessment service ( hira ) from 2007 . during this process , han et al.4 ) reported 5 clustered cases of coronary ostial stenosis after carvar procedure . they also reported several cases of re - operation from valvular dysfunction or endocarditis and even cases of mortality after operation to the korea food and drug administration . under the debates on the safety and effectiveness of the cavar procedure , the ministry of health and welfare , korea offered a prospective randomized study . for the design and production of patient information for prospective study , it was required to establish a data of safety from previously performed operations.5 ) vitualy the entire carvar procedure was performed by a single operator ( dr . myeong gun song ) at 2 university hospitals : from march 2007 to july 2007 at asan medical center ( seoul , korea ) and from october 2007 to november 2009 at konkuk university hospital ( seoul , korea ) . three hundred ninety seven patients ( 26 cases at asan medical center , 371 cases at konkuk university hospital ) received carvar operation during this period and were enrolled for this study . data from medical records were gathered by a trained investigator from national evidence - based health care collaborating agency ( neca ) . to obtain more complete information , a follow up was performed via 2 tracks including medical records of the out patient department and claim data of medical service in hira . four major threatening clinical events including serious surgical bleeding requiring transfusion over 20 units of packed red blood cell , endocarditis , re - operation from any cause and death were focused for evaluation of safety . clinical events at out patients ' department were followed up till march 2010 . to compare with conventional valve replacement surgery , 337 patients without aortic root disease { aortic valve disease ( avd ) only group } were analyzed separately . total incidence during the follow up period ( % ) and 1-year cumulative incidence ( % /year ) were calculated by the kaplan - meier method . this study was approved by the institutional review board of neca ( necairb 10 - 001 ) and organized data review board with 6 professional experts from the korean society of thoracic and cardiovascular surgery and the korean society of cardiology for peer data review . importantly , there were 9 cases of age under 19 and 8 cases of older than 80 years - old . there were 20 fatal cases and 25 re - operated cases and 19 cases of endocarditis . even in the avd only group , the 1 year cumulative death rate was 4.41%/year and risk of re - operation was 5.81%/year . for the treatment of avd , aortic valve replacement is regarded as a standard treatment . but , aortic valve sparing surgery can be applied to aortic regurgitation due to dilatation of the aortic root or ascending aorta without significant leaflet deformity . theoretically , carvar is one of the aortic valve sparing surgical techniques . hahm et al.1 ) described that the advantages of this technique are a wide range of indication , preservation of aortic root function , easy surgical technique and low recurrence of valvular dysfunction . but , from the results of this study , the carvar technique failed to show any advantage in mortality and morbidity . in a recently reported 28 years experience ( from 1982 ) of the bentall procedure , the operative mortality was 5.5% , and risk of late reoperation and endocarditis were 3.2% and 1.4% respectively.6 ) moreover , lim et al.6 ) reported that , in patients with aortic root dilatation with advanced aortic regurgitation , operative mortality was 2.4% in the bentall procedure group and 0% in the valve - sparing operation group.7 ) compared with those data , in patients with carvar surgery , mortality seems quite higher than recently reported results and the risk of endocarditis and re - operation are much higher than in previous reports . in the least , it was restricted in gathering enough clinical data from medical records , hence we could not evaluate data comprehensively . nontheless , the primary aim of this study is to provide basic safety data for further prospective randomized study . therefore , it can be suggested that the carvar procedure should undergoe more in - depth investigation in consideration for the safety of patients .

comprehensive aortic root and valve repair ( carvar ) is a recently introduced surgical technique for aortic valve disease . the national evidence - based health care collaborating agency was offered by the ministry of health and welfare , korea to perform a restrospective outcome analysis for this surgical procedure . the aims of this study were to evaluate the safety of patients who underwent carvar surgery and to provide a rationale for further prospective randomized study . during the period of march 2007 to november 2009 , 397 patients received this procedure and enrolled in this study . clinical events including major bleeding , endocarditis , re - operation and death were followed - up till march 2010 by medical records . during the follow - up periods , 1-year cumulative incidence of major bleeding , re - operation , endocarditis and death were 3.55 , 5.65 , 5.05 and 5.33%/year respectively . this study showed that the carvar technique is not beneficial , and is indeed even more harmful than conventional valve replacement surgery .

a 6yearold male was brought to our emergency department having sustained an accidental penetrating injury to zone 1 of the neck with a sickle . on examination , there was a foreign body sickle ( fig . 1 ) with its wooden handle as an entry point at the right submandibular region with no active bleeding and without evidence of vascular or neurological injuries . the sickle had serrated part on its concave surface and blunt part on its curvature . 2 . what is the superior limit of foreign body piercing the neck in this patient ? penetrating neck injury can be life threatening because of the increased risk of injury to the vital structures such as blood vessels , airway , cervical spines , and nerves which are present in such a small confined area 1 . the foreign body may be providing tamponade effect on a major blood vessel so it should not be blindly pulled out until radiological evaluation 2 . our patient initially has undergone plain xray of the neck as a means of costeffective investigation . but from xray alone , it was not possible to find the accurate information regarding the relation of foreign body with the adjacent vital structures . computed tomography scan can be helpful to know the extent of the injury sustained by the patient with penetration of neck with sharp objects such as sickle , knife , broken glasses , metallic and wooden foreign bodies . in this case , the computed tomography showed the metallic foreign body penetrating the soft tissue of neck on right side reaching the opposite side orbit . intraoperatively , the foreign body was found to be penetrated to floor of mouth , involving dorsum of tongue and soft palate , then entered into left nasal cavity , piercing the middle turbinate , and finally entered into left orbital cavity lying posterior , that is , very close to the orbital apex ( fig . 2 , 3 , 4 ) . coronal view of ct scan showing the entry point and the extent of foreign body . axial view of ct scan showing metallic foreign body in left orbit . correlating the radiological and clinical finding , although xray plain film is a costeffective investigation method in the case of metallic foreign body penetrating the neck , one should not rely alone on it , as it can not reveal status of neurovascular structures lying adjacent to foreign body in an anatomically important area such as head and neck region . ct scan is a definitive imaging technique which yields important information and makes interpretation easy . so , it must be taken before planning the removal of foreign body in operation theater .

key clinical messagect scan is the most important investigation in patients with penetrating neck injury in which it can show the extent of internal injury which may be overlooked . without ct scan being performed , one should not try to remove foreign body by just pulling blindly , as it can injure vital structures .

a 52-year - old korean female visited seoul veterans hospital with a complaint of acute pain and gingival swelling on the right mandibular molar region . on palpation , bilateral buccal bony expansion was noted on the posterior mandible and maxilla ( fig . 1 ) . she had a complete denture , however her denture was out of use due to the gingival swelling and pain . panoramic radiograph showed diffuse , lobular , and irregularly shaped radiopacities or cotton - wool appearance throughout the alveolar process of both quadrants of the maxilla and mandible . multiple sclerotic masses with radiolucent borders were found in the maxilla and mandible , confined within the alveoli at the level corresponding to the roots of the teeth , above the inferior alveolar canal ( fig . cone beam computed tomography ( cbct ) ( kavo 3d exam , kavo , biberach , germany ) images also revealed large radiopaque shadow extending into the mandible and maxilla . the bucco - lingual aspects of the lesions could be visualized on the cbct images , which demonstrated the relationship of the bony lesions to the cortical plates in the bucco - lingual dimension . some lesions appeared larger and connected with the buccal and lingual cortical plates . on the parasagittal reformatted images at this level , the radiographic appearance varied from radiolucent to mixed lesions or rather radiopaque masses . under local anesthesia , incision and surgical curettage was performed on the right mandibular posterior area . irregular bony defects and inflammatory fibrous tissue were seen in the operation field . histological finding of this lesion showed the formations of dense sclerotic calcified cementum - like masses . the lesion was composed of cementum - like substances characterized by islands of calcified deposits and areas of loose fibro - collagenous stroma , which showed the evidence of proliferation . the patient of the present case has been followed up over the last 12 month and fcod has remained asymptomatic . exuberant fibro - osseous lesions occurring in multi - quadrants of the jaws were designated as gigantiform cementomas or familial multiple cementomas in the first edition of the world health organization 's histological typing of odontogenic tumor , jaw cysts and allied lesions.11 however , the etiopathogenesis has not been clear . our case was diagnosed with fcod based on the clinical , histologic , and radiographic features . fcod should be differentiated from paget 's disease , chronic diffuse osteomyelitis , and gardner 's syndrome . paget 's disease is polyostotic and shows the raised alkaline phosphatase level which is not a consistent feature of fcod . it is a primary inflammatory condition of mandible with cyclic episodes of unilateral pain and swelling . fcod is a reactive , non - neoplastic process confined to tooth - bearing areas of the jaws that is found most frequently in middle - aged and older black women . melrose et al reported a study of 34 cases of such lesions , of which 32 were black women ( in a predominantly caucasian population ) with mean age of 42 years.12 the definite female gender predilection of the condition is unclear.2,3 in the present case , the patient was a 52-year - old korean female ; it was rare in regard to the race and gender . fcod may be familial with an autosomal dominant inheritance pattern . however , there were only few examples in the literatures in which the familial pattern had been confirmed.10,13,14 in this case , the patient 's mother and twin daughters had similar lesions in the jaw , and they were diagnosed with familial gigantiform cementoma in other clinic , however the lesions were focal without pain and any other symptom . conventional radiograph , which exhibit multi - quadrant diffuse radiopaque masses in the tooth - bearing areas of the jaws , plays an important role in the diagnosis for asymptomatic fcod patients . the ct findings of the lesion have been previously reported.10 axial ct images clearly showed the location and extent of the lesion , especially in the maxilla . the expansion of the cortical bone was clearly evaluated on the ct images even though it was slight . extraction is not recommended due to the poor socket healing from the impaired blood circulation in the affected area of the bone . extensive surgical resection and saucerization are proposed as treatment options when lesions become extensive and symptomatic.15,16 in this case , surgical resection and saucerization were performed due to the symptoms of the pain and gingival swelling on the edentulous area .

cemento - osseous dysplasias are a group of disorders known to originate from periodontal ligament tissue and involve , essentially , the same pathological process . they are usually classified into three main groups : periapical , florid , and focal cemental dysplasias depending on their extent and radiographic appearances . radiographically , florid cementoosseous dysplasia ( fcod ) appears as dense , lobulated masses , often symmetrically located in various regions of the jaws . the best management for the asymptomatic fcod patient consists of regular recall examinations with prophylaxis . the management of the symptomatic patient is more difficult . a case of fcod occurring in a 52-year - old edentulous korean female is reported which is rare with regard to race and sex .

on the day of surgery , all donor tissues are dissected in the operating room prior to the start of the first dsaek surgery . dissection is performed using a microkeratome ( altk cbm ; moria japan kk , tokyo , japan ) equipped with a 300 m head . after microkeratome - dissection , the donor - endothelial lamella ( with the repositioned , dissected cap ) is transferred to a punching system , and cut with an 8.0 mm diameter punch ( barron donor cornea punch ; katena products inc , denville , nj ) . the busin glide surface is then wetted with several drops of balanced salt solution ( figure 2a ) . after the composite of donor - endothelial lamella and microkeratome - dissected cap is punched out , several drops of dispersive ophthalmic viscosurgical device are placed onto the endothelial surface ( figure 2b ) . next , hydrodissection of the potential space between the donor - endothelial lamella and the microkeratome - dissected cap is carefully performed , using ophthalmic irrigation solution ( bss plus ; alcon , fort worth , tx ) to enable smooth detachment of these two lamellae ( figure 2d ) . this technique enables smooth detachment of the composite , without causing the formation of any wrinkles or folds ( figure 2e ) . the donor lamella is then pulled into the busin glide opening , using a 25-gauge anterior - capsular forceps ( cat # mf801l ; inami co , ltd , tokyo , japan ) ( figure 2f ) . we reported herein a modified surgical technique , prewetting of the glide , and hydrodissection of the donor lamella aimed at optimizing the use of the busin glide for dsaek surgery . hydrodissection of the donor lamella enables the smooth detachment of the composite of donor - endothelial lamella and microkeratome - dissected cap on the busin glide without the formation of any wrinkles or folds . this technique is quite useful when the dsaek is performed using pre - cut tissue , as these tissues are usually distributed with the cap adhered to the dissected stromal bed . in ten out of ten consecutive cases , we saw that simply dragging donor - endothelial lamella directly onto the glide caused macroscopic wrinkling or folding of the donor lamella . it has been shown previously with in vitro vital dye staining9 that folding of the donor endothelial lamella resulting from the forceps manipulation can cause endothelial cell damage . we too , have preliminary vital dye staining data ( not shown here ) that wrinkling or folding of the donor lamella as it is dragged onto the busin glide causes endothelial cell damage . to date , we have used this modified technique in more than 50 consecutive dsaek cases , and no wrinkles or folds were caused during loading of the donor lamella onto the busin glide . furthermore , prewetting of the glide enabled quite smooth pull - through of the donor lamella in all cases . we strongly believe that this technique eliminates additional endothelial - cell loss caused by wrinkle formation , during donor manipulation . however , care should be exercised in using viscoelastic materials over the graft , especially on the stromal side , because of the increased risk of donor dislocation . currently , these modifications are our preferred endothelial keratoplasty technique during busin glide use .

we describe a modified technique for loading donor corneal endothelial lamella onto a busin glide without causing wrinkles , as part of the procedure of descemet - stripping automated endothelial keratoplasty . briefly , after punching out a composite of the donor - endothelial lamella and a microkeratome - dissected cap , several drops of dispersive ophthalmic viscosurgical device are placed onto the endothelial surface . the busin glide surface is then wetted with several drops of balanced salt solution . after the composite is transferred onto the busin glide , hydrodissection of the potential space between the donor - endothelial lamella and the microkeratome - dissected cap is carefully performed to enable smooth detachment of these two lamellae . whereas simply dragging the donor - endothelial lamella directly onto the glide can cause wrinkling or folding of the donor lamella , this technique enables smooth detachment of the composite without wrinkle or fold formation , and results in less endothelial cell damage .

persistent cloaca is defined as a defect in which rectum ; vagina and urinary tract meet and fuse into a single common channel . this is a rare anomaly seen exclusively in girls with an incidence of 1 in 50,000 live births and accounts for 10% of all anorectal malformations in females . it is a complex malformation with a wide spectrum of severity and remains a difficult reconstructive challenge . achieving bowel and urinary control , as well as normal sexual function are the main management issues , whereas malignancy is rarely of concern in this group of patients . although cloacogenic tumors of anorectum , bladder , and vulva are reported , which are mainly adenocarcinomas ; development of squamous cell carcinoma of bladder in patients with cloacal malformation is unknown . a 36-year - old married female having two children , both delivered by caesarian section , presented to us with complaints of urinary frequency , urgency , and urge incontinence associated with low - grade fever . she had history of recurrent urinary tract infections ( uti ) since childhood and had received multiple courses of antibiotics . she had been diagnosed as having a persistent cloaca and had undergone multiple cutback procedures at birth . on pelvic examination , ultrasound abdomen showed a mass lesion in urinary bladder [ figure 1 ] . computed tomography ( ct ) abdomen and pelvis with three dimensional reconstruction confirmed the presence of persistent cloaca , a large mass in the bladder with infiltration into the pubic bones [ figure 2 ] with uterus didelphys and rectum crossing between the two uteri and opening into the bladder base [ figure 3 ] . cystoscopy revealed a large solid , sessile growth arising from dome and anterior wall of urinary bladder , rectum opening just distal to bladder neck and two cervical openings posteriorly . cold cup biopsy from growth revealed a moderately differentiated squamous cell carcinoma ( scc ) . ultrasonogram abdomen showed a mass lesion in urinary bladder ct scan with 3d reconstruction shows the presence of persistent cloaca contrast enhanced ct scan abdomen and pelvis showing uterus didelphys and rectum crossing between the two uteri and opening into the bladder base with a diagnosis of squamous tumor with persistent cloaca , radical cystectomy and urinary diversion were planned . intraoperatively , we found a 15 cm pouch colon along with a large tumor involving anterior wall of bladder , infiltrating the pubic bones . pelvic exenteration , standard bilateral pelvic lymph node dissection , pubectomy , and wet colostomy were performed . operative time was 6 hours with 1200 cc blood loss and the patient received 2 units of packed cell transfusion . postoperative course was uneventful except for a small incision disruption which was managed with secondary suturing . she was started on adjuvant methotrexate and platin - based combination chemotherapy but finally lost to follow up . cloacogenic tumors i.e. , tumors arising from remnants of cloacal membrane have been reported in the anorectum , vulva , bladder , and vagina . most of these are adenocarcinomas and less commonly of transitional cell origin . squamous cell carcinoma arising from cloaca to best of our knowledge , this is probably the first case of squamous cell carcinoma of urinary bladder occurring in a patient with persistent cloacal anomaly . the reason for recurrent uti in our patient may be fecal contamination of urinary tract due to persistent cloaca . studies from john hopkins institute have shown that history of uti is an important risk factor ( risk ratio = 1.6 , confidence interval ( ci ) = 1.4 - 1.8 ) for development of scc . these are : i ) production of excess nitrites by bacteria , ii ) conversion of nitrites into nitrosamines , and iii ) increased absorption of carcinogens through bladder mucosa because of inflammation . development of malignancy in patients with cloacal malformations is exceedingly rare but a possibility should be kept in mind , particularly while treating recurrent and unexplained utis in a patient with persistent cloaca . taking all treatment perspectives together , the most serious problem is the lack of any histological or clinical data allowing a reliable prognosis of future bladder growth and long - term storage and voiding function after birth .

a rare case of squamous cell carcinoma of bladder occurring in a 36-year - old female with persistent cloacal anomaly who presented with frequency , urgency , dysuria , and recurrent urinary tract infection is reported . contrast enhanced computed tomography with three dimensional reconstruction showed presence of bladder tumor and persistent cloaca . she underwent pelvic exenteration and wet colostomy . histopathologic findings revealed locally advanced moderately differentiated squamous cell carcinoma .

osteoid osteoma ( oo ) is a benign tumor characterized by a small calcified lesion , usually less than 2 cm in diameter , with nocturnal pain alleviated by the administration of nonsteroidal anti - inflammatory drugs ( nsaids ) . oo usually affects the long bones and mostly occurs in the first 2 decades of life . oo arising in the rib is extremely rare , and only 12 cases have been reported in detail to date . treatment for this tumor is resection of the nidus ; however , difficulty in reaching the nidus through normal tissues increases the invasiveness of the surgical procedure . in the reported cases of rib oos with surgical documentation we present the first case of oo arising in the rib treated with a computed tomography ( ct)-guided procedure without en bloc resection of the affected rib . a 20-year - old male complained of nocturnal pain in his left anterior chest which had persisted for 2 years . conservative treatment was performed for a period of 22 months with administration of nsaids at a nearby hospital . therefore , he was referred to our hospital for further treatment . at the initial visit to our hospital a plain radiograph showed bulging and mild bone sclerosis of the left 8th rib ( fig . ct examinations revealed a well - demarcated 5-mm nidus with peripheral bone sclerosis in this area ( fig . clinical and radiological findings were compatible with an oo of the left 8th rib . because the patient refused to undergo en bloc rib resection , the operative plan was to perform resection of the nidus under ct guidance . the operative procedure was performed in the ct room under total anesthesia . after identifying the nidus with a marker , a guide pin was inserted by a power drill just adjacent to the edge of the nidus . a 5.0-mm cannulated drill was inserted over the guide pin to remove the nidus . after removing the lesion , the bone specimen which resided in the cannulated drill subsequently , heat ablation by an electrosurgical knife using a standard electrosurgical generator was performed to completely destroy any residual tumors . histopathological studies showed the characteristic appearance of an oo with differentiated osteoblasts lining the osteoid and interconnected trabeculae of woven bone ( fig . complete pain relief associated with the nidus resection was achieved from the first postoperative day . the patient was free of pain at the final follow - up after 4 years , and no local recurrence was observed . oos may affect any bone , but more than half of the tumors occur in the long bones of the lower extremities . the frequency of oos affecting the ribs is extremely low ( 11.4% ) , with only 12 reported cases with surgical intervention to date [ 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ] . conservative treatment consists of nsaid administration for a prolonged period of time , which reportedly leads to alleviation of pain in select cases . the common principle for operative treatment of oo is thorough resection of the nidus , and incomplete resection could lead to local recurrence . a complete resection of the nidus by open surgery may lead to further damage of bone and soft tissues around the lesion , when the affected bone is not subcutaneous or when visual localization of the nidus is technically difficult . although the ribs are easily accessed , the reported lengths of en bloc resection of the nidus ranged from 5 to 9.5 cm , which is significantly wider than the size of the nidus [ 4 , 5 , 6 , 7 ] . there are reports of varying degrees of functional impairments due to rib resection . in 1990 , voto et al . introduced the successful treatment of oos by percutaneous ct - guided resection . over the years , several percutaneous treatment methods using ct guidance have been introduced : drilling resection , thermocoagulation with radiofrequency , ethanol injection , and a combination of these methods . however , recurrence rates have been reported to be as high as 1020% , and in cases where the nidus is > 10 mm , these procedures have been reported to be more likely to fail . despite these recurrence rates , a secondary operation either by ct guidance or en bloc resection leads to good results due to the remaining trace left by the primary treatment , enabling minimally invasive en bloc resection . one drawback of ct - guided resection is that a histological diagnosis may be difficult in some cases , because the resected specimens are small in quantity . by using a cannulated drill and careful curettage , we were able to make a histological diagnosis in over 90% of the cases ( data not shown ) . ct - guided percutaneous treatment should be considered as a first - line therapy for oo in the majority of cases , except for lesions difficult to access due to the proximity of vital organs , lesions presenting with atypical findings that are difficult to diagnose as oo , and failed primary ct - guided treatments . we were able to avoid rib resection without any recurrence of symptoms by the use of a ct - guided resection and heat ablation . in addition , we were able to obtain enough tissue for histological examination by using a 5.0-mm cannulated drill . ct - guided procedures should be considered as a treatment of choice for oo of the rib in order to minimize the loss of respiratory function . informed consent was obtained from the patient for this case report and any accompanying images .

osteoid osteoma ( oo ) usually occurs in the extremities of young adults . the tumor can arise in any part of the skeletal tissue ; however , it is rarely found in the rib , with limited reports to date . in this report , we present a rare case of oo arising in the rib , which was successfully treated under computed tomography guidance with minimal invasiveness . at the final follow - up after 4 years , no local recurrence was observed .

intranodal schawnomas are extremely rare and just a few cases have been described before . clinical presentation comprises a symptomatic mass in several anatomical regions , but they can also be found during analysis of surgical specimens resected for other reasons . the report is based on the case of an 80-year - old patient who was underwent to right hemicolectomy for an adenocarcinoma . an 80-year - old female patient , with personal history of intellectual development retardation , without other associated pathologies . besides she had been diagnosed with right colon adenocarcinoma , during the study of anemia . the extension study with thoracoabdominal computed tomography scan showed no signs of local or distant disease from the primary tumor . histopathological analysis of the surgical specimen revealed the confirmation of a low - grade adenocarcinoma , infiltrating perintestinal fat without evidence of serosa affectation ( t3 ) . for the rest of the specimen examination , 12 perintestinal lymph nodes were observed , 10 of them with normal macroscopic and microscopic characteristics . the two others instead showed whitish coloring and increased consistency , highly suspicious of involvement of primary adenocarcinoma , with a total size of 7 mm . the second , however , was microscopically constituted by a spindle cell proliferation without atypia , mitosis or necrosis , displacing the normal lymphatic tissue toward periphery ( fig . we also had positive result after immunohistochemical study for vimentin and protein s100 , and a negative one for actin , desminia , cd34 and cd117 , all of this was compatible with intranodal schwannoma ( fig . 2 ) . figure 1:mesenteric node tumor microscopically constituted by a spindle cell proliferation without atypia , mitosis or necrosis , displacing the normal limphatic tissue toward periphery . figure 2:positive result after immunohistochemical study for vimentin and protein s100 , compatible with intranodal schwannoma . mesenteric node tumor microscopically constituted by a spindle cell proliferation without atypia , mitosis or necrosis , displacing the normal limphatic tissue toward periphery . positive result after immunohistochemical study for vimentin and protein s100 , compatible with intranodal schwannoma . lymphatic affectation ( within lymph nodes ) is extremely rare and poorly described in the literature . the lesions to beware of in the differential diagnosis are : metastatic tumor cells , including spindle cell sarcoma , spindle cell carcinoma and melanomas . among the benign lesions , the most important distinction must be made with the miofibroblastoma , whose characteristics include hemorrhage focuses and areas of starry arranged collagen . while miofibroblastomas show a positivity result for actin immunohistochemistry , they do not do it for s100 protein , whose positivity is strongly linked to the schwannomas . in our case , it was reported just one case before by piana , of mesenteric lymph node affectation by schawnnoma in a piece of colonic resection . remaining reports describe tumors located in retroperitoneal nodes , thoracic region , groin location or neck mass relative to growth lymph nodes [ 210 ] . in our case , as in the rest of the consulted case reports , lymph node involvement by schwannoma , could not be identified until the histopathological analysis are completed , either preoperative extension studies or macroscopic study of the surgical specimen , could suspect lymph node involvement by this tumor , because , there are not specific characteristics that could make it suspicious . it is also noteworthy that such lymph node involvement occurred in a different one from the affected by adenocarcinoma metastasis . intranodal schawnomas are extremely rare and < 12 cases have been previously described in the literature . the origin of those remains unknown ; therefore , as far as our review is concerned , there are not currently theories that could explain lymphatic localization . on the other hand , we have to notice that this type of diagnosis , although anecdotal by its infrequency , highlights the importance of correct microscopic evaluation of lymphatic tissue , included in the pieces of surgical , beyond their macroscopic appearance , because it has not only diagnostic importance , as in our case , but also implications in staging and subsequent treatment if malignant lesions are present .

abstractintranodal schawnomas are extremely rare . just a few cases have been described before . clinical presentation comprises not only symptomatic mass in several anatomical body parts , but also , they can be found during analysis of surgical specimens resected for other reasons . the report is based on the case of an 80-year - old patient who underwent to right hemicolectomy for an adenocarcinoma . the histopathologic analysis revealed one mesenteric intranodal schwannoma in the surgical specimen . the diagnosis was confirmed by immunohistochemistry with positive result for vimentin and s100 protein . less than 12 cases have been reported in the literature before . the findings pointed out our patient as , one of these few reported with such diagnosis .

seminoma is the most frequent carcinoma of the testicle in the fourth decade of life and constitutes 60% to 65% of germ cell neoplasias . several histopathological characteristics of the tumour have been evaluated and three types of pure seminoma have been described : classic , anaplastic and spermatocytic . we report a patient with seminoma arising in an undescended testis which presented as a palpable painful mass of lower abdomen . a 29 year old man with no known previous complaint presented with 4 month history of progressively enlarging mass on his left lower abdomen . the mass was slightly tender and located immediately above the left groin ( figure 1 ) . ct scan revealed a mass of 211311 cm located between the abdominal subcutaneous and external oblique fascial layers . mass was located immediately above the left groin he underwent surgery and en - bloc resection of the tumour via a left oblique flank incision was performed ( figure 2 ) . the specimen demonstrated typical characteristics of classical seminoma with a smoothly demarcated fibrous capsule , which had a vascularized outer surface , and some spermatic chord structures were also identified macroscopically . immunohistochemistry studies revealed plap ( plasental alchaline phosphatase ) positive ( figure 3 ) , p53 positive and cd45 negative tumour cells . tunica vaginalis was intact , however , the tunica vasculosa that was located under tunica albuginea nested tumour cell piles ( positive lymphovascular invasion ) . plap positive tumour cells ( x200 ) he was referred to oncology clinic after discharge . germ cell tumours ( gct ) of testes can be benign ( teratomas ) or malignant ( seminoma and non - seminoma ) . gct most frequently occur in the gonads , only 2 - 5% of them arise in extragonadal regions such as the mediastinum , retroperitoneum , pineal gland and sacral area ( 1 ) . the undescended testicles carry 20 - 48 times higher potential for malignant transformation than the normally descended testicles ( 2 ) . testicular ectopia is uncommon and the most frequent ectopic location of testis are superficial inguinal pouch , infront and lateral to the external inguinal ring and very rarely in the abdomen ( 3 ) . the position of the undescended testis is related to the likelihood of carcinogenesis with intra - abdominal testis having the highest malignant potential . the majority of undescended testes locate distal to the external inguinal ring and are palpable ( 2 ) . exogenous estrogen administration to the mother during pregnancyhas been associated with an increased relative risk for testicular tumours in the fetus , ranging from 2.8 to 5.3 over the expected incidence . other acquired factors such as trauma and infection - related testicular atrophy have been associated with testicular tumours ; however , a causal relationship has not been established . our patient had his right testis in the scrotum and there was no palpable testis in the left scrotum . this rapidly enlarging tumour was detected in the region betwen the external oblique fascia and the abdominal subcutaneous layer , distal to the external inguinal ring ( figure 4 ) . exogenous estrogen administration to his mother during pregnancywas not reported . rapidly enlarging tumour distal to the external inguinal ring . approximately 7 - 10% of testicular tumours develop in patients who have a history of cryptorchidism ; seminoma is the most common form of tumour these patients have . however , 5 - 10% of testicular tumours occur in the contralateral , normally descended testis . the relative risk of malignancy is highest for the intra - abdominal testis ( 5% ) and is significantly lower for the inguinal testis ( 1.25% ) ( 4 ) . orchiopexy does not alter the malignant potential of the cryptorchid testis ; however , it facilitates examination and tumour detection ( 5 ) . three clinical stages for the determination of the extension of the tumour have been described . stage i is where the tumour is limited to the testis with or without invasion of epididymis or the spermatic cord . in stage the germ cell tumour often gives lymph node metastasis , except from choriocarcinoma , which is characterized by early hematogenous spread . age , tumour size , lymphovascular invasion , mitotic count , necrosis , percent of giant cell and tumour infiltrating lymphocytes are possible prognostic factors in the treatment of seminomas . in this particular case , the tumour was classified as stage i classical seminoma with positive lymphovascular invasion ( tunica vasculosa nested tumour cells ) . unilateral rapidly enlarging tender abdominal wall mass with undescended testis should alert clinicians towards consideration of the possibility of seminoma and initiation of prompt intervention .

seminomas in undescended testes may present as abdominal wall tumours . a unilateral testis tumour in a 29 year old man with ipsilateral undescended testis is presented and relevant literature is reviewed.a 29 year old man presenting with a tender left lower abdominal mass was admitted to our clinic and initial diagnostic tests followed by abdominal computerized tomography ( ct ) and positron emission tomography / computerized tomography ( pet / ct ) were performed . abdominal ct clearly demonstrated the tumour location between the lower left abdominal subcutaneous layer and the external oblique fascia . he underwent surgery and the tumour was resected via en - bloc excision.pathological diagnosis of the resected specimen was consistent with classical seminoma and no distant metastasis was detected with pet / ct . he was referred to oncology clinic after discharge.tumours of undescended testis can present as an abdominal wall mass and clinicians must be aware of their existence .

lipomas are the most common benign mesenchymal tumors developing in any location where fat is normally present . the etiology of lipomas is uncertain and the tumors mainly affect the region of the trunk , shoulders , neck , and axilla . involvement of the oral cavity is rare , with lipomas corresponding to less than 4.4% of all benign oral soft tissue tumors . they commonly present as slow - growing asymptomatic lesions with a characteristic yellow color and soft , doughy feel in the buccal mucosa , floor of the mouth and tongue in the fourth and fifth decades , and generally with no gender predilection . oral lipomas can occur in various anatomic sites including the major salivary glands , buccal mucosa , lip , tongue , palate , vestibule , and floor of mouth . although benign in nature , their progressive growth may cause interference with speech and mastication due to tumor 's dimension . a 10-year - old female patient reported with a chief complaint of swelling on left cheek . the swelling was first noticed two years ago , which showed slow continuous gradual enlargement . intraoral examination revealed a pinkish , well - defined oval swelling measuring 2.5 3 cm present in the left buccal mucosa [ figure 1 ] . on palpation , the swelling was soft , fluctuant , non - tender , mobile , and the margins were slippery under the palpating finger . the lesion was excised under local anesthesia and the excised tissue was sent for histopathological examination [ figures 2 and 3 ] . showing fibrolipoma of left buccal mucosa buccal mucosa after surgical resection of the lesion microscopic examination revealed adipose tissue with compressed blood vessels embedded within dense collagen fibers . the overlying epithelium was 8 to 10 layers thick , atrophic , parakeratinized and stratified squamous type . correlating with the clinical and histopathological examination , the excised lesion was suggestive of fibrolipoma [ figure 4 ] . histologic appearance of fibrolipoma [ h & e , 10 ] postoperative healing of buccal mucosa the first description of oral lipoma was provided in 1848 by roux in a review of alveolar masses which he referred it as a yellow epulis . the lipoma is a very common benign tumor of adipose tissue , but its presence in the oral and oropharyngeal region is relatively uncommon with a prevalence rate of only 1/5000 adults . fibrolipoma is a microscopic variant of lipoma characterized by a significant fibrous component intermixed with lobules of fat cells . the consistency of this lesion varies from soft to firm , depending on the quantity and distribution of fibrous tissue and the depth of the tumor . the tumor has been reported to be more frequent in the buccal mucosa and buccal vestibule , and it also shows a slight predominance in females . in our case , fregnani et al . collected several cases and diagnosed 45.7% cases as lipomas and 39.1% cases as fibrolipomas . hereditary , fatty degeneration , hormonal basis , trauma , infection , infarction , and chronic irritation are probable representative theories to elucidate the pattern of a lipoma . the most common of these is the fibrolipoma , characterized by a significant fibrous component intermixed with the lobules of fat cells . the spindle cell lipoma is another variant that demonstrates variable amount of uniform appearing spindle cells in conjunction with a more typical lipomatous component . intramuscular lipomas are often more deeply situated and have an infiltrative growth pattern that extends between skeletal muscle bundles . this tumor can be life threatening due to obstruction of upper airway by virtue of its size as sudden asphyxia death has been reported in a case of esophageal fibrolipoma . lesions outside the oral cavity could show greater recurrence rates after surgical excision , but intraoral intramuscular lipomas , although not well - limited , rarely show recurrence if completely excised . most of lipomas develop in the subcutaneous tissues but deeper tissues may be involved as well . the complete resection should be emphasized , which is the key factor to avoid recurrence .

the lipoma is a very common benign tumor of adipose tissue , but its presence in the oral and oropharyngeal region is relatively uncommon . fibrolipoma , a histological variant of lipoma , mostly affect the buccal mucosa and causes functional and cosmetic disabilities . hence , accurate histopathological examination of lipomas is important for a correct treatment plan . this article describes a case of 10 year old girl with fibrolipoma of the buccal mucosa with a relevant review of tumors .

. they can be either pedunculated or sessile and are more common in the extremities . we present a case of 18 year female , who came with a swelling in right groin since 2 years which was diagnosed to be osteochondroma on x - ray and magnetic resonance imaging . excision biopsy was done as the patient wanted it to be removed for cosmetic purpose and confirmed it to be non - malignant osteochondroma . thus osteochondroma of the pelvis should be kept in mind as a differential diagnosis when evaluating mass in pelvis . . they can be either pedunculated or sessile and are more common in the extremities , i.e. distal femur , proximal tibia and proximal humerus in decreasing order . indications for excision are cosmetic deformity , pressure symptoms on neuro - vascular bundle or malignant transformation to chondrosarcoma which is rare . osteochondroma of the pubic ramus is rare entity and the actual incidence is not known . it can present as a solitary lesion or as a part of multiple hereditary exostosis . pelvic osteochondromas can present as compressive neuropathy or compressive symptoms on urethra , bladder or other vital structures and so on . on the contrary a pubic bone mass may need to be removed in young females which might be prominent at labia for cosmetic reasons as in our case . an 18 year female came to the out - patient department with complaints of swelling in right groin since 5 years which was insidious in onset , small in size initially but grew over last 5 years and was noticeable to the patient . , there was a bony hard swelling 3 5 cms in size in the groin at the pubic tubercle of the right side . plain x - ray s of pelvis ap , inlet and outlet view ( fig.1 to 3 ) and magnetic resonance imaging ( fig 4 & 5 ) showed bony growth of 543746 mm in size in transverse , craniocaudal and anteroposterior dimension which was arising from right superior pubic ramus and was extrapelvic in situation with a cartilage cap of 4 mm . 6 ) was taken and as the soft tissue was retracted cartilage cap of the osteochondroma was seen ( fig . manual palpation was done and one more piece was found which was then excised ( fig . 9 ) . inguinal ligament was closed in layers maintaining the external iliac ring with continuous sutures to prevent future inguinal hernia ( fig . osteochondromas are benign tumors which have an unknown etiology . it is considered as a developmental physeal abnormality rather than a primary bone neoplasm . a few theories have been suggested which include virchow theory , muller theory , keith theory , and a few more . the most common sites are metaphysis of long bones like distal femur , proximal tibia and proximal humerus . osteochondromas can also be found as a part of multiple hereditary exostosis which is thought to be associated with ext1 and ext 2 gene . osteochondromas are as such an incidental finding in patients and only a few are symptomatic . it is usually present in growing age and the growth of the mass stops after skeletal maturity . various studies have mentioned about the size of cartilage cap as a predictor for malignancy with a cartilage cap of more than 2 cm after skeletal maturity indicative of malignant transformation . pre operative investigations and planning in patients presenting with a bony neoplasm must be done . pre - operative x - rays and mri were done for our patient to see the extent and measure the cartilage cap of the osteochondroma . pelvic osteochondroma involving ilium has been reported in literature which caused nerve root compression and had to be removed . osteochondroma of the pubic symphisis has been reported which was removed due to bladder outlet obstruction . thus with a thorough search in literature we concluded that it is a rare entity and it was diagnosed due to the compressive symptoms caused by it . here in our case the swelling near the private part was the cause for the patient to seek medical help . there were no compressive symptoms either on vessels or on urinary tract which was confirmed by arterial doppler and micturating cysto - urethrography . a similar case was reported by qaisrani gh and associates which was also present on superior pubic ramus and was removed for cosmetic deformity . complete en - bloc removal of the mass was done in our case for cosmetic reasons and she is being followed up regularly . even after 1 year there has not been any recurrence of the lesion . benign osteochondromas are usually incidental findings and are removed most commonly for cosmetic purposes with a very low incidence of recurrence if removed after skeletal maturity . also pelvic osteochondromas are rare entity but it has to be kept in mind for any bony mass when looking for differentials . pelvic osteochondromas are rare entity but it has to be kept in mind for any bony mass when looking for differentials .

introduction : osteochondroma are benign neoplasms which arise from small cartilage nodules within the periosteum . they can be either pedunculated or sessile and are more common in the extremities . they rarely develop in bones like scapula , feet , hands and pelvis . management of the lesion is by en - bloc excision.case report : we present a case of 18 year female , who came with a swelling in right groin since 2 years which was diagnosed to be osteochondroma on x - ray and magnetic resonance imaging . excision biopsy was done as the patient wanted it to be removed for cosmetic purpose and confirmed it to be non - malignant osteochondroma . there has been no recurrence even after 1 year of follow up.conclusion:thus osteochondroma of the pelvis should be kept in mind as a differential diagnosis when evaluating mass in pelvis . also these have to be removed when they pose cosmetic problems .

the type 1 boston keratoprosthesis ( kpro ) is a poly ( methyl methacrylate ) device that has gained acceptance in many types of end - stage corneal diseases as a viable surgical option.13 the kpro is assembled using a carrier donor tissue , and its optics afford excellent visual acuity and field of vision4 assuming that the alignment of the kpro is optimized . centration of the kpro is determined during preparation of the donor carrier tissue and host trephination . the manufacturer s recommended steps for kpro preparation involve punching the donor with an 8.5 mm or greater diameter followed by a 3-mm central punch . we have found that centration of the kpro in the carrier tissue can be difficult using this procedure , and we present a modification for minimizing centration error . the center of the donor carrier tissue is marked using a surgical marker , and a 3-mm central punch is performed using the centration mark ( figure 1a ) . . the 3-mm - diameter punched tissue is removed , and the edge is inspected . an appropriate outer diameter punch size is selected , which should be at least 8.5 mm diameter if possible , and a disposable barron corneal punch ( katena eye instruments , denville , nj ) is typically used . the donor carrier tissue is placed on the punch block and the 3-mm hole is centered between the vacuum holes of the punch block ( figure 1b ) , and the vacuum is engaged . the punch is then carefully performed , and the kpro is assembled and sutured to the host rim ( figure 1c ) . the type 1 boston kpro is a viable therapeutic option for many end - stage corneal diseases that are poor candidates for traditional penetrating keratoplasty , and the reported visual results of the kpro have been good.2,3 the assembly of the kpro involves preparation of a carrier tissue with two punches that are ideally concentric . we have found difficulty in creating concentric punches using this technique ( figure 2 ) , and we believe that punching the central 3-mm hole first and then using this hole to center within the barron corneal punch s four vacuum ports affords much better control . if the manufacturer s recommendations are followed and the outer punch is performed first , then the free - hand 3-mm dermatologic punch must be placed perfectly for a concentric result . the optical performance of the kpro on an optical bench using a 3-mm pupil and precise alignment was evaluated and found to produce a sharp , crisp image with a tight point - spread function.4 the optical cylinder , under these optimized alignment conditions , produced scattered ghost images when the 3-mm pupil was widened to 10 mm . if the alignment of the kpro is suboptimal with the cylinder off - axis from the fovea , then the projected image will most likely be further degraded . we believe the centration of the kpro in the donor carrier and host cornea is integral for optimal alignment of the cylinder and minimization of scatter and other optical phenomena . our technique of punching the 3-mm inner hole first and then centering the outer punch on this hole relieves much centration uncertainty in kpro preparation . in addition to the optical advantages of optimizing centration , suturing to the host rim is much easier with better distribution of tension when the kpro is centered . we have not found any limitations or problems from this simple modification of kpro assembly .

the type 1 boston keratoprosthesis preparation requires a 3-mm central punch and an 8.5 mm or larger punch in the carrier tissue . these punches are ideally concentric , but we have found difficulty in achieving concentric punches when the larger punch is performed first . we present a modification in the preparation procedure to help minimize centration error .

the use of the waterpipe , or shisha , for smoking tobacco is an old tradition in the eastern mediterranean region that goes back centuries . this habit is relatively rare in singapore , a country with a predominantly chinese population . carbon monoxide ( co ) poisoning can be notoriously deceptive and non - specific in its initial presentation to the emergency department ( ed ) . its correct diagnosis and eventual management require a high level of suspicion on the part of the emergency physician ( ep ) . our patient was a 19-year - old gentleman of saudi descent who was a student in singapore and had no past medical history of note . he had been having dinner with a friend at a restaurant 4 h prior to presentation and had been smoking shisha at that time . collateral information from his friend revealed that he had been smoking shisha with three other friends and had hit his occiput after a fall . his vital signs revealed a temperature of 36.7c , blood pressure of 108/61 , pulse rate of 99/min and pulse oximetry reading of 99% on room air . physical examination revealed that he was alert and orientated to time , place and person . bedside capillary blood sugar was 5.1 mmol / l , and the baseline electrocardiogram was normal . the initial working diagnosis was that of stable head injury and a few other possible explanations for the dizziness , including cardiac arrhythmias , transient hypoglycemic episode , viral illness and substance overdose . he was scheduled for computed tomography ( ct ) of the brain . however , a carboxyhemoglobin ( cohb ) level was taken in view of the shisha smoking . he was immediately transferred to the critical monitoring area and put on 100% oxygen via a non - rebreather mask . a bedside arterial blood gas on high flow oxygen revealed respiratory alkalosis with ph of 7.441 , pco2 of 37.3 mmhg and po2 of 501 mmhg . he was admitted to the medical high dependency unit ( mdu ) for further monitoring and management . he was placed on 100% oxygen for the next 46 h while he was in the mdu , and his dizziness resolved . he was discharged 2 days post - admission with a follow - up date for psychometric testing and neurological review at the outpatient clinic . this case highlights the challenge to emergency physicians regarding the timely diagnosis of co poisoning , a highly treatable condition . the non - specific neurological complaints can mimic many illnesses , such as viral illness or stable head injury . it binds to hemoglobin 200300 times more tightly than oxygen , forming cohb . as such , it inhibits the release of oxygen from hemoglobin to peripheral tissues , causing tissue hypoxia . the half life of cohb is 4 to 5 h in a person breathing room air and changes to 60 min in the presence of 100% oxygen at sea level . as such , our index patient would have been symptomatic for a prolonged period of time if the initial suspicion of co poisoning had not been made and he had been managed as a person with stable head injury . shisha smoking is one form of waterpipe smoking among others , including hookah , nargileh and arguileh . shisha smoking is relatively rare in singapore , but is common in the mediterranean regions , according to a who report . the report stated that the overall prevalence of shisha smoking in egypt was estimated at 10% from a national survey in 2002 focusing on hypertension , obesity and diabetes in such smokers . it has been estimated that smoke exposure could be as much as 100200 cigarettes per session . co poisoning is difficult to diagnose in the ed as its presenting symptoms are usually non - specific . undoubtedly , a history of potential co exposure is the most reliable indicator of poisoning . eps should have a high index of suspicion , even though the exposure can be exotic , as in this case . it is important to realize that when dizziness occurs in co poisoning , it usually corresponds to a caboxyhemoglobin level of 20% and above , a level considered to be at least moderately severe . making a diagnosis in a timely fashion can expedite the management of such patients .

carbon monoxide poisoning has been reported as a result of exposure to various sources of smoke , such as car exhaust fumes , home water heaters and tobacco smoke . we describe a case of symptomatic , moderately severe carbon monoxide ( co ) poisoning in a young mediterranean man after smoking a waterpipe , or shisha . this case highlights the importance of considering carbon monoxide exposure in patients presenting with non - specific neurological symptoms to the emergency department ( ed ) .

lichen planus pigmentosus ( lpp ) , an uncommon variant of lp , is characterized by mottled or reticulated hyperpigmented , dark brown macules in sun - exposed areas and flexural folds . the histopathologic findings of lpp consist of hyperkeratosis , atrophic epidermis with vacuolar alteration of the basal cell layer , and scarce lymphohistiocyte or lichenoid infiltrates in the dermis with pigmentary incontinence and the presence of melanophages ( 1 ) . although there have been a few reports of linear lichen planus , there has been no report of lpp with a linear pattern ( 2 , 3 ) . we describe two patients with lpp who had skin lesions in a linear distribution related to blaschko 's lines on their extremities . a 23-yr - old korean woman presented with asymptomatic dark brown macules on the left leg for 2 yr . one or two dark brown macules first appeared and spreaded gradually without any preceding erythematous or scaly skin eruption . there was no history of prolonged sun exposure or trauma on the lesion site . on examination , she had linear streaks of dark brown macules from the left ankle , across the calf and to the thigh , consistent with the pattern of blaschko 's lines ( fig . skin biopsy showed atrophic epidermis , basal hydropic degeneration with sparse perivascular lymphohistiocytic infiltrates , and numerous melanophages ( fig . these findings were consistent with lpp . a 16-yr - old korean woman presented with linear dark brown pigmentation on the left arm for one year . she stated that recurrent asymptomatic erythematous papules first appeared and then the lesion had developed into dark brown macules during 1 - 2 weeks . examination showed two linear streaks of dark brown macules from the left dorsum of hand to the upper arm probably related to blaschko 's lines ( fig . skin biopsy showed orthokeratosis , focal basal liquefaction , a sparse perivascular inflammatory infiltrate , and pigmentary incontinence , confirming the diagnosis of lpp ( fig . a 23-yr - old korean woman presented with asymptomatic dark brown macules on the left leg for 2 yr . one or two dark brown macules first appeared and spreaded gradually without any preceding erythematous or scaly skin eruption . there was no history of prolonged sun exposure or trauma on the lesion site . on examination , she had linear streaks of dark brown macules from the left ankle , across the calf and to the thigh , consistent with the pattern of blaschko 's lines ( fig . skin biopsy showed atrophic epidermis , basal hydropic degeneration with sparse perivascular lymphohistiocytic infiltrates , and numerous melanophages ( fig . a 16-yr - old korean woman presented with linear dark brown pigmentation on the left arm for one year . she stated that recurrent asymptomatic erythematous papules first appeared and then the lesion had developed into dark brown macules during 1 - 2 weeks . examination showed two linear streaks of dark brown macules from the left dorsum of hand to the upper arm probably related to blaschko 's lines ( fig . skin biopsy showed orthokeratosis , focal basal liquefaction , a sparse perivascular inflammatory infiltrate , and pigmentary incontinence , confirming the diagnosis of lpp ( fig . lpp has been described as a condition of unknown etiology which clinically differs from the classical lichen planus by exhibiting dark brown macules and/or papules and a longer clinical course without pruritus or scalp , nail , or mucosal involvement . the lpp is most common on sun - exposed areas such as the face , neck , and flexural folds including the axilla , inguinal , and submammary regions ( 1 ) . some authors observed a striking predominance of lesions in an intertriginous location , with most of them in the axillae , thus they proposed the designation lpp - inversus ( 4 ) . less common presentations include zosteriform pattern on the trunk ( 5 ) and involvement of non sun - exposed areas such as thigh ( 6 ) . the linearity of the lesions is probably related to blaschko 's lines , which suggests that the predisposition to develop lpp might be determined during embryogenesis . the differential diagnoses of our cases include lichen striatus ( 7 ) , linear and whorled nevoid melanosis and incontinentia pigmenti . in particular , because lichen striatus may have post - inflammatory hyperpigmentation ( 8) and lacks a well - defined histopathological picture ( 9 ) , it should be differentiated in our patients . lichen striatus almost always have preceding inflammatory papules or scaly eruption , which last for 4 months to 4 yr ( 8) . there was no previous papule in patient 1 and the short duration of preceding papules ( 1 - 2 weeks ) favor the lpp in patient 2 . there were no epidermal changes consisting of spongiosis and exocytosis , and a deeper dermal inflammatory infiltrate around adnexal structures which are features frequently seen in lichen striatus ( 9 ) . in summary , lpp can present with a linear pattern and thus should be considered in the differential diagnosis of linear hyperpigmented skin lesions .

we report two cases of lichen planus pigmentosus ( lpp ) that developed in a unilateral linear pattern . the patients presented with unilateral linear brown macules on the extremities . skin biopsy showed orthokeratosis , basal hydropic degeneration with scarce lymphohistiocytic infiltrates , and numerous melanophages in both patients . these patients , to the best of our knowledge , are the first cases of lpp presenting with a linear pattern . lpp should be considered in the differential diagnosis of linear hyperpigmented skin lesions .

a 31-year - old female patient consulted to our outpatient clinic because of a mass protruding from her right nipple . on her breast examination , an 8 mm prolapsed mass was seen on the right breast areola ( figure 1 ) . during physical examination any abnormality was not detected on other parts of the breast , and her left breast . from her personal and family medical history her breast ultrasonographic ( us ) examination demonstrated an avascular , hypoechoic prolapsed solid mass measuring 8x5 mm which filled the areolar region completely . based on physical , and us examination findings surgery was planned with the initial diagnosis of intraductal papilloma . the prolapsed mass , minimal portion of the overlying areolar skin and communicating ductus were totally excised under local anesthesia . histopathological examination of the specimen revealed intraductal papilloma without atypical dysplasia ( figure 2 ) . any postoperative complication did not develop , and any recurrence was not seen during 2 years of follow - up . intraductal papillomas ( ip ) are benign tumours which develop as a result of papillary proliferation of the ductal epithelium . its incidence is 2 - 3% , and it is seen between 30 , and 77 years of age . central type is a solitary ip which settles in the subareaolar region , and it is observed in perimenauposal women . peripheral type is situated on the proximal parts of the laciferous ducts of young female patients and tends to be multiple . however , the patient consulted to the physician at an earlier stage because of the protruding characteristics of the mass . although it is generally localized in the breast tissue , and subareolar region , in our case , it protruded from the nipple of the patient . intramammary masses are detected by us , and the diagnosis is conclusively confirmed by biopsy . radiological imaging techniques are helpful in establishing the diagnosis , however for the discrimination between benign , and malign lesions core needle biopsy should be performed . treatment of intraductal papillomas consists of total excision . since the mass lesion of our patient was protruding , total excision was performed both for diagnosis , and treatment . if intramammary ip lesion can be located using radiological techniques , then excision , without needle biopsy is recommended . core biopsy is recommended for cases with radiologically suspect malignancy or in the presence of microcalcification , and distorted tissue ultrastructure . if small papillary lesions can be totally excised , and histopathologic examination does not reveal any evidence of atypia , then the patient can be followed up with us , and mammographic monitorization . in the differential diagnosis , nipple adenoma , and papillary lesion , paget s disease , eczematous dermatitis , and pyogenic granuloma histopathological differentiaton of the excised mass can be achieved . if untreated , papillary lesion of the nipple also protrudes . paget s disease , and eczema can be discriminated from other lesions with their characteristic cutaneous incrustrations . ip prolapsed from the nipple is a rarely seen abnormality . for its diagnosis , and treatment ,

intraductal papillomas ( ip ) are benign papillary lesions caused by proliferation of mammary ductal epithelium . ip occurs in the breast tissue . prolapse of ip from nipple can be rarely seen . ips are generally treated with total excision . a 31-year - old female patient was admitted to our clinic because of a protruded lesion from the nipple of her right breast . on her breast examination , an 8 mm- prolapsed mass was seen on the areola of her right breast . breast ultrasonography showed no other lesions in the breast . the patient was operated with initial diagnosis of ip . the prolapsed mass , the overlying nipple skin and related ductus were totally excised under local anesthesia . histopathological examination of the specimen revealed intraductal papilloma without atypical dysplasia . herein , we are presenting a rarely encountered case of ip prolapsed from the nipple of a female patient .

these extrahepatic lesions are most commonly found in the lungs , lymph nodes , and bones . there have been reports of extrahepatic lesions found in urogenital sites , such as the kidneys , testes , and bladder [ 24 ] . we encountered a patient with a metastatic hcc lesion presenting as a tender right inguinal mass . to the best of our knowledge , this case represents the first such report in the english language literature . a 57-year - old man was referred to our urology out - patient department from a gastrointestinal doctor because of a tender inguinal mass that had become progressively larger over the previous one and half months . the patient had a past history of hcc ( underwent radiofrequency ablation in july 2004 and transcatheter arterial chemoembolization in november 2004 ) , hepatitis b virus infection , rightside inguinal hernia ( status postherniorrhaphy in 2007 ) , a cholecystectomy in 2000 , and a vasectomy in the 1990s . he noticed a painful hard mass in the right inguinal area one and half months prior to visiting our department . physical examination revealed a 2 2 centimeter hard , movable , tender mass in the right inguinal area . an excision biopsy was performed , and the pathological report revealed tumor cells with abundant amphophilic to pale eosinophilic cytoplasm , round nuclei , mitosis , and focal necrosis , and the cells were hep par 1 positive as determined by immunohistochemical staining ( figure 1 ) . due to a persistent , painful sensation in the right inguinal area , removal of the right inguinal metastatic mass was arranged . during inguinal exploration a right radical orchiectomy was performed because the tumor could not be freed from the spermatic cord . the pathological report showed multiple metastatic hcc tumor nodules and tumor emboli in the lymphatic and blood vessels of the spermatic cord and peritesticular soft tissue ( figure 2 ) . hcc is commonly seen in taiwanese hospitals due to high incidence of hepatitis b and c in taiwan . most documented extrahepatic metastatic lesions have been found in the lungs followed by the lymph nodes , bones , and adrenal glands , but there are cases of distal metastasis to the genitourinary system , such as the kidneys and bladder [ 1 , 3 , 4 ] . similar to other metastatic lesions , the clinical presentation of extrahepatic metastatic lesions depends on their location and the affected areas . presentations include hematuria , flank pain , and testicular pain ; these signs and symptoms are very similar to those of other common genitourinary diseases [ 14 ] . in our case , this patient presented with a painful inguinal mass . when patients present with an inguinal mass , we need to take into consideration several differential diagnoses ranging from benign to malignant lesions . malignant tumors , including primary tumors and metastases , are extremely rare [ 68 ] . painless scrotal or lower inguinal mass was the most common clinical presentation in the metastatic spermatic cord tumors . the metastatic spermatic cord tumors could be misdiagnosed as hydrocele , hernia , and testis tumor . when a tumor is found in the inguinal area in patients with a history of malignancy or peritoneal carcinomatosis , retrograde extension through the vas deference and transperitoneal seeding had been reported . in this case a metastatic tumor originating from hcc was confirmed after excision biopsy . according to the national comprehensive cancer network clinical practice guideline for metastatic hcc , only sorafenib ( for child - pugh class a or b ) , supportive care , or clinical trials because of persistent pain in the inguinal area and progressive enlargement of the tumor , a radical orchiectomy was performed . what kind of treatment is suitable for tumor emboli in the surgical margin of the spermatic cord ? according to previous reports , palliative radiation therapy has been used to treat hcc with brain and bone metastasis with successful symptom control . hawkins and dawson showed that radiation therapy can prolong survival for hcc patients with portal vein thrombus . because of the lack of a standard treatment for metastatic lesions of hcc , we used radiation therapy for local control , and no recurrence was found after 6 months . in conclusion , we report the first case of metastatic hcc in the spermatic cord , which presented as a painful inguinal mass . palliative radiation therapy is a choice for the treatment of metastatic hcc with tumor emboli in the surgical margin .

most spermatic cord masses are benign , and malignant spermatic cord tumors are uncommon . spermatic cord metastases originating from hepatocellular carcinoma ( hcc ) have not been previously reported in the english language literature as determined by a pubmed search . we report a male patient who presented with a painful palpable mass in the right inguinal area . the patient was diagnosed with hcc in 2004 and undertook a nonsurgical approach to control the cancer . a radical orchiectomy was performed , and the pathological report showed metastatic hcc in the spermatic cord . the patient received palliative radiation therapy because of a positive surgical margin . no recurrence was noted after 6 months of followup .

we present a case of an 80-year - old gentleman presenting to the emergency department with a swelling on the anterior abdominal wall in the right upper quadrant extending over the right costal margin . the swelling had developed spontaneously , was painless and increasing in size over two months . he had specifically not complained of any symptoms at all previously in this area and had no other significant medical or surgical history apart from hypertension controlled by beta blockers and thiazide diuretics . prior to admission the area had acutely become inflamed with a purulent discharge and an abscess was diagnosed . the patient showed no signs of systemic sepsis with a mildly elevated serum c - reactive protein of 55 mg / ml being the only biochemical abnormality . incision and drainage was performed and antibiotics were given . at operation a hard , smooth surfaced structure was encountered deep into the cavity , thought to be either a costal margin edge or possibly an intraperitoneal structure . ultrasonography of the area was performed postoperatively , but this was unable to define the anatomy surrounding the abscess cavity . in the postoperative period the wound continued to discharge pus , which on gram stain demonstrated leucocytes and gram - negative bacilli , culturing lactose - fermenting coliforms . from this , the possibility of a colonic component to the pathological process was raised . subsequent computerised tomography scanning of the area revealed an intraabdominal collection in front of segment iv of the liver which was extending inferiorly and pointing on to the abdominal wall where three low density structures were identified , presumed to be loculations of pus ( fig . a kocher incision was made and an inflammatory mass containing the gallbladder , an edge of the duodenum and omentum was found to be adherent to the under surface of the liver and to the anterior abdominal wall . careful dissection revealed a chronic fistula from the fundus of the gallbladder to the abdominal wall measuring around 5 mm in diameter . the gallstones were smooth , firm , brown coloured structures consistent with cholesterol - based gallstones usually encountered during elective cholecystectomy . histological examination of the removed gallbladder and adherent abdominal wall demonstrated evidence of gallstone migration both microscopically and macroscopically secondary to active chronic cholecystitis . the abdominal wall section showed inflamed fibrofatty connective tissue containing gallbladder lumen and wall demonstrating fibrosis , chronic inflammation , rotitansky aschoff sinuses and muscular hypertrophy , confirming gallstone fistulation as the underlying aetiology . the patient made an uneventful recovery and was discharged home on day 7 following the procedure with the abscess cavity wound dressed regularly , with a calcium alginate fibre dressing , and allowed to heal by secondary intention . he suffered no recurrence in the following months and was discharged from the surgical team after 12 months having made a full recovery . abdominal wall and intraperitoneal abscess formation after iatrogenic spillage of gallstones following laparoscopic cholecystectomy has been reported [ 1 , 2 , 3 ] , although this is rare . cholecystocutaneous fistulation is noted in the literature but is still extremely uncommon , with only around 22 cases described over the last two decades or so . the aetiology described usually results from spilled gallstones following laparoscopic cholecystectomy , as mentioned , or is associated with previous episodes of recurrent acute cholecystitis , although rarely other aetiologies such as malignancy have to be considered [ 6 , 7 ] . this is presumably due to the fact that one may suffer symptoms early such as those experienced with cholecystitis and , therefore , have definitive imaging and treatment before this particular eventuality is reached . this theory is also supported by the evidence that prior to 1950 , courvoisier had described 169 cases , with henry and orr adding another 36 cases , of external biliary fistulae , but subsequently relatively few cases described . the great majority of biliary fistulas occur with connection to the duodenum , colon , stomach and choledochal duct . spontaneous cholecystocutaneous fistula presenting as a subcutaneous abscess is an exceedingly rare presentation of this pathological process , having only been reported a few times [ 8 , 9 ] in the last twenty years with the patients usually having a known history of gallbladder disease . as is the case represented here , the most likely pathological process is recurrent gallbladder inflammation secondary to gallbladder calculi and chronic cholecystitis , causing adherence to the abdominal wall with eventual fistulation ( confirmed histologically ) , but what is surprising in this case is the lack of symptoms experienced by he patient prior to abscess formation . this case report highlights the need for vigilance by the clinician when investigating unusual and suspicious clinical presentations in this particular area and supports the liberal use of computerised tomography , or other modalities such as magnetic resonance cholangiopancreatography , early to gain an accurate diagnosis so that the appropriate treatment can be instituted .

abdominal wall abscess secondary to spontaneous cholecystocutaneous gallstone fistulation is an uncommon presentation of a rare pathological process . having been described relatively frequently in the 19th century , it is now much less common in the late 20th and early 21st century , probably due to earlier recognition of symptoms , better imaging and surgical treatment of biliary tract disease . here we describe a report of a case with an unusual clinical presentation of the already rare pathological disease process of spontaneous cholecystocutaneous fistula .

hellp syndrome represents a severe form of preeclampsia , presenting with hemolysis , elevated liver enzymes , and low platelet count . visual symptoms can be present in up to 25% of patients with preeclampsia , usually in the form of decreased visual acuity . retinal detachment is a rare , but the well - document cause of visual loss in patients with preeclampsia and eclampsia . it is observed in < 1% of patients with preeclampsia , specially in the patients with severe hypertension . in women with preeclampsia and eclampsia , coexistence of hellp syndrome point - of - care ocular ultrasonography allows for bedside detection of ocular pathologies such as retinal detachment , globe rupture , lens dislocation , and vitreous hemorrhage . here , we report a case or retinal detachment in a patient with hellp syndrome , which was detected at the bedside by an intensivist , using ocular ultrasonography . a 26-year - old female , para 2 and gravida 3 , presented with the history of 2 days of swelling of whole body , headache , and blurring of vision associated with decreased urine output . her liver enzymes and lactate dehydrogenase were raised , platelet count was 55,000 per ml , and urine examination revealed 4 plus albuminuria and hematuria . emergency lower segment cesarean section was performed , and the patient was transferred to the intensive care unit . an intensivist , trained in bedside focused ultrasonography , performed ocular ultrasound ( using high frequency linear probe ; frequency range of 613 mhz ; micromaxx ; sonosite , usa ) , which revealed a linear hyperechoic membrane floating off the posterior globe , with the medial end attached to the margin of optic nerve head , which was suggestive of retinal detachment [ figure 1 ] . she was started on injection glyceryl trinitrate , along with amlodipine 10 mg 12 hourly , prazosin 2.5 mg 12 hourly , metoprolol 50 mg 12 hourly , clonidine 100 mcg 12 hourly , and methyldopa 500 mg 6 hourly . with these drug combinations , blood pressure was controlled ( 130/80 mm hg ) and glyceryl trinitrate was tapered and stopped after 24 h. the patient underwent four sessions of hemodialysis for acute kidney injury . renal function and liver function gradually improved . a linear hyperechoic membrane floating off the posterior globe ( marked by white arrow ) , with the medial end attached to the margin of optic nerve head , suggestive of retinal detachment the patient was explained about the favorable prognosis . with the supportive care , ocular ultrasound repeated after 7 days showed regression of retinal detachment [ figure 2 ] . after another 1 week , she had complete recovery of vision . resolving retinal detachment ( marked by white arrow ) . retinal vascular changes , usually in the form of spasm and narrowing of retinal vessels , occur in up to 40%100% of patients with preeclampsia / eclampsia syndrome . arteriolar vasospasm affecting the retinal pigment epithelium leads to breakdown of blood - retinal barrier . subsequent leakage of protein and fluids from the capillaries , into the subretinal space , causes retinal detachment . the combination of microangiopathic hemolysis , hypoalbuminemia , and severe hypertension further contributes to the pathophysiology of retinal detachment . bedside ultrasound by a trained physician has been shown to be reliable and accurate for the diagnosis of retinal detachment . . the incidence of retinal detachment in these conditions can be much higher than actually detected . in our patient , early initiation of aggressive supportive care was coupled with favorable prognostication of visual outcome to the patient . the progressive improvement of vision correlated with both the ophthalmoscopic evidence of resolution of retinal detachment and sonographic appearance of resolution . to conclude , bedside ocular sonography can be a valuable and easily available tool for early detection of retinal detachment in patients with preeclampsia / eclampsia / hellp syndrome , presenting with visual symptoms .

retinal detachment is a rare , but well - known cause of visual impairment in patients with hemolysis , elevated liver enzymes , and low platelet count ( hellp ) syndrome . with supportive care , patients usually improve , with complete recovery of vision . bedside ultrasonography of the orbit can be helpful for early detection of retinal detachment in these patients . here , we present a case of hellp syndrome presenting with severe visual symptoms . retinal detachment was detected with point - of - care ocular sonography , which was confirmed with ophthalmoscopic examination . the patient was reassured of the favorable prognosis . early initiation of aggressive supportive care was followed by progressive improvement of vision , which correlated with sonographic evidence of resolution of detachment . her vision recovered completely in 2 weeks .

this is an unusual case of a 42-year - old gentleman , admitted to the intensive treatment unit ( itu ) following an attempted suicide . he was observed to develop significant polyuria following admission to itu and this polyuria resolved when propofol was stopped with no further treatment . this is a rare occurrence of this side effect with this drug , considering how frequently it is used . it may be the case that it occurs more frequently than is known about at present since it may be under - reported , which is why we feel this case report and the discussion it may stimulate are important . a 42-year - old man with a known psychiatric history was admitted in the morning to itu for respiratory and circulatory support following a mixed overdose . he had taken 50 mg of ramipril , 150 mg of olanzapine , and 200 mg of citalopram . he had taken no alcohol , paracetamol , aspirin , or recreational drugs and had not suffered any head injury . on itu he was sedated with 120 mg / h infusion of propofol 1% . in the afternoon , he was noted to be polyuric with a urine output greater than 500 ml / h and his urine was noted to be progressively more dilute [ figure 1 ] . catheter bag showing progressively more dilute urine since admission urine and serum osmolarity were measured . the following morning , sedation was stopped and he was extubated successfully . shortly thereafter , urine concentration returned to normal . medline was used to perform searches with combinations of the term diabetes insipidus and the drugs taken in overdose . there were no results found for a medline search of ramipril and diabetes insipidus or citalopram and diabetes insipidus . the search diabetes insipidus and olanzapine gave three results : one case report detailing the case of a 17-year - old who had taken an overdose of olanzapine and developed cranial diabetes insipidus whilst in itu ; a case report of a patient treated for diabetes insipidus secondary to lithium in a patient also taking olanzapine ; and a pilot study of the use of olanzapine in a palliative care setting in which one of the 24 patients developed diabetes insipidus . olanzapine is well absorbed via the oral route and its half - life is approximately 33 h , making it highly unlikely to be the culprit in our case where the polyuria resolved completely less than 36 h following ingestion of the overdose . on reviewing the notes , it was found that the resolution of the polyuria seemed to occur shortly after sedation with propofol was stopped . a further search of diabetes insipidus and propofol was performed . this found one case report linking the use of propofol as an anesthetic with diabetes insipidus . the mechanism of action of propofol ( 2 , 6-diisopropylphenol ) as an anesthetic is not fully understood , but it enhances gaba ( gamma - aminobutyric acid)-mediated inhibition of adh ( anti - diuretic hormone / arginine vasopressin ) release in rats , which is a potential mechanism for transient neurogenic diabetes insipidus in humans . the onset of the action of propofol is 30 s and its action is short - lived . the case report linking olanzapine and diabetes insipidus does not state what sedation was used whilst the patient was on itu . this case report shows that it is possible for propofol to induce polyuria in humans as it does in animal studies . why this does not occur more frequently , given how commonly propofol is used in the itu setting , is unclear and should be the subject of further investigation . it is possible that the use of other drugs in conjunction with propofol may have led to the under - recognition of the association with propofol . propofol is often used for the induction of anesthesia rather than maintenance , so polyuria may be less pronounced with smaller doses , attributed to other drugs or to the administration of iv fluids intra - operatively .

case report detailing the occurrence of diabetes insipidus in a 42-year - old man admitted to the intensive treatment unit ( itu ) following an overdose . whilst on itu , he was sedated with propofol . cessation of treatment with propofol coincided with resolution of the polyuria . animal studies suggest a theoretical mechanism for propofol as the causative agent , but this phenomenon is not commonly seen in humans .

lupus panniculitis ( lp ) occurs in 3% of the patients with cutaneous lupus erythematosus . it primarily affects subcutaneous tissues of the face and the proximal areas of the limbs , leading to residual atrophy . lp may lead to major aesthetic sequelae that severely decrease quality of life ( even during good long - term control of the autoimmune processes ) . given the condition 's low prevalence , treatment strategies in lp only 1 case of lipofilling has been reported with a follow - up period limited to 12 months . here , we report on the strikingly good aesthetic outcomes , the long - term quality - of - life benefits , and the safety of lipofilling in 2 patients with lp - associated subcutaneous atrophy . patient 1 ( a 13-year - old boy ) was referred for an ill - defined subcutaneous inflammatory nodule on the chin . a histopathological examination revealed a marked lymphocytic infiltrate ( in superficial and deep tissues ) with juxtafollicular involvement , prompting us to diagnose lp . treatment with hydroxychloroquine for 18 months led to the complete disappearance of inflammatory signs but resulted in a cup - shaped lipoatrophy and facial asymmetry . patient 2 ( a 32-year - old female ) had been monitored over a 6-year period for systemic lupus erythematosus with positive antinuclear and anti - double - stranded dna antibodies . during treatment with hydroxychloroquine , she presented with subcutaneous inflammatory lesions on the thighs and cheeks . a diagnosis of lp was confirmed by histopathological examination of a skin biopsy according to the criteria by peter and su . the initial response to oral prednisone was good , but the patient became steroid dependent . a series of steroid - sparing agents was then administered ( including thalidomide , cyclophosphamide , and azathioprine ) . four weekly intravenous infusions of rituximab ( 375 mg / m ) , which were repeated 1 year later , led to complete remission , although atrophic scarring in malar areas persisted . following a request from both patients for correction of the aesthetic sequelae , we chose to use lipofilling . briefly , 10 ml of fat were collected via a 2-mm incision below the umbilicus . next , fat cells were injected into the submental ( patient 1 ) or malar ( patient 2 ) areas using coleman needles . there were no complications , and the positive aesthetic outcome was maintained 3 years after the procedure with no signs of the recurrence of lp ( fig 1 ) . the dermatology quality of life index decreased from 16 before lipofilling to 0 six months thereafter ( patient 1 ) . lipofilling is a well - established technique widely used in the rejuvenation of the aging face and in iatrogenic lipoatrophy [ 7 , 8 ] . this technique was also used successfully in some cases of linear scleroderma en coup de sabre . most of the common side effects of lipofilling are not severe . nevertheless , it is critical for surgeons to have a firm knowledge of the vascular anatomy because some cases of irreversible blindness have been reported . the good response of patient 2 to rituximab suggests that the efficacy of rituximab as a salvage therapy for treatment - refractory lp should be assessed in prospective trials . along with a previous report , the 2 present cases suggest that lipofilling is effective for treating the atrophic scars that result from permanent alterations of the subcutaneous fatty tissue in lp . moreover , the short- and long - term absence of any signs of lupus relapse or postsurgical complications is encouraging . the lipofilling procedure appears to be very safe when performed in patients with stable disease and thus paves the way for prospective , larger - scale studies in patients with completely controlled autoimmune disorder . these long - term , controlled trials will be able to accurately assess the benefit - risk ratio of lipofilling in lp and other immune - related subcutaneous scarring conditions .

lupus panniculitis is a rare manifestation of cutaneous lupus erythematosus , which may lead to major aesthetic sequelae with a severe impact on patients quality of life . we report 2 cases supporting the short- and long - term efficacy and safety of lipofilling in the treatment of lupus panniculitis - induced atrophy . these observations pave the way for prospective , larger - scale studies in patients with scarring lupus panniculitis , provided that the autoimmune pathogenic process is in complete , stable remission .

darier disease ( dd ) is a rare , autosomal dominant , inherited acantholytic dermatosis caused by a mutation in the atp2a2 gene on chromosome 12 . the diagnosis of dd is suggested by the clinical findings of a persistent eruption of greasy hyperkeratotic papules and plaques usually occurring over seborrheic areas as well as distinctive nail abnormalities . numerous treatments such as topical corticosteroids , topical retinoids , topical 5-fluorouracil , diclofenac sodium 3% gel , dermabrasion and laser therapy have reportedly been used for the treatment of dd , with limited success . systemic retinoids , including acitretin , isotretinoin and alitretinoin , are the most effective treatment for dd . however , their use is limited by potential deleterious side effects . considering the recently reported efficacy of doxycycline for hailey - hailey disease , an inherited acantholytic skin disorder pathogenetically similar to dd , we report the case of a patient with extensive dd who showed a dramatic response to oral doxycycline monotherapy . a 77-year - old patient with a 57-year history of dd was referred to our department for a severe exacerbation of dd that was recalcitrant to conventional topical treatments , including emollients , topical corticosteroids and topical mupirocin ointment . physical examination revealed malodorous eroded hyperkeratotic papules and plaques on the axillae , groin , perineum and lower back ( fig . classical nail changes , which included white and red longitudinal bands , were present . the mucosa was not affected . a skin biopsy specimen from a lower back lesion showed characteristic histopathological findings consistent with a diagnosis of dd ( fig . 2 ) . a therapeutic regimen of oral doxycycline ( 100 mg / day ) was started . the skin lesions showed marked improvement and were in complete remission after 1 month ( fig . 3 ) . the patient was maintained on a half - dose therapy ( 50 mg / day ) and did not experience any relapse within 3 months of follow - up . dd is caused by mutations in the atp2a2 gene that encodes the sarcoplasmic / endoplasmic reticulum calcium atpase 2 ( serca2 ) , which is a calcium pump . serca2 plays a central role in cellular calcium homeostasis and actively transports calcium ions from the cytosol into the lumen of the endoplasmic reticulum in order to maintain a low cytoplasmic calcium level . the molecular mechanisms by which specific atp2a2 mutations alter the function of the serca2 protein and cause acantholysis ( loss of cell - to - cell adhesion ) and dyskeratosis ( premature and abnormal keratinization ) , the histological hallmarks of dd , remain unclear . as a consequence of the loss of serca2 calcium transport , darier keratinocytes display depleted endoplasmic reticulum calcium stores . in addition to their antibiotic potential , tetracyclines and their analogues exhibit anti - inflammatory properties by inhibiting granulocyte chemotaxis and secretion . interestingly , matrix metalloproteinase 9 and its inhibitor , tissue inhibitor of metalloproteinase 1 , have been shown to be involved in dd and hailey - hailey disease . tetracyclines bind divalent metal cations and circulate in blood plasma primarily as calcium and magnesium chelators . furthermore , once chelated , tetracyclines can act as ionophores that are capable of transporting bound calcium and magnesium through lipophilic phases , such as cellular membranes , and delivering ions into intracellular compartments . after intracellular incorporation , calcium can act as a secondary messenger and affect pathways , such as those involved in secretory processes , receptor activation or inhibition , cell division and metabolic reactions . it can be hypothesized that these chelation properties can affect the release of calcium from storage organelles such as sarcoplasmic / endoplasmic reticulum and act on the molecular mechanisms involved in the disruption of calcium homeostasis in darier keratinocytes , leading to the clinical symptoms of the disease . due to its non - antibiotic properties and favorable safety profile compared to oral retinoids further studies are warranted to confirm these findings and to assess the efficacy of oral doxycycline in the treatment of dd .

darier disease ( dd ) is a rare dominantly inherited genodermatosis characterized by loss of intercellular adhesion ( acantholysis ) and abnormal keratinization . dd is often difficult to manage . numerous treatments have reportedly been used for the treatment of dd , with limited success . systemic retinoids are considered the drug of choice for treating dd . however , their use is limited by potential deleterious side effects . considering the recently reported efficacy of doxycycline for hailey - hailey disease , an inherited acantholytic skin disorder pathogenetically similar to dd , we report the case of a patient with extensive dd who showed a dramatic response to oral doxycycline monotherapy .

blue nevus is an acquired benign melanocytic nevus described as a blue or blue - black , firm papule , nodule or plaque - like lesion occurring on the skin and mucous membranes . malignant blue nevus is rare , and a common blue nevus rarely needs a differential diagnosis from malignant melanoma . although a melanocytic nevus with a satellite lesion is usually suggestive of a peripherally disseminating malignant melanoma , very few cases of blue nevus with satellite lesions have been reported thus far [ 1 , 2 , 3 , 4 , 5 , 6 ] . to our knowledge , this is the seventh case of a blue nevus with satellitosis . a healthy 24-year - old japanese man was referred to our hospital with a blue - black skin lesion on his left forearm . as confirmed by the patient , this lesion had developed after he accidentally pricked his forearm with a pencil 13 years earlier . physical examination revealed a 10 7-mm , blue - black nodule with an irregular border , which was accompanied by 12-mm guttate macular satellite lesions ( fig . dermoscopic examination showed a homogeneous , blue - white structure in the absence of any other dermoscopic structures ( fig . an excisional biopsy was performed with the suspicion of a common blue nevus versus a malignant melanoma . the lesion was excised with a 3-mm margin of surrounding normal skin down to the level of the superficial fascia . we recognized a black - colored restiform structure in the dermis during the operation and added another 3-mm margin . in the histopathological examination of the excised lesion , nevus cells were dispersed in the dermis , and hyperpigmented , spindle - shaped melanocytes infiltrated among the collagen bundles ( fig . there were no features suggestive of malignancy , such as cytological atypia , atypical mitoses or necrosis . common blue nevi are usually solitary , blue - black , dome - shaped papules , and are not difficult to diagnose . however , in a very small number of cases [ 1 , 2 , 3 , 4 , 5 , 6 ] , including our case , a blue nevus can be accompanied by satellite lesions . this is when the physician needs to differentially diagnose it from malignant melanoma , especially the nodular type . under a dermatoscope , a blue nevus usually shows a typical steel - blue , homogeneous coloration generated by the presence of heavily pigmented melanocytes in the dermis , in the absence of any other dermoscopic structure . however , a recent study showed that a wide spectrum of local dermatoscopic features ( whitish , scar - like depigmentation , dots / globules , peripheral streaks or vessels ) may also be observed in blue nevi . in such cases , clinical and dermatoscopic distinction from a malignant melanoma may be difficult , or impossible , and surgical excision is necessary . kang and chung reported that nevus cells aggregated densely around the blood vessels in the main papule , and also in the satellite lesions , suggesting that nevus cells may spread along the perivascular space to manifest clinically as guttate or linear satellite lesions . in our case , periappendageal and perivascular concentrations of nevus cells were observed in the main papule as well as in the satellite lesions . clinically , we recognized a black - colored restiform structure in the dermis during the operation . these findings suggest that blue nevus cells could infiltrate along the perivascular area in the dermis and form multiple satellite lesions . in conclusion , we suggest that a blue nevus should be considered as a differential diagnosis when a locally disseminating malignant melanoma is suspected .

malignant blue nevus is rare , and a common blue nevus rarely needs a differential diagnosis from malignant melanoma . although a melanocytic nevus with a satellite lesion is usually suggestive of a peripherally disseminating malignant melanoma , very few cases of blue nevus with satellite lesions have been reported thus far . to our knowledge , this is the seventh case of a blue nevus with satellitosis . periappendageal and perivascular concentrations of the nevus cells were observed in the main papule as well as in the satellite lesions . these findings suggest that blue nevus cells could infiltrate along the perivascular area in the dermis and form multiple satellite lesions . blue nevus should be considered as a differential diagnosis when a locally disseminating malignant melanoma is suspected .

a 10-year - old boy came with a complaint of anterior cross bite to our department . the patient had no relevant past dental or medical history and no habits . on extra - oral examination [ figure 1 ] , patient had a dolico - cephalic head shape , lepto - prosobic facial form , concave profile , anterior divergence and acute nasolabial angle . pre - treatment extraoral photographs on intraoral examination [ figure 2 ] , all soft - tissues and hard tissues were normal . molar , canine and incisor relationship were class iii on the both right and left side and there was a reverse overjet of 2 mm and overbite of 5 mm and anterior cross bite . the patient had class iii skeletal base with retrognathic maxilla and prognathic mandible having average growth pattern with labially tipped mandibular incisors . the objective of the treatment was ( 1 ) to intrude and proclined the upper incisors , ( 2 ) to retroclined the lower incisors . ( 3 ) obtaining class i canine relation . ( 4 ) obtaining ideal overjet and overbite . ( 5 ) obtaining ideal esthetics . pre - treatment intraoral photographs patient was treated with a combination of face mask and rme [ figures 3 - 5 ] until 2 mm positive overjet was achieved . the expansion screw was activated one to three turns ( 0.25 mm / turn ) at weekly visits until the desired amount of expansion had been achieved . the face mask was adjusted to rest on the forehead and the chin of the patient . elastics ( 5/16 inch by 14 ounces ) were worn from hooks located 2 - 3 cm in front of the lips to the intraoral attachments located on the expansion appliance , approximately at the gingival level of the canine . rapid maxillary expansion appliance rapid maxillary expansion appliance the face mask applaince after duration of 9 months of orthopedic correction , then the pre - adjusted edgewise appliance was fixed with extraction of lower 1 premolar and treatment was continued for 12 months . maxillomandibular relations [ figures 6 and 7 ] showed significant improvements during the treatment period , with changes due primarily to the increase in the sella nasion- point a angle ( sna ) angle . the sella - nasion - point b ( snb ) angle showed no significant changes during protraction . the dental measurements showed a tendency for the upper incisors to flare during treatment ; the lower incisors were uprighted significantly . patient was treated with a combination of face mask and rme [ figures 3 - 5 ] until 2 mm positive overjet was achieved . the expansion screw was activated one to three turns ( 0.25 mm / turn ) at weekly visits until the desired amount of expansion had been achieved . the face mask was adjusted to rest on the forehead and the chin of the patient . elastics ( 5/16 inch by 14 ounces ) were worn from hooks located 2 - 3 cm in front of the lips to the intraoral attachments located on the expansion appliance , approximately at the gingival level of the canine . rapid maxillary expansion appliance rapid maxillary expansion appliance the face mask applaince after duration of 9 months of orthopedic correction , then the pre - adjusted edgewise appliance was fixed with extraction of lower 1 premolar and treatment was continued for 12 months . maxillomandibular relations [ figures 6 and 7 ] showed significant improvements during the treatment period , with changes due primarily to the increase in the sella nasion- point a angle ( sna ) angle . the sella - nasion - point b ( snb ) angle showed no significant changes during protraction . the dental measurements showed a tendency for the upper incisors to flare during treatment ; the lower incisors were uprighted significantly . this case report showed the results of the treatment of patients with class iii malocclusion at an early stage with an efficient orthodontic therapy of rme plus maxillary protraction . class iii combination therapy is a comprehensive non - surgical treatment strategy designed for developing skeletal class iii malocclusions by incorporating orthodontic and orthopedic mechanics to effectively improve the patient 's occlusion and profile . in properly selected cases , this modality of treatment can be a successful alternative that satisfies a patient 's request to avoid surgery or premolar extraction .

a case report is presented of a class iii malocclusion with a class iii skeletal pattern and maxillary retrusion . patient , a 10-year - old boy was treated with an orthopedic face mask in conjunction with rapid maxillary expansion and standard pre - adjusted edgewise appliance . treatment was completed after 3 years and proved to be stable following the active treatment .

a 44 year old single male , presented to our outpatient department with complaints of day time excessive sleepiness , lethargy , low mood and disturbed sleep at night for the past 3 months . history revealed that these symptoms were triggered by the death of his father . on detailed evaluation , it was found that he had been on treatment for his mental illness from 2005 . the course of illness was continuous characterized by withdrawn behavior , preoccupation , fear , auditory hallucinations , referential delusions and decline in social and occupational functioning . he was evaluated by a psychiatrist and started on psychotropics . during follow - up , the patient complained of episodes of depressed mood , anxiety and sleep disturbance , lethargy and sleepiness that affected his shift work , for which he was prescribed modafinil 200 mg , along with the antipsychotics risperidone 4 mg and amisulpride 400 mg . the patient himself gradually increased the dose to overcome the drowsiness that interrupted his shift work . he started with 100 mg every 3 - 4 h over a shift work of 12 h. for the last 6 months he was unable to overcome his sleepiness during work without modafinil 100 mg / h thus making a total of 1200 mg / day of modafinil which he used to obtain over the counter . he claimed to have symptoms of worsening of lethargy , tremors of hands , anxiety and erratic sleep hours when he skipped modafinil , patient reported a sense of well - being only with the drug and with the above dose . 12.4 gm% ; , wbc count 6300 cells / mm ; platelet count 2.4 lakhs / mm ; , random blood sugar 122 mg / dl . his metabolic parameters including renal function , liver function , lipid profile were within normal limits . an additional diagnosis of modafinil dependence syndrome ( dependence criteria as per dsm v ) was made in view of the tolerance , withdrawal , inability to cut down , progressive increase in the amount of drug over a longer period of time and craving . the dose was tapered slowly over a period of 1 month with 100 mg every 2 - 3 days and started on bupropion . he reported sleep disturbance , increased sense of body warmth , lethargy and low mood during the process of tapering the drug . in literature , only one case study has been reported on modafinil dependence at higher doses . in our case report , the patient reported himself started consuming more tablets to increase the effects derived from modafinil and landed with dependence phenomenon . unlike amphetamine and its derivatives , modafinil is said to act by mechanisms independent of dopminergic system which is involved in dependence phenomenon of sympathomimetics and opioids and hence is devoid of addiction potential . however there are few recent studies reporting that modafinil also binds to dopamine receptors and also affects dopamine uptake by dopamine transporters in the neurons . increasing doses of modafinil another study conducted to know about modfinil 's subjective and behavioral effects showed that modafinil increases rating scale of the addiction research center inventory ( arci ) as much as amphetamine . modafinil dependence can be attributed to its dopamine uptake blockade thereby increasing its concentration in dopaminergic areas of brain . overdose of modafinil is not safe ; as a central nervous system stimulant it is prone to cause insomnia , agitation , tachycardia , rise in blood pressure etc . there are no controlled trials or reports available for the treatment of modafinil addiction . in this patient , we cross - tapered modafinil with bupropion because of its action on dopamine and norepinephrine reuptake inhibiton , thus producing an effect similar to that of modafinil with antidepressant activity . modafinil is listed as a schedule iv drug in the united states for its restricted sale . there is no regulation on modafinil sale which has to be revised to prevent its abuse . it is widely purchased over the counter by night shift workers to increase work the efficiency without sleep . though abuse potential is claimed to be less , it should be considered serious due to increased use of modafinil among youngsters . our case report is one among the very few reports of modafinil dependence , it gives a call for the need of regulations on the sale of modafinil .

modafinil , a non - amphetamine psychostimulant , is indicated for narcolepsy , shift work sleep disorder and severe obstructive sleep apnea syndrome . modafinil is prescribed at the dose of 100 mg once in a day or as two doses , 12 h apart in a day . it has also been found that it reduces cocaine dependence and withdrawal phenomenon . modafinil is claimed to have very low liability for abuse and dependence . here we report a rare case of modafinil dependence .

the trigger finger is in the clinical practice , frequently caused by stenosing tenosynovitis at the a1 pulley characterized by pain , swelling and a triggering sensation with the limitation of finger motion . the first treatment is conservative using anti - inflammatory drugs and steroid injection , but some resistant cases may need surgery . post - traumatic trigger finger is a rare case of resistant trigger finger that can be suspected recording an accurate clinical history and in case of resistant trigger finger after anti - inflammatory drugs therapy and steroid injection.[26 ] . we report a case of post - traumatic trigger finger due to a partial longitudinal tear of the flexor digitorum superficialis . a healthy 22-year - old caucasian male referred to our department suffering from pain and limited range of motion ( rom ) of the right ring finger . the patient sustained in august 2015 a penetrating injury on the palm of the right hand during his sport activity . he did not refer to any emergency department or general pratictioner , the wound was small and healed naturally . one month later pain started and limitation of rom of the right ring finger gradually worsened . because of his clinical disorders , a trigger finger was diagnosed by another orthopedic who performed a steroid injection . the clinical examination showed a small scar on the palm , located proximally to the fourth metacarpophalangeal joint and the rom of the proximal interphalangeal ( pip ) joint of the ring finger was limited to 40 degrees of extension and complete ( 100 degrees ) in flexion , both in passive and active motion . the feeling of numbness just under the scar , the first steroid injection that was not effective and the young age of the patient , led us to perform an ultrasound examination of the hand tendons ( figure 1 ) , which showed a suspect tear of the flexor digitorum superficialis tendon of the ring finger , proximally to the pulley a1 that appeared thickened . the surgical exploration of the tendon was the treatment of choice , which was performed 2 months and 10 days from the injury . the ultrasounds examination shows an irregular region ( arrow ) of the flexor digitorum superficialis tendon suggestive of a partial rupture , accompanied by the thickening of the pulley a1 ( asterisk ) . p : proximal phalanx ; m : metacarpus ; mpj : metacarpo - phalangeal joint . the incision was made at the pulley a1 and extended brunner - like proximally in direction of the scar . a partial longitudinal flap - shaped tear was discovered , large approximately half of the entire tendon diameter , of the radial half of the flexor digitorum superficialis tendon that hooked at the entrance of the a1 pulley ( figure 2 ) . the flexor digitorum profundus tendon was intact . because of the size of the flap - shaped tear , it was decided not to remove it , but it was sutured to the tendon in anatomic position with simple stitches ( nylon 4 - 0 ) and the pulley a1 release completed the procedure to avoid risk of post - operative re - triggering . the examination during surgery showed the restoration of ring finger rom ( 0100 degrees ) and the disappearance of the trigger , then the exploration of the distal pulleys ( a2 and a3 ) was not necessary . also , a capsulotomy of the pip was not necessary because the limitation of rom was not due to a capsular contracture . the patient was recommended to frequently move the fingers even with the bandage , to prevent the formation of adhesions . there was no need for physiotherapy as the rom has been completely restored almost immediately . after 3 months of follow - up , no evidence of relapse was recorded and the rom was 0100 degrees . the picture shows the longitudinal partial flap - shaped tear of the flexor digitorum superficialis . most of the patients affected by trigger fingers are treated with anti - inflammatory drugs or steroid injection . the success rate of the single - dose of a steroid injection is reported to be 50% and when the conservative treatment fails , open a1 pulley release has a success rate of approximately 100% . in literature some cases of resistant trigger finger caused by rare conditions , such as phalangeal osteochondroma , tendon sheets tumor ( fibroma or giant cell tumor ) or calcifying tenosynovitis have been reported . more frequent , but still rare in the clinical practice , is the trigger finger due to a partial tear of the flexor digitorum . to our knowledge , there are only few reports in literature.[210 ] previous reports advised the imaging support for the diagnosis of triggering after partial flexor tendon tear . more recently , okano and couceiro in two different reports used mri for the diagnosis . our recent case , together with the other few reported in literature , demonstrates that the diagnosis of trigger finger , although does not present difficulties in the majority of the cases , have to be supported by an accurate clinical history and clinical examination , because in some cases it can be the consequence of rare clinical conditions . in selected cases , mostly if post - traumatic , the ultrasound imaging or the mri can be used to perform a correct diagnosis , and subsequently a correct treatment . the authors declares that there is no conflict of interest regarding the publication of this paper .

abstractwe report a case of post - traumatic trigger finger due to a partial longitudinal tear of the flexor digitorum superficialis . the suspect came from the clinical history and the young age of the patient . it was successfully treated with tendon flap suture and pulley a1 release .

we report the case of one patient undergoing routine gastric bypass who experienced major complications . a 56 year old female was referred from a district general hospital after a protracted history of abdominal pain and vomiting . past medical history included osteoarthritis and hypertension , and a past surgical history of laparoscopic roux - en - y gastric bypass in 2008 ( pre - operative bmi of 48 kg / m2 ) . a laparotomy and revision of roux - en - y gastric bypass was undertaken with post operative management on hdu , but the patient had ongoing problems with pain and wound discharge . a ct scan revealed a 7 cm collection adjacent to the alimentary limb which was percutaneously drained under ultrasound guidance . due to clinical deterioration , a further ct was performed which demonstrated a large communicating collection filling the paracolic gutters and pelvis , with a multiloculated left lobe liver abscess , and a smaller abscess in the right lobe ( figure 1 ) . the patient was discharged home . multiloculated abscess within the left lobe of liver the patient re - presented 2 weeks later with increasing epigastric pain and malaise . imaging showed a persistent collection in the pelvis and liver , and a further two percutaneous procedures were performed . during inpatient stay , she became haemodynamically unstable with spiking temperatures and an elevating white cell count . she also complained of bilateral discolouration of her toes and examination revealed increasing oedema with diminished pedal pulses . a contrast ct scan of the abdomen confirmed ongoing collections with evidence of an aortic thrombus extending into the left iliac artery , presumed to be the embolic source for her vascular findings ( figure 2 & 3 ) . there was resolution of vascular symptoms and evidence of improvement in peripheral perfusion postoperatively , and the patient was eventually discharged . thrombus within the distal aorta shown by a filling defect ( red arrow ) extension into the left iliac artery shown by a filling defect ( red arrow ) surgery has inherent risks and complications , which may be further be potentiated by the high risk nature of bariatric patients . a systematic review of the literature concluded that peri - operative complications were encountered more frequently in bypass patients compared to those undergoing laparoscopic gastric banding ( 9% and 5% ) , although long - term re - operation rates were lower ( 16% and 24% respectively ) ( 1 ) . the mortality of both bypass and band operations were low ( 0.17% and 0.06% ) . further systematic reviews have reported major early complications rates of gastric bypass surgery as 6.3% , with major complications including death ( 0.2% ) , perforation ( 0.5% ) , venous thromboembolism ( 0.3% ) , significant postoperative bleed ( 0.9% ) , postoperative infection ( 2.9% ) and anastomotic leaks ( 0.9% ) ( 1 ) . despite these risks gastric bypass is an effective operation for obesity ; one study reported 76% excess body weight loss and a 78% resolution of diabetes at 1 year in patients undergoing bypass compared to 48% weight loss and 50% diabetes resolution in patients undergoing banding ( 2 ) . generally high levels of patient satisfaction are recorded , estimated to approach 80% ( 3 ) . venous thrombosis is well documented in the literature as a complication of obesity and bariatric surgery . one study reported an incidence of deep vein thrombosis in the group of 500 consecutive patients to be 0.2% ( 4 ) . however , there is little data regarding arterial thrombosis as a complication of bariatric surgery . bariatric patients have significant risk factors for atherosclerotic disease , both due to obesity , and to secondary diseases such as hypertension and diabetes , which may develop as part of the metabolic syndrome . however , with this patient there was no evidence of aortic thrombosis on previous imaging , and a new presentation of clinical signs and symptoms would be in keeping with a new onset thrombosis . there are also factors relating to a hypercoagulable state , which in this patient could be numerous . this patient had recurrent episodes of sepsis , which is well known to precipitate hypercoagulability , which at the severe end of the spectrum , exists disseminated intravascular coagulation ( dic ) . sepsis mediated hypercoagulability occurs as a result of the activation of inflammatory and coagulation cascades ( 5 ) . dehydration secondary to both poor intake and insensible losses through either infection or surgery may also cause an increased coagulable state . inflammatory and hypercoagulation may be due to the direct effects of surgery through the stress response ( 6 ) . roux - en - y gastric bypass is deemed a safe operation in the management of obesity . we present a case complicated postoperatively by recurrent intra - abdominal collections and sepsis , and aortic thrombosis with distal embolisation .

laparoscopic gastric bypass is becoming a frequently performed bariatric operation for patients with obesity . however , bariatric surgery has inherent risks and complications , which are further potentiated by the high risk nature of bariatric patients . these complications can be either site specific i.e. anastomotic leaks , or systemic i.e. venous thromboembolism , however they can intimately related . we present the case of one patient undergoing routine gastric bypass complicated postoperatively by recurrent intra - abdominal collections and sepsis , and aortic thrombosis with distal embolisation .

polytrauma patients with pelvic fractures challenge the surgeon 's diagnostic , operative , and peri - operative management skills , especially because of the frequent associated injuries to the abdominal viscera . the use of an external fixator for the initial and , in some cases , the definitive fixation of unstable , complex pelvic injuries with hemodynamic instability is effective for multiply injured patients . we present a documented case of small bowel entrapment in a sacral fracture stabilized with an external fixator . a 51-year - old man , with no medical history of note , was in a motorcycle accident . in the emergency room , he presented with hemodynamic instability due to a pelvic fracture and a concomitant catastrophic soft tissue injury involving the scrotum , perineum , and anus with absence of the anal reflex . the pelvis x - ray showed ischiopubic and ileopubic fractures associated with symphyseal disruption ( anterior posterior fracture apii , see young and burgess ) . after the resuscitation phase , the patient underwent full - body computed tomography ( ct ) [ figure 1 ] and was subsequently transferred to the operating theater . the white vertical arrow indicates the sacral fracture pelvis x - ray showing the external screws an exploratory laparotomy was performed to exclude abdominal organ damage , and a loop colostomy was performed for the anal incompetence . then , the patient was admitted to our intensive care unit ( icu ) , where no bowel function was observed for the first 6 post - operative ( po ) days . on po day 7 , the patient presented with abdominal distension , elevated inflammatory indices , and fever , so we performed abdominal ct with oral and intravenous contrast looking for signs of intestinal obstruction . the clinical hypothesis of obstruction was confirmed by the presence of numerous dilated small bowel loops with air / fluid levels ; ct showed an ileum segment trapped in the sacral fracture [ figure 3 ] . the white horizontal arrow shows the ileum segment trapped in the sacral fracture the patient underwent an exploratory laparotomy that confirmed the cause of the obstruction ; a small bowel resection and an end - to - end manual anastomosis were thus performed . the second post - operative period was uneventful , and the patient was discharged from the icu to a ward . an evaluation of the rectal sphincter showed normal function ; therefore , after the peroneal wound healed , the colostomy was closed . injured arteries , veins , and bony structures are all likely sources of blood loss . angio - embolization is the accepted method for treating arterial bleeding , while reduction and stabilization with external fixation or other methods are considered the most appropriate for controlling blood loss from veins and bony surfaces . the risk of hemorrhage makes major pelvic fractures one of the most serious skeletal injuries , with substantial mortality . in addition , pelvic fractures are often associated with other major injuries , which can contribute to an increased mortality . the mortality following pelvic fractures has declined radically since introduction of more effective methods of controlling hemorrhages and general trauma management . hemorrhage control , fracture stabilization , and infection prophylaxis in cases of open fracture can be achieved with the placement of schanz screws . post - traumatic bowel entrapment was first described in 1907 . since then , there have been only occasional reports in the literature . in a literature review , stubbart and merkley documented 19 similar cases . the diagnosis of entrapment is often difficult and delayed . with the introduction of multi - detector ct and the associated reformatting capabilities patients with pelvic fractures and disruptions have usually sustained high - energy trauma and have myriad other possible reasons for symptoms of ileus , obstruction , perforation , or intra - abdominal problems . bowel injury associated with pelvic fractures or the surgical treatment thereof is relatively rare and is consequently not always ranked highly in the differential diagnosis . as with our case , most cases of distension and nausea post - pelvic fracture are thought to be due to adynamic ileus and not to mechanical obstruction . hurt et al . stated that such ileus usually lasts 5 days , but can persist longer than 2 weeks . reported cases of bowel entrapment in pelvic fractures , especially in sacral fractures , are exceedingly rare . in most situations , the iliac and psoas muscles serve as buffers between the abdominal contents and posterior pelvic ring injury , protecting the peritoneum from injury and preventing the bowel from communicating with the fracture site . although accurate prediction and prevention of this type of complication might be impossible , earlier recognition and proper treatment are reasonable ways to obtain good results . the diagnosis is often delayed due to the difficulty distinguishing entrapment from the more common adynamic ileus . therefore , all general surgeons who care for patients with pelvic injuries should be conscious of this potential complication and consider it in their workup of patients with post - operative abdominal symptoms after major pelvic trauma or subsequent pelvic surgery , especially in patients treated with a percutaneous technique that prevents direct visualization of the fracture and abdominal or pelvic contents . in conclusion , clinicians and radiologists should be aware of this potentially lethal complication of pelvic fractures treatment . to exclude bowel entrapment , patients with a persistent ileus or sepsis

the use of external fixation for the initial treatment of unstable , complex pelvic injuries with hemodynamic instability remains an effective treatment for multiply injured patients . bowel entrapment within a pelvic fracture is a rarely reported , potentially fatal complication . here , we report a polytrauma patient with pelvic fractures who developed an intestinal obstruction after an external fixation . at an explorative laparotomy , we found an ileum segment trapped in the sacral fracture . reported cases of bowel entrapment in pelvic fractures , especially in sacral fractures , are exceedingly rare . the diagnosis is often delayed due to difficulty distinguishing entrapment from the more common adynamic ileus . in conclusion , clinicians and radiologists should be aware of this potentially lethal complication of pelvic fractures treatment . to exclude bowel entrapment , patients with persistent ileus or sepsis should undergo early investigations .

a 60-year - old man presented to the emergency room with a sudden onset of intractable pain in the left leg . the patient had a history of intermittent abdominal pain and hypertension without other risk factors for atherosclerosis . a computed tomographic angiogram ( cta ) revealed chronic total occlusion of the abdominal aorta from the inferior mesenteric artery level to the level of both common iliac arteries ( fig . the cta also showed chronic total occlusion of the left external iliac artery and acute total occlusion of the left popliteal artery ( fig . , the popliteal artery occlusion was removed , and angiography confirmed good distal run - off through the anterior and posterior tibial arteries ( fig . however , 3 days after the procedure , the patient suffered from the same intractable pain in the left leg . repeated femoral angiography showed a recurrence of the acute total occlusion of the left popliteal artery . after repeated endovascular treatment , urgent surgery was performed to prevent the reoccurrence of thromboembolism . exploration of the abdominal aorta found fresh white clots that were adherent to the aortic wall ( fig . resection of the abdominal aorta below the inferior mesenteric artery was followed by aortic replacement with a 201010-mm dacron y graft ( meadox medicals , oakland , nj , usa ) . distal anastomosis of the right and left arteries was performed on the common iliac artery and common femoral artery levels , respectively ( fig . however , due to the abnormal ranges of the platelet count since the first day of admission ( ranging from 53310/l to 1,14910/l ) , a bone marrow biopsy was performed postoperatively . the exam showed markedly increased numbers of megakaryocytes , which were clustered with mature cytoplasm and hyper - lobulated nuclei . therefore , the final diagnosis of the patient was essential thrombocytosis ( et ) , according to the 2008 world health organization ( who ) diagnostic criteria . medical therapy was started immediately with hydroxyurea and aspirin once daily at doses of 1,000 mg and 100 mg , respectively . the platelet count decreased gradually and the patient was discharged on postoperative day 17 without any complications . the therapeutic target for the platelet count ( < 40010/l ) was achieved 2 months after surgery . on the last follow - up , more than 2 years after the operation , the patient was in good condition with a patent graft ( fig . et is an uncommon myeloproliferative disorder in which a proliferation of megakaryocytes in the bone marrow leads to an elevated platelet count . et is defined by the following 4 major criteria : ( 1 ) platelet count 45010/l ; ( 2 ) megakaryocyte proliferation with large and mature morphology , and little to no granulocyte or erythroid proliferation ; ( 3 ) not meeting the 2008 who criteria for chronic myelogenous leukemia , polycythemia vera , primary myelofibrosis , myelodysplastic syndromes , or any other myeloid neoplasm ; and ( 4 ) demonstration of jak2 or other clonal markers , or no evidence of reactive thrombosis . in general , common causes of aortic thrombosis include cardiac sources of embolism , hypercoagulable states , and other complications from atherosclerotic disease . although et remains an uncommon cause of aortic pathology , some reports have discussed cases of et - associated aortic mural thrombus . to the best of our knowledge , et caused a chronic obstruction of the abdominal aorta and acute obstruction of the arteries . we encountered a fast recurrence of artery occlusion ( 3 days after thrombus removal ) . we would have been able to prevent the recurrence of popliteal artery occlusion if we had immediately controlled the platelet count . many options exist for managing et , such as medical therapy with heparin anticoagulation , aspirin , and cytoreductive chemotherapy , and surgical treatment with aortic thrombectomy and/or endovascular surgery . in order to ensure the optimal treatment of et , the location of the thrombus , potential for embolism , individual risk of the patient , and the pathology of the thrombus we decided to perform surgical treatment due to the rapid formation of the thrombus , the location of the original chronic thrombus , and the insufficiency of endovascular treatment . according to harrison et al . , hydroxyurea and low - dose aspirin are superior to other combinations of drugs for patients with et at high risk for vascular events , especially arterial thrombosis . in our case , once the diagnosis of et was made , the patient was treated with hydroxyurea and low - dose aspirin for a goal platelet count of < 40010/l . the patient s platelet count was normalized and maintained within a range of 21910/l to 25210/l . in conclusion , although et rarely presents in large vessels , early diagnosis and immediate management are essential .

essential thrombocytosis ( et ) is a myeloproliferative disorder characterized by an anomalous increase in platelet production . many patients with et are asymptomatic . few studies have reported et - associated thromboembolism in large vessels such as the aorta . we report a patient with et who presented with peripheral embolism from an abdominal aortic thrombus and developed acute limb ischemia . the patient underwent aortic replacement successfully . the patient s platelet count was controlled with hydroxyurea , and no recurrence was noted over 2 years of follow - up .

a problem that has frequently emerged as a critical issue in patients with venoarterial ( va ) extracorporeal membranous oxygenation ( ecmo ) is a dilatation of the left heart due to volume overload of the left ventricle . conventionally , a venting cannula is placed in the left atrium via the right upper pulmonary vein or the la auricle with a sternotomy or a lateral thoracotomy . however , these approaches are risky because of significant complications such as bleeding and scarring . the procedure chosen for percutaneous left heart decompression varies from insertion of the la venting cannula to placement of an atrial septal stent . recent reports showed that there was no significant difference between these procedures . here , we describe a successful percutaneous balloon atrial septostomy and an la venting cannula insertion during va ecmo in a patient with severe acute myocarditis . a 38-month - old , 11.7 kg boy he had suffered from intraventricular hemorrhage and intracranial hemorrhage caused by neonatal asphyxia , and he had been kept on antiepileptic medication due to infantile spasm . the patient was transferred to the intensive care unit with very poor hemodynamics and subsequent supraventricular tachycardia ( heart rate > 200/min ) , which did not respond to intravenous amiodarone or adenosine . despite conventional therapy including inotropes , his condition continued to deteriorate with tachycardia . echocardiography revealed a marked decrease of 20% in the ejection fraction , and we therefore decided to support him with va ecmo . arterial cannulation was performed via the right carotid artery with an 8 fr percutaneous arterial cannula ( rmi ; edwards lifesciences , irvine , ca , usa ) , and a 14 fr percutaneous venous cannula ( rmi , edwards lifesciences ) was placed in the right internal jugular vein . ecmo flow was initially 1,300 ml / min and was maintained between 700 to 800 ml / min . after ecmo insertion , the patient s vital signs stabilized and his chest x - ray improved ( fig . however , he began to produce a large amount of frothy , bloody endotracheal secretions and his pulse pressure disappeared twelve hours later . follow - up echocardiography revealed marked left heart distention and a left ventricular ejection fraction lower than 10% . therefore , fourteen hours after ecmo insertion , the patient was taken to the cardiac catheter laboratory for an atrial balloon septostomy and la venting cannula insertion . the procedure was accomplished with a percutaneous approach through the right femoral vein without complications and an 8.5 fr la venting cannula ( mullins sheath ; cook inc . 2 ) . after placement of the la venting cannula , the pulse pressure appeared again , with a 15 mmhg gap between the systolic and diastolic pressure . his follow - up chest x - ray improved ( fig . four days later , we observed recovery of left ventricular function and improvement of the chest x - ray ( fig . follow - up echocardiography showed improved lv systolic function and an ejection fraction of 65% . since its introduction as a major support for severe respiratory distress , ecmo has become a well - established therapy in pediatric patients , particularly those with severe but reversible neonatal respiratory failure , cardiac failure , or cardiorespiratory failure . in particular , va ecmo has been used in pediatric patients with cardiac dysfunction , such as myocarditis , cardiac arrest , and cardiomyopathy . left heart distension during va ecmo may develop , leading to progressive left heart deterioration , pulmonary edema , and impairment of myocardial oxygenation . despite its clinical importance , the management of left heart decompression in a patient with ecmo is rarely discussed . only sporadic case reports and a few articles have shown the efficacy of la decompression on functional recovery of the left heart [ 57 ] . conventionally , la decompression is achieved by insertion of an la venting cannula via sternotomy or thoracotomy . however , sternotomy or thoracotomy themselves are risky and have several complications , such as bleeding and significant scarring . la decompression with a percutaneous cardiac catheterization - based technique including septostomy using a blade or radiofrequency ablation , balloon dilatation , and la venting cannula insertion has been effective [ 2,46,8 ] . several institutions with la vents have identified technical issues related to management of the indwelling catheters , such as kinking , poor flow , movement of the catheter with required patient care , and ongoing concern for thrombosis . therefore , a recent study showed a shift in preference from la vent insertion to balloon dilation alone . however , balloon atrial septostomy alone is not always successful because of varying degrees of atrial septal thickness . we believe that using an la venting cannula after balloon dilation offers several advantages over balloon dilatation alone . first , the placement of an la venting cannula potentially allows for controlled decompression of the left heart by adjusting flow rates on the ecmo circuit or clamping the cannula . third , the size of the cannula can be tailored to each patient , so this procedure can be adjusted for use in smaller patients . for patients with left heart dysfunction causing pulmonary edema during va ecmo , percutaneous balloon atrial septostomy with la venting cannula insertion is a treatment option that carries a low risk of other complications such as bleeding .

patients with venoarterial extracorporeal membrane oxygenation ( ecmo ) frequently suffer from pulmonary edema due to left ventricular dysfunction that accompanies left heart dilatation , which is caused by left atrial hypertension . the problem can be resolved by left atrium ( la ) decompression . we performed a successful percutaneous la decompression with an atrial septostomy and placement of an la venting cannula in a 38-month - old child treated with venoarterial ecmo for acute myocarditis .

a twenty one year old primi gravida at six months gestation presented with a history of rapidly enlarging lump in the left breast associated with pain . on examination , a mass approximately measuring 20 x 14 cm was present in the upper and lower quadrants of the left breast . the specimen received by the pathology laboratory measured 16 x 10 x 5cms and weighed 750 gm ( fig.1 ) . the enucleated specimen : the external surface was lobulated and the cut surface was nodular with focal white areas . haematoxylin and eosin stained four - micron sections showed a well circumscribed tumor composed of hyperplastic acini retaining the configuration of normal breast lobules ( fig.2 ) . lactating adenomas present as small , well circumscribed , freely mobile masses during pregnancy or lactation . benign breast tumors associated with pregnancy can be of different types . in a study of 37 cases of benign breast tumors associated with pregnancy by o hara et al , only eight cases were lactating adenomas.(1 ) the others were fibroadenomas with lactational changes and tubular adenomas . lactating adenoma is a rare tumor and there are differing views on its histogenesis . james et al considered lacating adenoma to be a pure and readily recognisable morphological form clearly distinguishable from tubular adenoma and fibroadenoma that is always related to current or recent pregnancy.(2 ) according to them , most tumors diagnosed as lactating adenomas are diagnosed during pregnancy and do not have lactational secretion . the secretory changes seen are similar to the physiological changes of pregnancy in the adjacent breast tissue . this is also supported by slavin et al , who in a study of 30 cases of nodular breast lesions of pregnancy , described 12 lesions that fitted with the description of lactating adenoma . according to slavin et al , lactating adenomas are nodules of physiologic lobular proliferation which become more prominent than the adjacent breast tissue and appear clinically to be a distinct mass and histologically resemble focal exaggerated physiological hyperplasia.(3 ) hertel et al however proposed that lactating adenomas arise in preexisting adenomas.(4 ) in a study by hertel et al , five of the seven postpartum patients with tubular adenomas , first observed the lump during pregnancy , leading to the authors conclusion that tubular adenomas and lactating adenomas are two ends of a spectrum , the latter with secretory changes associated with physiological states of pregnancy . both the views are given in the latest who fascicle on breast tumors , that is to say that a lacating adenoma is considered as a tubular type adenoma that may show extensive secretory changes in the epithelial cells during pregnancy and lactation.(5 ) it has also been suggested that such lesions represent focal accumulation of hyperplastic lobules . usually , lactating adenomas are slow growing tumors which are smaller than 5 cm in size and are well demarcated from the surrounding breast tissue.(6 ) in a series of 14 lactating adenomas by james et al , most of the tumors were 2.5 3.5 cm in size . they reported a giant breast mass which grew to a maximum size of 25 x 18cms.(7 ) the present case measured 16cms in diameter and qualifies for the second largest reported case of lactating adenoma . sonologically , lactating adenomas are oval , sharply circumscribed , solid hypoechoic mass which can have a prominent central tubular structure presumed to be a dilated duct.(8 ) lactating adenomas are characterised by glands with a tubuloalveolar architecture and florid secretory features . the histologic changes relate to the stage of pregnancy and approximate the changes in the adjacent breast . if removed during pregnancy , the secretory changes are much less pronounced than in the tumor removed postpartum ( 6 ) as was observed in the present case . the characteristic microscopic features of the tumors that come in the differential diagnosis is discussed by ohara , james and slavin.(1,2,3 ) tubular adenomas are characterised by uniform closely approximated tubular structures lined by epithelial and myoepithelial cells with little or no cytoplasmic vacuolisation . fibroadenoma with secretory hyperplasia should be distinguished from lactating adenoma ; the latter lacks the characteristic stroma in a fibroadenoma . rapid increase in size in a lactating adenoma can be due to infarction.(9 ) reeves et al have also described rapid increase in size in their report of giant lactating adenoma . ( 7 ) even though there was a history of pain and rapid growth , there was no evidence of infarction in the present case . huge size and rapid increase in size can lead to a mistaken clinical diagnosis of malignancy . enucleation is the recommended treatment for lactating adenomas as there is a low risk of recurrence . ( 7 ) bromocriptine can suppress lactation , the benefits of tumor shrinkage must be weighed against the cessation of lactation in a mother who is breast feeding . in summary we report a case of a lactating adenoma presenting as a giant breast mass . in a case of rapidly enlarging breast mass in a pregnant lady

lactating adenoma is one of the breast tumours associated with pregnancy . a case of lactating adenoma , unusual on account of its huge size , is presented . large size and history of rapid growth can lead to a mistaken diagnosis of malignancy . a review of the literature of this particular tumour with the different views on its histogenesis and the differential diagnoses are also discussed .

at hcb , as part of the routine workup for febrile patients , serum samples were collected , stored at 20c , and transported in liquid nitrogen to quito for pcr . hospital personnel also tested these samples by using a dengue igm / igg - capture elisa with high specificity and sensitivity ( panbio , waltham , ma , usa ) . at the snem laboratory , 24 drops of whole blood were collected on filter paper ( whatman 903 , kent , uk ) from persons spontaneously seeking or referred for malaria diagnosis . filter papers were left to dry overnight , stored at 0c in a zipper bag , and transported to quito for analysis . denv was amplified from total rna from blood spots and serum as described ( 12,13 ) . pcr products were sized in 1.5% agarose gel electrophoresis and sybr safe dna gel stain ( invitrogen , carlsbad , ca , usa ) ( 1:10,000 ) under uv light . pcr product was sent to functional biosciences ( madison , wi , usa ) for sequencing . the study was approved by institutional review board committees at the universidad san francisco de quito ( quito , ecuador ) and the university of michigan ( ann arbor , mi , usa ) . from july 2010 through february 2011 , a total of 77 samples ( 36 serum , 41 blood spot ) were collected from febrile patients . of these 36 hospital patients , 10 were from borbn and 26 were from the surrounding communities ; patients were 274 years of age ( median 19 years ) , and fever duration was 320 days ( median 6 days ) . six ( 17% ) of the 36 serum samples and 7 ( 17% ) of the 41 blood spots were positive for dengue by pcr ; whereas 10 ( 29% ) of the 34 serum samples tested by elisa were positive for dengue igm ( table ) . the ages of the 10 patients with positive results by elisa were 363 years ( median 38 years ) , and fever duration was 413 days ( median 6.5 days ) . although positive pcrs are sufficient indicators of acute infection , the positive igm reflects a cumulative incidence over 6090 days . therefore , the 17% pcr - positive estimate is a lower bound , and the 42% estimate by pcr or elisa is an upper bound . the denvs in the 13 samples that were positive by pcr were either serotype 2 or 3 ; samples from 1 patient contained both serotypes , probably resulting from a co - infection . each institution ( hcb and snem ) submitted samples from the same 2 patients , but only 1 was positive for dengue by pcr . during this same period , denv-1 , -2 , and -4 were detected in coastal cities in other regions of ecuador ( denv-3 has not been reported in ecuador since 2009 ) . colombia is a likely source , given the proximity of the study region to colombia and the fact that denv-3 was circulating in colombia ; but without sequence data , the geographic location of the source can not be confirmed . * only 34 serum samples were tested by elisa ; only 1 of the 10 positive samples was also positive by pcr . this study provides evidence of a transition of febrile disease etiology from plasmodium spp . , other possible fever - causing agents for which we did not test include leptospira spp . given that malaria has historically been the predominant cause of fever in the developing world , febrile patients are often triaged toward malaria treatment , especially in resource - poor areas . moreover , the awareness of malaria is embedded culturally and behaviorally in these communities : having a fever is equated with having malaria . of the 40 febrile patients who sought treatment for malaria , none had malaria but 17% had dengue ( positive for denv by pcr ) . further research is needed to refine this estimate and explore how the ministry of health and the general population should be directed to manage cases of fever during this etiologic transition . the need to bring attention to this transition is exemplified by our finding of denv-3 in our study site ; this serotype has not been isolated in other parts of ecuador since 2009 . esmeraldas , therefore , may be a major source of newly introduced dengue serotypes into ecuador .

in tropical areas , the predominant cause of fever has historically been malaria . however by 2011 , among febrile patients in northwestern ecuador , dengue was identified in 42% and malaria in none . this finding suggests a transition in the cause of fever from malaria to other illnesses , such as dengue .

a 15-year - old boy diagnosed as intracranial germ cell tumor underwent surgery , followed by cranial radiotherapy ( 45 gy ) and later treated with bleomycin , etoposide and cisplatin(bep ) regimen . after third cycle of chemotherapy , he developed asymptomatic erythematous rashes over the back , chest and thighs , which later subsided with persistence of hyperpigmentation [ figure 1 ] . hyperpigmentation of flagellate erythematous rash over the back and thigh bleomycin is a chemotherapeutic antibiotic associated with various skin related toxicities such as raynaud 's phenomenon , flagellate erythema , and sclerodermoid reaction . in the acute stage they are erythematous rashes later may persist as hyperpigmentation marks . other conditions which may be associated with flagellate erythema are docetaxel , adult still 's disease , dermatomyositis and ingestion of shiitake mushrooms . during the acute phase , topical with or without oral steroids

bleomycin is a chemotherapeutic antibiotic used in various malignancies . its toxicity is mainly lung and skin with marrow sparing effect . here we would like to describe a characteristic skin reaction developed because of bleomycin in a case of intracranial germ cell tumor . flagellate erythema which is a self - limiting toxic reaction can cause residual hyperpigmentation .

arachnoid cysts in the brain usually have an indolent course unless complicated by headache , seizures , increasing head circumference , behavioral disturbances , ocular , motor , speech disorders , and sudden cyst changes such as acute cyst expansion , sudden hemorrhage into the cyst , subdural hematoma , or subdural hygroma . rupture of arachnoid cyst causing subdural hygroma is very rare , with few case reports . we herein present a clinical case , radiology , and discussion of asymptomatic middle cranial fossa arachnoid cyst in a 15-year - old male child who presented with raised intracranial features following a trivial trauma . a 15-year - old male child presented with complaints of headache , visual blurring , and projectile vomiting for 20 days duration . the child had a history of trivial fall about 10 days prior to onset of headache , with no loss of consciousness . on examination , the child had bilateral florid papilledema and right lateral rectus palsy . there were no other focal deficits or signs of meningeal irritation . computed tomography ( ct ) scan of the brain showed a left middle fossa , galassi type 3 arachnoid cyst , with bilateral subdural hygroma / hematoma ( chronic ) , bilateral diffuse cerebral edema , and mass effect causing compression of both frontal horns [ figure 1 ] . magnetic resonance imaging ( mri ) of the brain showed bilateral collection in the subdural space , hypo on t1w [ figure 2 ] and hyper on t2w [ figure 3 ] images , matching with the intensities of cerebrospinal fluid ( csf ) with widened sylvian fissure on the left side and a compressed temporal lobe on the left side , suggestive of arachnoid cyst with subdural hygroma and mass effect . computed tomography scan plain , axial section showing hypodense region compressing the temporal horn with bilateral subdural hygroma magnetic resonance imaging brain t1w image showing subdural hypointensity in the temporal region and bilateral convexities compressing temporal and frontal lobes on the left side suggestive of arachnoid cyst with subdural hygroma and mass effect magnetic resonance imaging brain t2w image showing subdural hyperintensity in the temporal region and bilateral convexities compressing temporal and frontal lobes on the left side suggestive of arachnoid cyst with subdural hygroma and mass effect left pterional craniotomy , evacuation of hygroma , fenestration of cyst into suprasellar cistern , and marsupialisation of the cyst was performed . the patient developed pseudomeningocele , which was managed with lumbar csf drainage for 5 days and was discharged without any deficits . the postoperative imaging showed resolution of the subdural hygroma with small extradural and subgaleal collection of the csf [ figure 4 ] . the postoperative imaging showed resolution of subdural hygroma with small extradural and subgaleal collection of cerebrospinal fluid arachnoid cysts are considered intra - arachnoidal in location and account for 1% of the intracranial mass lesions . they can develop anywhere in the cerebrospinal axis but have a predilection toward the middle cranial base . they are usually asymptomatic , but may present with raised intracranial pressure , focal neurologic deficits , or seizures . being indolent and slowly growing , most of the arachnoid cysts can be managed conservatively , reserving surgical intervention for symptomatic lesions . intra - cystic hemorrhage and subdural rupture of the veins running over the surface of the cyst are well described . subdural rupture of the arachnoid cyst per se,[46 ] either traumatic or spontaneous , is sparingly reported with about 21 cases documented in literature . even a minor trauma can cause rupture of the cyst as seen in the present case , where the patient fell down while playing , without any loss of consciousness . the gradual seepage of the csf from the cyst into the subdural space , probably through a flap- valve effect , caused a gradual rise in the intracranial pressure . ruptures are usually asymptomatic in areas other than the cysts in the middle cranial fossa . however , immediate operative intervention was warranted in view of raised intracranial pressure and progressive neurologic deterioration .

intracranial arachnoid cysts developing in relation to the cerebral hemispheres and middle cranial fossa are usually incidental or asymptomatic . however , most of the clinically active cysts present with seizures because of chronic compression . presentation as raised intracranial pressure due to cyst rupture into the subdural space is a rare clinical entity . we herein present a case of an asymptomatic arachnoid cyst with rupture into the subdural space bilaterally and presenting as raised intracranial pressure .

an 18-year - old male patient presented with pneumothorax on postoperative day four after the minimally invasive repair of pectus carinatum . the pectus carinatum repair was performed using the sandwich technique , which involves a 33.02-cm press - molded internal bar and a 30.48-cm press- molded external bar ( fig . a small- bore central venous access catheter was inserted to relieve the pneumothorax in a less invasive manner . a chest computed tomography scan indicated the presence of multiple bullae at the apex of the upper lobe of the right lung . on postoperative day seven after the pectus repair , three days after the development of pneumothorax , we decided to remove the bullae through video - assisted thoracoscopic surgery ( vats ) because the lung collapse was persistent . under general anesthesia , using double - lumen endotracheal intubation with the patient in the left lateral decubitus position , a 10-mm thoracoscopic port was placed at the eighth intercostal space of the middle axillary line , below the pectus bar insertion level in order to avoid bar interruption . a 2-cm working incision was made at the fourth intercostal space of the anterior axillary line and a 5-mm working port incision was made at the subscapular tip area of the posterior axillary line for a three - port vats approach . vats exploration using a 30 thoracoscope ( karl storz endoscope ; karl storz , tuttlingen , germany ) revealed minimal hemothorax and multiple apical multiple bullae as indicated by the preoperative computed tomography scan . a finding that we did not anticipate was that the middle lobe of the right lung was entrapped between the chest wall and the pectus bar . adhesion was present around the pectus bar and the entrapped lung , but we did not observe air leakage at that moment ( fig . the entrapped lung was separated from the adhesion and carefully pulled out of the pectus bar . however , a portion was injured , and it had to be resected with endostaplers ( tristapler ; covidien , norwalk , ct , usa ) . an air leak test confirmed that both resected areas of the apex and the entrapped middle lobe were airtight . bio - absorbable felt ( neoveil ; gunze , osaka , japan ) was used to cover the lesions , followed by glue injection on the resected lesions . pectus deformity repair using pectus bars is a standard operation to correct pectus excavatum that has been widely performed since its development in 1998 by donald nuss . pneumothorax is one of the early postoperative complications of this procedure , and is caused by an incidental lung injury or air that was retained during the surgical procedure . in order to prevent this early complication , we routinely insert hemovac catheters into the bilateral pleural cavities in cases of the parallel insertion of two bars , intrapleural procedures , such as suturing for the placement of hinge plates , or in adult cases . however , primary spontaneous pneumothorax , caused by the rupture of subpleural blebs or bullae , may occasionally occur in combination with pectus repair . in such instances , it is difficult to determine the etiology of the pneumothorax and the subsequent treatment strategy . initially , pneumothorax can be conservatively managed by chest tube or catheter insertion , but prolonged air leakage or recurrent pneumothorax must be treated by thoracoscopic wedge resection . lung entrapment by surgical hardware is sharply distinct from usual cases of trapped lung , in which a part of the lung is unexpandable due to pleural inflammation , the development of adhesion after a surgical procedure , such as coronary artery bypass surgery , or pleural diseases including empyema , hemothorax , tuberculosis , and pleuritic . the entrapment of part of the lung can occur in pectus repair using pectus bars , and it may be difficult to recognize without surgical exploration . our vats finding , although it was incidentally discovered during a surgical procedure for pneumothorax , clearly demonstrated that the lung was caught between the pectus bar and the chest wall in our patient . in our case , a sizable portion of the parenchyma of the right middle lobe was caught between the pectus bar and the anterior chest wall , with adhesions formed around it . the cause of pneumothorax was uncertain in this case because no definitively identifiable ruptured bullae were leaking air at the time of surgery . although the air leak points in the entrapped lung were also uncertain , we thought that the damaged lung may have been leaking air , which may have been the cause of the pneumothorax . our surgical approach , therefore , combined resecting all bullae that we encountered and relieving the lung entrapment , which was ultimately accompanied by the removal of some damaged lung tissue . we report a case of spontaneous pneumothorax involving lung entrapment in a pectus bar and multiple bullae in the lung . this case demonstrates that pectus repair may be complicated by lung entrapment in the pectus bar .

we report a case of an entrapped lung after the pectus bar repair of a pectus deformity . the entrapped lung was found incidentally during video - assisted thoracoscopic surgery ( vats ) for pneumothorax . based on vats exploration , multiple bullae seemed to be the cause of the pneumothorax , but the entrapped lung was suspected to have been a cause of the air leakage .

in a recent issue of critical care , brandt and coworkers performed fluid resuscitation on pigs with endotoxemia or fecal peritonitis using either moderate volumes of crystalloids ( 103 ml / kg / h ) or larger volumes of crystalloids supplemented by 130/0.4 hydroxyethyl starch ( combined 203 ml / kg / h ) . these protocols were designed to mimic the relative ' restrictive ' and ' liberal ' fluid resuscitation policies that have been previously compared in human major surgery and acute lung injury / acute respiratory distress syndrome [ 2 - 4 ] . in both sepsis models , mortality increased with ' liberal ' fluid loading protocols in spite of better haemodynamic stabilization . although supplemental hydroxyethyl starch use in both study arms was partially ' goal - directed ' - on the basis of cardiac output responses assessed by esophageal doppler - the doses used for fluid loading were relatively fixed rather than completely based on cardiac fluid responses ( fluid responsiveness ) . the latter is preferable at the bedside , even if we do not formally know whether such therapy causes less morbidity and mortality in septic shock than using fixed volumes or guiding infusion according to relatively crude hemodynamics , such as the central venous pressure , as currently recommended . it is likely , however , that tailored ' liberal ' therapy decreases the risk for iatrogenic and detrimental fluid overload compared to fixed ' liberal ' therapy [ 6 - 8 ] . the debate about fixed ' restrictive ' versus ' liberal ' versus ' goal - directed ' therapy in the case of major surgery is also unresolved . differing results among studies , which may relate to differing case mixes , definitions , hemo - dynamic monitoring techniques / endpoints and treatment strategies , preclude unequivocal conclusions . the authors used different types of fluid in the ' restrictive ' and ' liberal ' arms , with hydroxyethyl starch used particularly in the latter . a toxic effect of hydroxyethyl starch can not thus be ruled out , so it is possible that the higher mortality in the ' liberal ' arm was caused , in part , by toxicity rather than large volumes . indeed , mortality in the control non - septic pigs receiving the ' liberal ' protocol was 13% ( 1 out of 8) . toxicity may include renal damage , as was particularly noted from the histology of the ' liberal ' endotoxin - challenged animals . in any case , the histology of several tissues suggested that overhydration and ( pulmonary ) edema had not increased in the ' liberal ' compared to the ' restrictive ' fluid loading groups , even in the presence of so - called colloid plaques observed in lungs , for instance , although the nature of these remains relatively unclear . finally , starch preparations may have multiple anti - inflammatory effects , but we do not know whether this is good or bad during sepsis . collectively , the experiments reported raise the interesting idea that too much of a good thing is detrimental , whether related to relative overtreatment or to toxicity of the hydroxyethyl starch colloid . a comparison of these experimental results with the literature is difficult because of , for example , highly varying study goals and endpoints . morisaki and colleagues found that starches ( more so than ringers lactate ) ameliorated progression of microvascular and parenchymal injury during the development of peritonitis in sheep . su and colleagues noted that starch , albumin , gelatin and ringers lactate fluid resuscitation afforded similar survival benefits during protracted fecal peritonitis in sheep , in spite of greater hemodynamic effects with the first two . this illustrates that the current data provided by brandt and colleagues may need to be confirmed . the observations that hemodynamic and mortality endpoints may not go in the same direction also deserve further explanation . what are the clinical implications of these experimental results ? the potential but unconfirmed ( renal ) toxicity of hydroxyethyl starch is indeed a subject of ongoing research in human septic shock and the current experimental observations may further fuel these efforts [ 13 - 15 ] . for instance , the potential renal toxicity of starch preparations may depend on volume , type , substitution of starch and the underlying condition of patients in whom fluids are infused , so that general conclusions are hard to draw at this stage [ 13 - 15 ] . that colloids have greater hemodynamic effects , for a given fluid infusion volume , than crystalloids , even in sepsis with increased permeability and potential leakage of the compounds , is corroborated by recent clinical observations . the outcome benefits and drawbacks of fluid resuscitation in sepsis and shock may not solely relate to hemodynamic effects , so that more is not always better , even if overt overhydration and ( pulmonary ) edema do not occur . the experimental findings remind us that outcome may also be a matter of the type of fluid used for initial resuscitation during septic shock . obviously , this relates , among other factors , to the increasing evidence that starch solutions have important side effects , particularly when exceeding recommended maximum daily doses .

in a recent issue of critical care , brandt and colleagues report the effects of a ' liberal ' fluid loading protocol compared to a more ' restrictive ' protocol on hemodynamics and mortality in pigs in which septic shock had been induced . it appears that the former protocol was associated with higher mortality in spite of improved hemodynamics compared to the latter . the results of the paper are discussed here in view of the scope and mechanisms of these findings . with regard to fluid resuscitation , they indicate that too much of an otherwise good thing is harmful , even if overhydration and edema formation seem to have been prevented . they also do not exclude a specific toxic effect of the larger volumes of hydroxyethyl starch in the ' liberal ' strategy . the precise nature of a toxic effect remains obscure , however , but may involve the kidneys .

bd is a multisystemic disease that may affect any organ in different combinations ? characterized by recurrent oral aphthous ulcers , genital ulcers , uveitis , and skin lesions . involvement of the heart is called cardio - bd , which includes pericarditis , myocarditis , endocarditis , endomyocardial fibrosis , atrial fibrillation , ventricular arrhythmias , coronary arteritis , acute myocardial infarction , and dilated cardiomyopathy ( 1 ) . we report a rare case of this syndrome , associated with aneurysm of the non - coronary sinuses of valsalva , resulting in symptomatic aortic valve regurgitation . a 38-year - old man was referred for investigation of a 5-day history of paroxysmal nocturnal dyspnea in may 2008 . he had a three - year history of recurrent genital ulceration initially diagnosed as genital herpes , but never confirmed on culture or nucleic acid amplification testing ; sequential treatment with aciclovir over a four - month period did not alleviate his genital symptoms . and he had no history of cardiac or respiratory disease , nor any cardiac risk factors . clinical examination revealed aphthous stomatitis , genital ulceration , erythema nodosum bilaterally and a grade 3/6 systolic murmur , audible at the 2nd intercostal space on the left sternal border . hematologic examination showed that high sensitive c - reactive protein ( hs - crp ) was 105 mgl and erythrocyte sedimentation rate ( esr ) is 70 mmhr . anti nuclear antibody ( ana ) , anti double strand dna antibody ( anti ds dna ) and muscle biopsy specimens for connective tissue disease were negative . chest x - ray revealed cardiomegaly with a cardiothoracic ratio of 55% and a slightly widened mediastinum . 1 ) . the left ventricular ( lv ) end - diastolic was 58 mm , and the lv ejection fraction was 53% . based on these findings , the diagnosis of aneurysm of the sinus of valsalva associated with bd was made . because the patient 's condition was in the active phase , prednisolone was administered over one month until the inflammatory signs ( hscrp and esr ) became negative . considered that our patient presented a competent valve and only one sinus involved , surgeon repaired the affected sinus only . he was discharged without any complications on postoperative day 15 , and was doing well at five - year follow - up after the operation . showing non - coronary - sinus of valsalva aneurysm aneurysms of the sinus of valsalva 's etiologies include atherosclerosis , infection such as syphilis , congenital disease such as marfan 's syndrome , trauma , and autoimmune disease such as bd . bd is a chronic , relapsing multisystem vasculitis with predominant involvement of the oral and genital mucosa ( 1 , 2 ) . bd has a worldwide distribution but is prevalent in japan , the middle east , and some mediterranean countries , and it often affects younger adults and is more common in men than women . james et al . demonstrated that valsalva sinus aneurysm was the leading causes of death in patients with bd ( 3 ) . in our patient , echocardiography revealed aneurysm formation of the sinus of valsalva , and should bd is the etiology ? the patient had a history of recurrent genital ulceration , on admission , clinical examination revealed aphthous stomatitis , genital ulceration , and erythema nodosum bilaterally , which could provide clues to differentiate diagnosis . if neglected these symptoms , it maybe at a loss of initial diagnosis of genital herpes . in addition to recurrent genital ulceration , aphthous ulcers and skin lesion , a clinical diagnosis of bd should be made , because other examination showed that high crp and esr , and ana , anti dsdna and muscle biopsy specimens for connective tissue disease were negative . aneurysms of the sinus of valsalva may incur complications if untreated , such as right ventricular outflow tract obstruction , coronary artery occlusion , aortic regurgitation and congestive heart failure , so surgical treatment should be considered ( 4 , 5 ) . but to aim directly at etiology is the most of all , and continuous steroid and immunosuppressive agent therapy are most important to maintain the integrity to prohibit recurrence of bd . our patient was doing well at five - year follow - up after the operation . it also highlights the importance of recognizing systemic disease and maintaining a holistic approach when treating patients .

abstracta 38-year - old man with a history of recurrent genital ulceration initially diagnosed as genital herpes was admitted after presenting with paroxysmal nocturnal dyspnea . echocardiography revealed aneurysm formation of the sinus of valsalva . on diagnosis of an aneurysm of the sinus of valsalva associated with behet 's disease ( bd ) , surgeon repaired the affected sinus only , and continuous steroid therapy maintained the integrity .

this could be partly because of the racial predilection as a large percentage of the population has curly hair and also may be due to local cultural customs which unlike the west do not encourage daily shaving of facial hair . twenty - four consecutive male patients presenting to a university health center over a 1 year period from january 2014 to january 2015 with a clinical diagnosis of pseudofolliculitis involving beard area and not on any active treatment for the same were included in the study . patient with other associated skin conditions which according to the investigators might affect clinical feature and/or management including , but not limited to , acne vulgaris , seborrheic dermatitis , rosacea , and other forms of folliculitis were excluded from the study . patient history with regards to shaving habits , patient hair type , morphological patterns of the skin lesions , and dermoscopic findings were recorded . dermoscopic images were shown to the patients and the condition and the principles of treatment were explained to them using the dermoscopic images . most of the patients had a usual shaving frequency of 2 or less per week . all the patients who were using razors mentioned that they tended to stretch the skin while shaving . the most common dermoscopic findings included - handle bar sign showing curved hair attached to the skin on both ends [ figure 1 ] , white areas ( possibly indicating fibrosis ) and scaling [ figure 2 ] , underlying linear bluish pigmentation ( indicating the buried hair shaft ) [ figure 3 ] , and linear vessels with occasional areas of hemorrhage [ figure 4 ] . aerobic culture of specimens taken from the skin lesions showed positivity for staphylococcus epidermidis in eight of the case . sign showing curved hair attached to the skin on both ends white areas ( possibly indicating fibrosis ) and scaling underlying linear bluish pigmentation ( indicating the buried hair shaft ) linear vessels with occasional areas of hemorrhage there are very few studies which have tried to elucidate the dermoscopic correlates of pseudofolliculitis barbae . the first case report was from chuh and zawar , who used dermoscopy to demonstrate the ingrown hairs and also suggested that showing the dermoscopy image to the patients can help them understand the condition better and thus help in achieving better compliance and treatment results . described a unique dermoscopic feature of pseudofolliculitis barbae in the form of a solitary gray - blue , thick curved line and adjacent red lines set upon a structure - less pattern . this pattern does not correspond to known dermoscopic entities such as basal cell carcinoma and seborrheic keratosis . according to the authors , the solitary gray - blue , thick curved line corresponds to the edge of the tightly coiled cluster of ingrown hairs in the dermis and the red lines could represent aberrant vessels secondary to the inflammatory reaction . the gray and blue colors could be explained by the tyndall effect due the melanin in the pigmented hair shaft in the dermis . puhan and sahu recently reported a case of pseudofolliculitis over the back of a patient . pseudofolliculitis corporis for this condition which in this case was most probably induced by the effect of friction due to a pillow which the patient used to put behind is back while driving . our study showed that the most common pattern seen in all cases was the curved hair attached at both ends what we would like to label as the handle bar . white areas with scaling , underlying linear bluish pigmentation ( indicating the buried hair shaft ) similar to that described by ladizinski et al . , and linear vessels with occasional areas of hemorrhage were the other common dermoscopic patterns seen in our cases . other studies have highlighted the predisposition of african race and curly hair to develop pseudofolliculitis . another study showed that the ala12thr polymorphism of keratin k6hf of hair follicle may be partially responsible for the phenotypic expression . the racial and genetic factors might be important for explaining the high incidence of pseudofolliculitis in the population of our study . while we did not do a formal evaluation as done by chuh and zawar to see if showing the dermoscopy images helped patient compliance , as done by us we feel that in general the patients had a clearer understand of the problem and the principles of treatment after they were shown the dermoscopy images . dermoscopy shows characteristic features and can be a useful adjunct for diagnosis in pseudofolliculitis . stretching the skin while using razors and growing the facial hair to a point where it has the length to curve might be important risk factors in the development of pseudofolliculitis .

background : pseudofolliculitis of the beard area is a very common dermatological problem in our geographical region . this could be partly because of the racial predilection as a large percentage of the population has curly hair and also may be due to local cultural customs , unlike the west do not encourage daily shaving of facial hair.objectives:we aimed to mainly study the dermoscopic features of cases presenting with pseudofolliculitis . secondary objectives included evaluating clinical patterns and possible etiological factors.methods:twenty-four consecutive male patients presenting to a university health center with a clinical diagnosis of pseudofolliculitis involving beard area were included in the study . patient history with regards to shaving habits , patient hair type , morphological patterns of the skin lesions , and dermoscopic findings were recorded.results:majority of the patients had curly hair . most of the patients had a usual shaving frequency of 2 or less per week . all the patients who were using razors mentioned that they tended to stretch the skin while shaving . the most common dermoscopic findings included - handle bar sign showing curved hair attached to the skin on both ends , white areas indicate fibrosis and scaling , underlying linear bluish pigmentation ( indicating the buried hair shaft ) , and linear vessels with occasional areas of hemorrhage.conclusion:dermoscopy can be a useful adjunct for diagnosis and patient counseling in pseudofolliculitis . stretching the skin while using razors and growing the facial hair to a point where it has the length to curve might be important risk factors in the development of pseudofolliculitis.limitations:the lack of histopathological correlation is the main limitation in our study .

seborrheic keratosis ( sk ) is common benign epidermal proliferation , which can occur anywhere in the skin the exception of palms , soles , and mucosa ( there was only one report of mucosal sk in the conjunctiva ) . sk involving the genital region is a rare entity , which can be easily misdiagnosed as genital warts . recently , dermoscopy is available as a noninvasive diagnostic procedure which can be used to diagnose sk by its typical findings . we hereby report a rare and unusual case of large sk of the genitalia which initially caused a diagnostic confusion with condyloma acuminata . the diagnosis of sk in our case was established by dermoscopy and was confirmed by histopathology . a 50-year - old woman presented with a large polypoidal growth on the vulva of 2 years duration . the lesion started as a small pigmented patch on the right vulva , which slowly increased in size to become a large polypoidal mass and in extent to involve the entire external genitalia . there was no pain or discharge , but of late the lesion became foul smelling . there was no history of sexual promiscuity in either spouse . on physical examination , a large , pigmented , polypoidal mass ( of size around 15 10 cm ) was seen in the external genitalia involving both labia majora , labia minora , fourchette , and mons pubis [ figure 1 ] . dermoscopic examination was carried out , which showed fissures and ridges , cerebriform appearance , and comedo - like openings consistent with sk [ figure 2 ] . the histopathologic examination of a biopsy sample showed hyperkeratosis , acanthosis , and multiple horn cysts , which were also consistent with sk ( acanthotic type ) [ figure 3 ] . large polypoidal mass over the entire external genitalia dermoscopic image showing fissures and ridges and comedo - like openings histopathology showing hyperkeratosis , marked acanthosis , and multiple horn cysts ( hematoxylin and eosin stain , 100 ) sks are common benign epidermal proliferations , which present as sharply demarcated , tan to black , round or oval , elevated , stuck on skin lesions . classically , sk tends to increase with age . flat sk , pedunculated skin - tag - like , stucco keratosis , dermatosis papulosa nigra , melanoacanthoma , and inverted follicular keratosis . polypoidal mass ( as was seen in our case ) has been reported in the genital region in several case reports . reported large , polypoidal sk in the genitalia in 42-year - old and 50-year - old male patients , respectively . melanoacanthoma is a variant of sk characterized by epidermal proliferation of keratinocytes and melanocytes where the melanocytes are scattered throughout the tumor lobules rather than only in the basal layer as seen in sk . we considered the diagnosis of melanoacanthoma in our case , but ruled it was out as histopathology showed melanocytes only in the basal layer ( not throughout the tumor lobule ) . roth et al . reported a case of inverted follicular keratosis ( a variant of sk ) of the vulva . inverted follicular keratosis is considered a sk that involves the epithelium of hair follicles , that proliferates in an endophytic fashion , and that exhibits squamous differentiation in association with inflammation . the clinical diagnosis of sk may be difficult at times with only 49% accuracy in a study done by stern et al . diagnosis becomes more difficult in the genital region as the classical clinical features of sk ( distinct keratotic and follicular plugging , stuck - on appearance , etc . ) disappear because of the friction and maceration typical of this area . in our case , however , distinct keratotic and follicular pluggings were well discernible . sk may be grouped into different histological subtypes : acanthotic , hyperkeratotic ( also verrucous ) , adenoid ( reticulated ) , plane , clonal , bowenoid , irritated , inverted follicular keratosis , benign squamous keratosis , and melanoacanthoma . the acanthotic type , like in our case , shows marked acanthosis with predominantly basaloid cells , moderate papillomatosis and hyperkeratosis , and characteristic presence of horn cysts or pseudocysts . squamous eddies , as seen in irritated sk , are absent . because the lesions of sk may not be easily diagnosable in the genital region , dermoscopy could become a handy replacement to tedious and sometimes unacceptable biopsy / histopathologic examination . the most common dermoscopic features of cutaneous sk are comedo - like openings and milia - like cysts . other features include fissures , hairpin vessels , sharp demarcation , and moth - eaten borders . comedo - like openings , that is , keratin - filled invaginations of the epidermis , are usually not seen in the vulva , due to the friction that prevents their formation in this anatomical site . milia - like cysts , on the other hand , are histologically included in the epidermis , and therefore not eliminated by friction and maceration . in our case , comedo - like openings were plentiful , but milia - like cysts were not seen . multiple fissures ( giving a cerebriform appearance ) were also prominently seen in our case . our case highlights a rare presentation of sk as giant , polypoidal growth in the genital region and diagnostic utility of dermoscope in establishing the diagnosis .

genital seborrheic keratosis ( sk ) is a rare entity , which can be easily misdiagnosed as genital warts . dermoscopy is a useful tool to make diagnosis of sk in such cases . we report a 50-year - old woman with a large polypoidal growth on the external genitalia . dermoscopic examination showed fissures and ridges , cerebriform appearance , and comedo - like openings consistent with sk . the histopathology confirmed the diagnosis of sk .

a 64yearold woman presented with 68 sharply demarcated , darkly pigmented macules around the anus ( fig . 1 ) and a 3month history of intermittent rectal bleeding . the patient underwent a colonoscopy and an ulcerated 3.6 cm in diameter , polypoid , pigmented tumor of the anorectal verge was found ( fig . based on the patient 's history and physical examination findings , which one of the following is the most likely diagnosis ? peutzjeghers syndrome.genital warts.neurofibromatosis type 1.acrodermatitis enteropathica.metastatic anorectal melanoma . numerous biopsies were taken from the tumor at the time of colonoscopy and pathologic results were consistent with the diagnosis of melanoma . histopathology of the operative specimen showed a primary melanoma ( hmb45 and s100 stains positive ) with a breslow thickness of 1.4 mm . abdominal ultrasonography and contrast ctscan of chest , abdomen , and pelvis showed no evidence of metastases . anorectal melanoma is a rare disorder , approximately accounting for 1% of all anorectal carcinomas 2 . the anorectum is the third most common location for melanoma following cutaneous and ocular melanoma . primary rectal melanoma presents in the fourth decade with an increase of incidence in the fifth or sixth decade of life .

key clinical messageprimary mucosal melanoma occurs in under 2% of melanomas . anorectal melanoma is a rare disorder , approximately accounting for 1% of all anorectal carcinomas . primary anorectal melanoma presents predominantly in women , in the 4th6th decade of life . typical clinical manifestations include rectal bleeding and tenesmus . the prognosis remains poor .

at the first medical examination , the sister was 7 years 8 months old , and the brother was 5 years 3 months old . neither sibling had any specific birth history . slit lamp microscopic examination revealed no abnormalities in the anterior segments of either eye , in either patient . the best corrected visual acuities ( bcva ) were 0.1 ( right eye ) and 0.8 ( left eye ) in the sister , and 0.7 ( right eye ) and 0.1 ( left eye ) in the brother . the cycloplegic refractive powers in the sister were : -15.50 diopter ( dpt ) , cylinder ( cyl ) + 4.50 dpt ax 85 in the right eye and -1.00 dpt cyl . the differences in spherical equivalents between the two eyes were -12.50 diopters in the sister and -6.875 diopters in the brother . full - time right occlusion therapy was performed in both patients for three months , then four to six hours a day for two years . the sister was prescribed atropine for the left eye after six hours right - sided occlusion therapy a day for a year . three years later , the bcva in the brother 's left eye had improved from 0.1 to 0.7 . the bcva in the sister 's left eye improved from 0.1 to 0.7 during the first year ; however , she showed no further improvement after that time . the refraction and the radius of the anterior corneal curvature were measured using an autorefractokeratometer ( speedy - k ; nikon , tokyo , japan ) and a topographer ( orb - scan ; bausch & lomb , rochester , ny , usa ) . a - mode ultrasonography ( cinescan ; quantel medical , clermont - ferrand , france ) was performed . the results of a - mode ultrasonography and orb - scan are presented in table 2 . this condition is often associated with amblyopia , both in the presence of and in the absence of strabismus [ 6 , 7 ] . the prevalence of anisometropia reported in school - based and population - based studies of school - aged children is typically 5% , but this figure varies depending on the manner in which anisometropia is defined . myopic anisometropia is usually accompanied by strabismus , especially exotropia in 30 - 60% of patients . this suggests that the development of binocular vision might be affected by mild infantile exotropia . when high myopia of one eye is more than -5 to -6 diopters , or the difference in spherical equivalents of both eyes is more than 5 diopters , then anisometropia may be responsible for amblyopia . , the present case is without any obvious complication and shows mirror image similarly . in the study of 78 monozygotic twins and 40 dizygotic twins , sorsby et al . reported that the concordances of corneal power , axial length , and vertical ocular refraction were higher in monozygotic twins than in dizygotic twins . interestingly , patients in the present study had similar axial lengths in their myopic eyes . in conclusion , we believe that severe myopic anisometropia may be genetically determined , and further investigation is recommended .

we report a case of one sister and brother with mirror image myopic anisometropia . one sister and brother complained visual disturbance . the sister was 10 years 11 months old , and brother was 8 years 4 months old . full ophthalmic examinations were performed , including slit lamp examination , intraocular pressure , keratometry , anterior chamber depth , axial length , fundus examination and the cycloplegic refraction . the cycloplegic refractive power was -15.50 dpt cyl.+4.50 dpt ax 85 ( right eye ) , -1.00 dpt cyl.+0.50 dpt ax 90 ( left eye ) in the sister ; -1.75 dpt cyl.+2.25 dpt ax 90 ( right eye ) , -9.50 dpt cyl.+4.00 dpt ax 80 ( left eye ) in the brother . the co - occurrence of severe myopic anisometropia in a sister and brother is extremely rare . the present case suggests that severe myopic anisometropia may be related by genetic inheritance .

the treatment of orbital floor fractures with silastic sheet was prominent , until the advent of the titanium plate . it was an adequate treatment ; however , it had a tendency to migrate through the skin . diplopia when present for months tends to be difficult to resolve surgically , and what makes this case unique is that diplopia has resolved after > 30 years . a 54-year - old male presented to our department with a right - sided chemosis , periorbital swelling and was systemically unwell . clinically , his visual acuity was 6/12 in his right eye and 6/6 in his left eye . he reported that he had surgery on a fractured right orbit 33 years ago and had had persistent diplopia since . he reported that his diplopia had worsened , but clinically his eye and swelling was much improved . a ct scan ( fig . inferior and medial recti are both trapped by the implant. figure 1:coronal slice of ct scan demonstrating silastic sheet protruding through the right orbital floor . a decision was made to remove the implant surgically via a caldwell luc approach . the patient reported that his diplopia had resolved , for the first time , in 33 years . the treatment of orbital floor fractures with silastic sheet is well documented and there are large case series published . however , there is a high complication rate when using silastic as a material to repair orbital floor fractures . complications include : implant migration to the skin and the maxillary sinus , skin fistula , persistent diplopia , communication between the orbit and the sinus , periorbital cellulitis . the treatment of the fractured orbital floor has advanced over the last 30 years . computerized tomography , custom made implants , resorbable and non - resorbable implants , the use of endoscopic surgery and stereolithography all have an important role in the treatment of the fractured orbital floor . silastic complications may develop late and the latest published resolution of diplopia following surgery is 20 years . we feel that our patient is fairly remarkable , in that his diplopia has resolved at 33 years after initial surgery .

a 54-year - old male sustained a fractured right orbital floor 33 years ago , which was treated with a silastic implant . his diplopia never resolved , and he presented to us with an acute orbital cellulitis . computerized tomography showed a displaced inferior rectus and entrapment of both inferior and medial recti . the implant was removed surgically via a caldwell luc approach and his diplopia completely resolved after 33 years .

ependymomas are rare forms of primary brain tumors , accounting for 37% of all brain tumors [ 1 , 2 ] . ependymomas , composed of neoplastic ependymal cells , are thought to arise from the ependymal cells in the ventricular system . the majority occur infratentorially in the pediatric population , while a smaller fraction occurs in adults , usually in the spinal cord . rare variants of ependymomas have been described and can include cellular , papillary , clear - cell , and tanycytic variants . tanycytic ependymomas are particularly rare and typically occur in the spinal cord as an intramedullary mass . first described by friede and pollak in 1978 , tanycytic ependymoma represents a who grade ii ependymoma with characterized pathology described as containing bipolar cells with absent mitosis and low - to - moderate cellularity . here the patient is a 58-year - old male with a history of hypertension and type ii diabetes mellitus who presented to an outside hospital after developing chin and right arm tremors , followed by a seizure . the seizure was complicated by a fall and urinary incontinence ; the seizure resolved on its own . a ct completed at an outside hospital revealed a large , complex cystic mass in the frontal lobe and left hemispheric subarachnoid hemorrhage . mri analysis revealed a 5.6 8 5 cm complex cystic lesion in the left frontoparietal lobe , with a mass effect on the left lateral ventricle ( fig . there was some enhancement in the cystic components that was also visualized on t1 imaging with gadolinium . surgery was performed , and a left frontoparietal brain lesion , which was initially suspected to be a low - grade glioma , was removed . however , the tumor was surprising in its grayness and more firm than it would be expected for a low - grade glioma . the surgery was repeated 3 days later for microdissection and tissue harvesting . during his hospital stay , the patient developed waxing and waning expressive aphasia , with the development of global aphasia , a right facial droop , and right - sided weakness . a ct demonstrated hemorrhage in the resection cavity , effacement of the left superior frontoparietal sulci suggestive of cerebral edema , and a slight increase in left to right midline shift from 1.3 to 1.5 cm . however , it was unclear if the aphasia stemmed from the clot or cerebral edema following the surgery . on the day following evacuation of the hematoma , the patient 's symptoms improved . the patient 's symptoms included residual slurred speech , which improved over the subsequent month . at his last visit , 18 months following surgery , he continued to do well with no evidence of clinical or radiographic recurrence . pathological analysis revealed brain tissue infiltrated by well - differentiated piloid cells with low - to - moderate cellularity ( fig . analysis of immunohistochemical staining revealed glial fibrillary acidic protein - positivity solely in reactive astrocytes . the proliferative index of the tumor was low , with only 2% of cells positive for ki67 staining . this case report shows the diagnosis and current clinical outcome of a male adult patient with a supratentorial tanycytic ependymoma , who grade ii . this rare variant of ependymoma commonly occurs in the spinal cord . in a review of the literature , we identified only 6 cases of ectopic supratentorial tanycytic ependymomas ( table 1 ) [ 4 , 5 , 6 , 7 , 8 , 9 ] . four cases were identified after the onset of seizures , one after the onset of headaches , and one was incidental . locations varied among the cases , including both cortical and subcortical locations as well as right and left hemispheres . tumors were frontal , temporoparietal , temporo - occipital , parietal , and parieto - occipital . in this series of patients , the wide age ranges of the patients and the presence of the tumors throughout the hemispheres underscore the importance of considering ependymomas in the diagnosis of tumors occurring throughout the brain . this is especially crucial with regards to tanycytic ependymomas , which can be easily mistaken for pilocytic astrocytomas or fibroblastic meningiomas . this can occur due to the bipolar nature of the tumor cells on pathology along with low - to - moderate cellularity . nonetheless , a number of nonconventional ependymoma variants can also mimic other tumors within the brain . papillary ependymomas may demonstrate features similar to those of choroid plexus tumors , while myxopapillary ependymomas may mimic chordomas . in undiagnosed tumors that lack the typical staining pattern for more common intraparenchymal tumors , alternative diagnoses , including variants of ependymoma , must be considered . in conclusion , this case report represents the rare presentation of a tanycytic ependymoma in the supratentorial region in an adult male patient . proper pathological diagnosis of the rare variant of ependymoma is warranted as it can impact prognosis and treatment .

ependymomas , tumors of the ependymal cells , are very rare and usually present in the pediatric population . furthermore , there are even rarer variants of ependymomas that can include cellular , papillary , clear cell , and tanycytic subtypes . we present a case of a supratentorial tanycytic ependymoma in an adult male and review the literature in regard to this rare primary central nervous system neoplasm .

the growth of home and community - based services ( hcbs ) under medicaid can be traced to the early 1980s when it was found that : a disproportionate percentage of medicaid resources were being used for institutional long - term care ( davidson , 1980 ; grannemann and pauly , 1983 ; holahan , 1975 ; spiegel and podair , 1975 ) . several studies documented that at least one - third of persons residing in nursing facilities that were medicaid funded would have been capable of living at home or in community residential settings if additional supportive services were available ( fox and clauser , 1980 ; kraus , et al . , 1978 ; pegels , 1980 ; weissert , 1986 ) . institutional bias in the medicaid benefit and eligibility structure ( grannemann and pauly , 1983 ; holahan , 1975 ; leonard , brust , and choi , 1989 ; weissert and scanlon , 1985 ) . residents in both nursing facilities and intermediate care facilities for the mentally retarded frequently reported an unsatisfactory quality of life ( de silva and faflak , 1976 ; gardner , 1977 ; lakin and hall , 1990 ; scheerenberger , 1976 ) . a number of court cases resulted in court orders to deinstitutionalize persons with developmental disabilities . the hcbs waiver program was established by section 2176 of the omnibus budget reconciliation act of 1981 and was incorporated into the social security act ( the act ) at section 1915(c ) . under the hcbs waiver program , states can elect to furnish under medicaid , as an alternative to institutional care , a broad array of services ( excluding room and board ) that are not otherwise covered under the medicaid program . passage of this statute represented a first step towards recognizing that many individuals at risk of institutionalization can be supported in their homes and communities , thereby preserving their independence and bonds to family and friends , at a cost not higher than institutional care ( health care financing administration , 1996 ) . the act lists seven specific services that may be provided under the hcbs waiver program . although not specified in the act , other services may be provided at the request of the state if approved by hcfa . for example , these services may include transportation , in - home support services , meal services , special communication services , minor home modifications , and adult day care ( health care financing administration , 1996 ) . hcbs waiver services may be provided to individuals who are elderly and disabled , physically disabled , developmentally disabled or mentally retarded , or mentally ill . hcbs waiver services may also be targeted to individuals with a specific illness or condition , such as children who are technology - dependent or individuals with aids ( health care financing administration , 1996 ) . in the absence of the hcbs waiver these individuals would require the level of care offered in a hospital , nursing facility , or intermediate care facility for the mentally retarded . states have a great deal of flexibility in designing their own unique hcbs waiver program(s ) . this enables a state to identify a specific population and target services to that population to meet the population 's unique needs . as previously noted , the hcbs waiver program gives states the flexibility to develop and implement creative alternatives to institutional care for individuals who are medicaid eligible . this flexibility is advantageous to the states as it allows states to tailor their programs to the specific needs of the populations they wish to serve . for example , under the hcbs waiver a state may : provide services in the home or community as a cost - effective alternative to institutional care . target services to a specific group by waiving section 1902(a)(10)(b ) of the act which relates to the comparability requirement . limit services to a specific geographic area by waiving section 1902(a)(1 ) of the act which relates to the statewideness requirement . request an exception to the deeming rules under the social security administration 's supplemental security income program , thereby the eligibility determination for an individual in the community on an hcbs waiver is made using institutional versus community deeming rules . the medicaid hcbs waivers are an important tool for states to meet the requirements of the americans with disabilities act ( ada ) as defined by the u.s . is properly regarded as discrimination based on disability in violation of the provisions of the ada . the court affirmed the policy that the ada supports access to community living for persons with disabilities by obliging states to administer their services , programs , and activities in the most integrated setting appropriate to the needs of the qualified individuals with disabilities . in addition , the court found that institutionalization severely limits a person 's ability to interact with family and friends , to work , and to make a life for himself or herself . to help states comply with the court 's ruling , hcfa and the department of health and human services ' office for civil rights have begun working with states and the disability community toward the goals of promoting hcbs and honoring individual choice in service provision . estimated total medicaid expenditures for the hcbs waiver program for 1998 were over $ 9 billion for an estimated 606,953 participants ( harrington et al . , 1999 ) . states continue to renew existing hcbs waivers , as well as request new hcbs waivers . ( arizona provides similar services under the authority of a section 1115 demonstration waiver rather than a section 1915(c ) waiver [ harrington et al . , 1999 ] . )

the history and current status of the medicaid home and community - based services waiver program are presented . the article discusses the states ' role in developing and implementing creative alternatives to institutional care for individuals who are medicaid eligible . also described are services that may be provided under the waiver program and populations served .

a 73-year - old diabetic patient presented with a recent - onset visual decline od . 1a ] with mild non - proliferative diabetic retinopathy with no macular edema ; left fundus was normal . optical coherence tomography ( oct ) revealed vitreomacular traction ; central macular thickness ( cmt ) was 630m [ fig . 1b ] . after obtaining an informed consent from the patient , he underwent vitrectomy , erm removal , and membrane peeling with dual staining : trypan blue dye 0.15% ( retiblue , aurolab , madurai , india ) for erm and brilliant blue g 0.05% ( ocublue plus , aurolab , madurai , india ) for internal limiting membrane . 4 weeks later , bcva had improved to 20/40 ; cmt was 379 m [ fig . , bcva gradually declined to 20/60 with cmt increasing again to 412 m and recurrence of macular cystic changes [ fig . the patient received intravitreal triamcinolone acetonide ( ivta , 4 mg/0.1 ml ) od . within 4 weeks , bcva recovered to 20/40 ( cmt : 323 m ) . over the next 10 weeks , the bcva improved to 20/20 od [ fig . ( a ) fundus od reveals macular epiretinal membrane , ( b ) horizontal oct scan reveals vitreomacular traction ; central macular thickness ( cmt ) is 630. note the central defect in the inner segment - outer segment ( is - os ) junction , ( c , d ) one month postoperatively , macula is free of membrane , oct shows partial recovery of foveal contours ( cmt : 379 ) , ( e , f ) 2.5 months postoperatively , macula developed cystoid thickening ( cmt : 412 ) , ( g - h ) six months postoperatively , macular edema resolved ( cmt : 319 ) , with an intact is - os junction and external limiting membrane persistence of macular edema after vitrectomy for erm removal is well - known ; and is generally attributed to chronic vascular leakage . but recurrence of edema after an initial post - surgical resolution has been rarely reported . we attempted treatment of recurrent macular edema with ivta on the basis that it would favorably affect macular edema due to both vascular and inflammatory etiologies . remarkably , ivta did not merely restore the post - operative visual outcome , but improved it to 20/20 ; a rare event in erm surgery in spite of the excellent visual gains reported . this outcome was obtained in spite of an interrupted inner segment - outer segment ( is - os ) junction in the pre - operative oct [ fig . finally , visual recovery is reported to peak around 12 - 24 months after erm removal with reconstitution of is - os junction ; we obtained both the milestones much earlier , at 6 months postoperatively in this case . konstantinidis et al used ivta routinely after vitrectomy for erm ; they reported excellent visual outcomes , which were obtained in a short time , as in our case . however , proactive use of ivta as reported by these authors may invite other problems like secondary glaucoma and cataract ; and can be recommended as a default part of surgical protocol only after a head - to - head trial against vitrectomy without ivta for erm . i propose a case for using ivta to enhance surgical outcome when residual or recurrent macular edema is observed after erm removal .

a patient underwent successful vitrectomy for macular epiretinal membrane with anatomical and functional improvement . 10 weeks later , there was a recurrence of macular edema with corresponding visual decline . an intravitreal injection of triamcinolone acetonide not only restored the macular anatomy but also improved the visual outcome beyond that achieved after surgery .

in a recent issue of critical care , parnell and colleagues examined host gene expression changes in whole blood from critically ill patients infected with pandemic h1n1 influenza a infection . the measurable genomic response of the host to influenza may provide important information not only on viral pathogenesis but also on the immune response , its dissemination within the infected host , and its transmission in a population . the authors evaluated transcriptional changes in blood samples obtained from 39 patients and 18 healthy controls . of the 39 patients , eight had polymerase chain reaction ( pcr)-confirmed pandemic h1n1 influenza a virus , 16 had culture - documented bacterial pneumonia , and 12 had systemic inflammatory response syndrome of undefined etiology . a support vector machine class predictor identified a blood - based h1n1 gene expression signature , but a separate unique bacterial signature , or secondary bacterial infection , could not be generated . distinguishing bacterial pneumonia from other causes of upper and lower respiratory tract infection , improvements in the timely and accurate classification of the causative agent(s ) of respiratory infection could have a profound impact on health and quality of life by improving appropriate antibiotic use and infection control interventions . the development of inexpensive and easy - to - use rapid diagnostics to accurately distinguish bacterial pneumonia from viral pneumonia in routine clinical specimens ( for example , blood ) would represent a major advance in health care and have a significant impact on improving the clinical management and outcome of acute pneumonias . at present , infectious disease diagnostics focus on one or more pathogens of interest ( for example , the urinary pneumococcal antigen test or multiplex pcr for respiratory viruses ) or one - analyte - at - a - time biomarkers ( for example , c - reactive protein or procalcitonin elevation as a marker for severe bacterial infections ) . in other fields , high - dimensional gene expression data offer a higher level of precision in the diagnosis of acute and chronic diseases . infectious disease lends itself well to these analyses since the host response to pathogens entails a cascade of cellular events and expressed molecules that can be readily measured on a genome scale . the dimension and complexity of such data provide unique opportunities to uncover patterns that can distinguish subtle phenotypes in ways that traditional single - molecule techniques can not and to use these patterns in models to predict with precision the way the genome interacts with environmental stimuli , such as infectious or other noxious agents . recently , strategies have been developed by several groups to use host gene expression to classify viral , bacterial , and fungal bloodstream infections - a strategy termed a ' paradigm shift ' by some investigators in the field . the rationale for this approach is clear - immune effector cells respond to pathogens with characteristic gene expression patterns reflecting the interaction of the pathogen with pattern recognition receptor signaling . these patterns , captured by microarray or alternative technologies , offer robust classification of infectious pathogens . in vitro [ 11 - 13 ] and ex vivo data provide proof - of - concept that gene expression patterns exhibited by host immune cells have , in addition to common cellular programs , pathogen - specific components . parnell and colleagues should be applauded for their work in this area and extending the paradigm of hostbased classification of infectious disease . however , the study has some limitations that need to be recognized so that future investigations of this type continue to move this important area of investigation forward . the sample size is relatively small and thus the generalizability of the findings remains to be elucidated . the authors recognize that additional validations with expanded cohorts are necessary to determine whether these findings represent an h1n1-specific molecular signature or one that is more representative of influenza viruses or other respiratory pathogens . in addition , the question of whether these results would be generalizable to population extremes ( such as the very young or the aged and immune - compromised ) and the impact of medications , particularly antiviral and other antimicrobial drugs , on the accuracy of the classifier would absolutely need to be addressed . has limited utility for clinical infectious disease diagnostics , and the signatures developed here need to be migrated to a more conventional platform for diagnostics , such as reverse transcription - pcr , and revalidated . critical work on sample processing , turnaround time , and sensitivity , specificity , and negative and positive predictive values also would need to be assessed prior to any claims about the suitability of the signatures as a diagnostic . it is interesting that the investigators were unable to develop a signature for the bacterial pneumonia where others have had some success . perhaps this reflects the heterogeneity of the subjects , issues with accurate phenotyping , or statistical methodology limitations . bacterial pneumonias are heterogeneous , and the details of the case definition and adjudication of the phenotypes in these types of studies are critical components of the study design . the development of a specific bacterial host response signature will be essential to the advancement of this technology to clinical application . nonetheless , the results of this work are a significant step forward in the use of genomics to understanding the host response to an important pathogen in global health . both authors are applicants for a patent to apply gene expression signatures for the diagnosis of viral infection . in addition both authors receive us government funding to study host based genomic biomarkers of infectious disease .

capturing the host response by using genomic technologies such as transcriptional profiling provides a new paradigm for classifying and diagnosing infectious disease and for potentially distinguishing infection from other causes of serious respiratory illness . this strategy has been used to define a blood - based rna signature as a classifier for pandemic h1n1 influenza infection that is distinct from bacterial pneumonia and other inflammatory causes of respiratory disease . to realize the full potential of this approach as a diagnostic test will require additional independent validation of the results and studies to examine the specificity of this signature for viral versus bacterial infection or co - infection .

in the previous issue of critical care we read with great interest a report of the first experimental study of recombinant human activated protein c ( rhapc ) in oleic acid - induced nonseptic acute lung injury ( ali ) in sheep . impairment of the protein c pathway plays a central role in the pathogenesis of sepsis . treatment with rhapc has been reported to increase survival from severe sepsis . the administration of rhapc may correct the dysregulated anticoagulant mechanism and prevent propagation of thrombin generation and the formation of microvascular thrombosis . it is likely that the beneficial effects of rhapc observed in experimental and clinical studies of severe sepsis result from a combination of mechanisms that modulate the interdependent processes of coagulation and inflammation . protein c levels also decrease markedly in ali , of both septic and nonseptic origin . low levels of protein c in ali are associated with poor clinical outcome . in the present study , the authors of the well known group of lars bjertnaes ( troms , norway ) showed that simultaneous administration of rhapc ameliorates oleic acid - induced ( non - septic ) lung injury . the rise in pulmonary artery pressure , the development of pulmonary edema and the derangement of arterial oxygenation subsequent to intravenous bolus infusion of oleic acid all improved significantly during coadministration of rhapc . we recently reviewed studies of rhapc treatment in sepsis - related ali and found the timing of drug administration to be critical in these experiments . when given prior to the injury in a porcine model or given simultaneously in pseudomonas aeruginosa - induced lung injury in rats , the oxygenation further deteriorated beneficial effects could only be shown when rhapc was given post injury in various ovine models [ 9 - 11 ] . we hypothesized that rhapc in the early stage of ali may disturb the complex coagulation balance at the alveolar level , and may impede an initially positive effect of coagulation activation , because in the early phase of ali the epithelial side as well as the endothelial side of the capillary barrier are involved with fibrin deposition , reflecting a shift in the alveolar / fibrinolysis balance . the beneficial effects of the simultaneous treatment in the present study , however , are in contrast to our hypothesis and lead away from the coagulation cascade to the activity of neutrophils in ali . during inflammation , activated neutrophils accumulate in the lungs and other organs , thus contributing to organ system dysfunction . neutrophils express receptors for rhapc and neutrophil chemotaxis is inhibited by exposure to rhapc , explaining its beneficial effects . our group uses an ovine model of smoke inhalation and sepsis to induce ali , since smoke inhalation and sepsis are major contributors to mortality in burn patients . the lungs of sheep have a special feature , a single bronchial artery , and a single lymphatic draining of the lung . a 10-fold increase in bronchial blood flow the venous outflow of the bronchial circulation drains into the pulmonary microcirculation at the precapillary level . considering the fact that initial damage to the airway appeared to drive the pathophysiology of the parenchyma , investigators hypothesized that the bronchial blood might deliver cytotoxic materials or cells into the pulmonary microcirculation . to test this hypothesis , several investigators have tied off the bronchial artery of sheep and then exposed the animals to smoke . in these studies what could be the linkage between the airway , the bronchial venous drainage and parenchymal injury to the lung ? many of the neutrophils , however , have been activated in the bronchial areas their f - actin is activated and the cells are stiff and can not deform . these stiff cells are carried to the pulmonary microvasculature , where they are impaled by the narrow pulmonary capillaries . the final proof of this hypothesis was to deplete the animals of their neutrophils and determine how this affected the response to inhalation injury . in these studies of sheep depleted of their leukocytes , when rhapc binds to these receptors , before the cells are drained via the bronchial venous system into the pulmonary microvasculature , a reduction of ali may be anticipated . taking these facts together , the results of waerhaug and colleagues appear in a different light ; of course oleic acid - induced ali is different from smoke inhalation , but , given the direct injury to the lung and the fact that sheep have the single bronchial artery , the beneficial effects of a simultaneous treatment with rhapc might be more advantageous than in other models especially since only sheep subjected to peritoneal sepsis or endotoxin infusion presented with reduced extravascular lung water . future studies are warranted to determine the effects of rhapc in an ovine model when the bronchial artery is tied off to clear its mechanism in ali .

impairment of the protein c pathway plays a central role in the pathogenesis of sepsis . treatment with recombinant human activated protein c ( rhapc ) has been reported to increase survival from severe sepsis . protein c levels also decrease markedly in acute lung injury , of both septic and nonseptic origin . low levels of protein c in acute lung injury are associated with poor clinical outcome . the present article discusses the beneficial effects of rhapc in oleic acid - induced lung injury as well as the controversies between different animal models and the timing of drug administration . the unique bronchial circulation in ovine models seems to be responsible for the beneficial effects of rhapc when given simultaneously to the injury .

klippel trenaunay syndrome ( kts ) is a rare congenital malformation first described in 1900 by maurice klippel and paul trenaunay . kts is characterized by the triad of capillary malformations , atypical venous malformations and varicosities , and bony and/or soft tissue hypertrophy . kts is estimated to affect 1 in 100 000 people worldwide with no predilection to race or sex . an 18-year - old man presented for consideration of exenteration of the rectum and giant venous malformations extending out the sciatic notch . he had experienced multiple significant episodes of haematochezia with associated anaemia ( haemoglobin of 4.5 g / dl ) and lethargy . this is on a background of kts complicated by a right leg amputation , bleeding skin lesions and chronic haematochezia . a non - obstructive pedunculated malformation was present near the ileocaecal valve occupying 50% of the lumen with the majority of malformations present in the rectum as a diffuse - dilated venous plexus ( fig . 1 ) . n - of-1 random allocation was performed to inject the rectum with 5 ml of phenol in almond oil to the left and 20 ml of 75% ethanol to the right - sided vessels just beyond the anorectal junction . the patient returned at 6 months for a flexible sigmoidoscopy to assess the rectal venous malformations . at the time of presentation the flexible sigmoidoscopy again identified the previous venous malformations with an obvious but subjective reduction in the right - sided lesions ( ethanol - injected lesions ) more so than the left ( fig . 2 ) . a further 20 ml of 75% ethanol was injected into the left - sided lesions as well as 10 ml of 75% ethanol into the right - sided lesions . the rate of venous malformations in patients with kts is 70% . however , case studies suggest that the rate of problematic haematochezia associated with kts is quite low [ 1 , 3 ] . surgical management of rectal haemangiomas is dependent on the extent of the anatomy of the haemangioma . proctocolectomy with coloanal anastomosis is an option that allows for preserved anal function with control of bleeding . however , extension of the haemangioma to the perianal and perineal region may require abdominoperineal resection with a permanent colostomy . parashette and cuffari describe the case of a child with kts complicated by haematochezia where endoscopic sclerotherapy with 75% ethanol was successful . ethanol has been used in sclerotherapy for many years and is tolerated in most cases . however , systemic toxic side - effects of ethanol have been reported in the literature . minor side - effects of percutaneous ethanol include skin blistering , ulceration and scar formation , while major side - effects include pulmonary embolism , cardiovascular collapse and death . wong et al . have described cardiovascular collapse in the case of an 11-year - old child with kts that underwent ethanol sclerotherapy . yakes and baker have described desaturation , bradycardia and cardiopulmonary collapse in three adults who underwent ethanol sclerotherapy . retrospective study has suggested that the only factor significantly associated with a systemic adverse event is the ethanol dose / weight ratio per intervention . suggest a maximal ethanol dose / weight ratio of 0.2 ml / kg in the treatment of venous malformations with ethanol as a sclerosant . this case offers further support for 75% ethanol as a sclerosant in the management of rectal venous malformations and their use in an adult population . it is important to note that the options for treatment of rectal venous malformations include surgery and/or endoscopic sclerotherapy , and that each of these options is associated with its own complications . evidence does not exist in support of one mode of therapy over the other and the treatment option should be based on an individual assessment .

klippel trenaunay syndrome ( kts ) is a rare congenital disorder characterized by the triad of capillary malformations , atypical venous malformations and varicosities and bony and/or soft tissue hypertrophy . we present the case of an 18-year - old man with kts affected by haematochezia secondary to rectal venous malformations that was managed with endoscopic sclerotherapy . in this case , we compared the use of ethanol to phenol as a sclerosant .

beedis ( or bidis ) are the commonest smoked form of tobacco in india . according to the global adult tobacco survey , 34.6% of adults are current tobacco users . a greater proportion of males ( 47.9% ) use tobacco compared to females ( 20.3% ) . among females , while only 2.9% smoke any form of tobacco and 1.9% specifically smoke beedis , a majority are chewers . cross - tobacco use refers to the use of tobacco in the form other than for what it was primarily intended . a review of the literature shows no data on cross tobacco use ( e.g. , chewing what is primarily meant for smoking ) . the authors report what to our knowledge is the first case of cross - tobacco use ( chewing beedies meant for smoking ) in a female patient with schizophrenia . a 22-year - old single lady was brought to the centre for addiction medicine with a request for help for tobacco cessation . she had been on treatment for schizophrenia for the last 6 years which had responded well to treatment and she was on maintenance with risperidone 4 mg / day and trihexyphenidyl 2 mg / day . only following 4 years of regular follow - up , following pressure from family , she reported the use of beedies in the form of chewing . her father was a habitual beedi smoker and her mother used areca nut and betel leaf with tobacco . the patient had begun chewing beedies at the age of 15 years , after having observed her father smoking beedies , which she was often sent out to procure . she said she had begun chewing as she could not smoke ( female smoking is not socially acceptable in most sections ) . initially , she would chew the stubs her father had dropped around , but later began procuring beedies for her own use . while buying the beedies , she would say it was for her father . the patient had developed a dependent pattern of tobacco use since the age of 18 years . on average , she was chewing up to one pack , which contains 24 beedis . at the time of her consultation for tobacco cessation , the positive symptoms of schizophrenia were well controlled , and she had minimal negative symptoms . the diagnosis of nicotine dependence syndrome along with undifferentiated schizophrenia was considered . despite significant improvement in her psychotic symptoms and occupational work function , treatment for tobacco dependence was challenging since patient reported very severe intense craving early in the morning and a wavering motivation for abstinence . a trial of nicotine gum 4 mg up to 12 mg per day and behavioral counseling was not useful to contain her tobacco use . she has stopped chewing beedies since the last 8 months and is not using any other form of tobacco . tobacco has been used in smokeless ( chewing ) and smoking forms throughout the world . chewing tobacco products there is a gender difference in the preference for different forms of tobacco in india . while males smoke beedies or cigarettes , females who use tobacco are generally chewers . in the reported case , unusual form of cross - tobacco use there are no data available on this form of cross - tobacco use in the published literature . in the reported case , she was also biologically predisposed to tobacco use , with both her parents likely to have been dependent on tobacco , the father a chronic beedi smoker and the mother likely to have been dependent on both tobacco and areca nut . in addition to a vulnerability to dependence , the presence of schizophrenia is yet another risk factor , and nicotine use in the form of tobacco is well known . unusual patterns of tobacco use , especially in psychotic patients are known , but not published . clinicians should be sensitive to unusual patterns of use , as highlighted by this case .

while tobacco use occurs in many forms all over the world , there is little information on cross - tobacco use . authors report an unusual case of tobacco use in the form of chewing beedies which are normally smoked ( cross - tobacco use ) . a 22-year - old single female , diagnosed with schizophrenia for the last 6 years , started chewing beedies from the age of 15 years and was using it in a dependent pattern since 7 years . after 3 years of treatment for her schizophrenia , patient 's family pressured her to seek tobacco cessation treatment . initial treatment with nicotine gum replacement and behavioral counseling did not prove useful . subsequently she was treated with bupropion 300 mg / day and able to successfully abstain . cross - tobacco use is relatively rare , and merits further study , especially in the mentally ill population .

india has the world 's highest burden of tuberculosis ( tb ) . in india , the multidrug - resistant tb ( mdr - tb ) prevalence among all patients with tb combined is estimated to be 4.1% . a crude estimate derived from these data is that 4500 6000 hiv - infected persons develop mdr - tb annually in india . diagnosis of any form of tb , including drug - resistant ( dr ) tb , is more challenging in the presence of hiv disease and together they result in higher case fatality rates . poly - drug resistant tb indicates resistance to two or more anti - tb drugs but not to both isoniazid ( inh ) and rifampicin ( r ) simultaneously . treatment of dr - tb in patients on antiretroviral therapy ( art ) is complex due to the drug interactions . dr - tb in hiv - infected children is difficult to diagnose and rarely reported . a 3-year - old hiv - infected boy was referred for further management in january 2005 . mother was diagnosed as tuberculous pleural effusion with hiv infection with acid fast bacillus ( afb ) seen on sputum examination and was on ofloxacin ( o ) , inh ( h ) , and rifampicin ( r ) for the same . he had cervical adenopathy ( non - tender , non - matted ) and other systems were normal . investigations showed positive mantoux test ( 20 22 mm ) and chest x - ray was suggestive of primary complex . his venereal disease research laboratory ( vdrl ) test , hbsag , and anti - hepatitis c were negative . he was started on anti - tuberculous therapy ( att ) consisting of 2 hrze + 10 hr ( z = pyrazinamide , e = ethambutol ) . he was asymptomatic till june 2007 , when we had mild molluscum contagiosum . in february 2009 , at the age of 7 years , he was hospitalized with right lower zone pneumonia and his sputum was positive for afb . his sputum culture grew mycobacterium tuberculous ( mtb ) complex after 6 weeks and sensitivity after another 2 weeks showed resistance to streptomycin ( s ) and h. he was then shifted to rezo in may 2009 and art was started in the same period in view of decreasing cd4 count , consisting of zidovudine ( azt ) , lamivudine ( 3tc ) , and nevirapine ( nvp at 400 mg / m / day ) . ofloxacin was stopped in august 2009 and he was advised rez for another 6 months . in india , mdr - tb is estimated to account for 2.3% [ 95% confidence intervals ( ci ) : 1.8 2.8 ] of new cases and 17.2% ( 95% ci : 14.9 19.5 ) of previously treated tb cases . those at highest risk of dr - tb are in whom prior treatment had failed , cases of relapse , defaulters , and contacts of mdr - tb . drug resistance is rarely acquired in the pediatric population due to the paucibacillary nature of the disease and originates mainly in the adults who are treatment failures or defaulters . thus , the main method of resistance in children is primary transmission of the resistant bacilli . our patient had been treated for pulmonary tb in 2005 for 1 year but again developed tb in 2009 , which is suggestive of a relapse . hiv co - infection is considered important in the development of dr - tb by increasing the rates of malabsorption of anti - tb drugs , thus causing treatment failures . the diagnosis of dr - tb is established by laboratory methods ( drug susceptibility tests or dst ) which , however , are not available in most resource - limited settings and are difficult to do in children . treatment of poly - resistant tb varies as per drug resistance pattern and consists of three to four sensitive drugs for six to eighteen months duration . for h and s resistance , as in our patient , the suggested regimen is rze for 69 months , and fluoroquinolone can be added in patients with extensive disease to strengthen the regimen . thus , children who had been treated for tb in the past should be screened for drug resistance by dst . this has also been reiterated in our series of children with mdr - tb and partial over extensively drug - resistant ( xdr ) tb in whom we found that over 50% of patients had been treated for tb in the past . dr - tb in hiv - infected children should be considered if the child has been treated with att in the past or there is contact with adults on second - line att therapy . poly - resistant tb is rare in children , especially in hiv - infected children .

drug - resistant tuberculosis ( dr - tb ) has been reported in india , but has been rarely documented in children . hiv co - infection has led to resurgence of tuberculosis ( tb ) , making treatment even more difficult due to complex drug interactions . poly - resistant tb is rare in children , especially in hiv - infected children . we report an hiv - infected child who developed poly - resistant tb ( resistance to streptomycin and isoniazid ) after 3 years of completion of anti - tuberculosis treatment ( att ) . his mother had also received att 3 years back . we conclude that dr - tb in hiv - infected children should be considered if the child had been treated with att in the past or there is contact with adults on second - line att therapy .

the prevalence of congenital anomalies of the coronary arteries ( caas ) is reported to be approximately 0.2 - 1.4% in the general population . of them , . it may be benign appearing as an incidental finding on routine coronary angiogram or sometimes , may be complicated with atherosclerosis and present with spectrum from stable coronary artery disease to acute coronary syndrome with stormy course . a 34-year - old male was admitted to emergency department with retrosternal chest pain at rest of 4 h duration with perspiration and occasional dizziness . electrocardiogram showed st elevation in leads ii , iii , and avf , reciprocal changes in leads i and avl , and complete heart block ( fig . 1a ) . he was preloaded with 325 mg aspirin , 40 mg rosuvastatin and 60 mg prasugrel along with iv fluids and vasopressors . the left coronary arteries were of normal origin and distribution with normal flow in left anterior descending artery ( lad ) and circumflex artery ( lcx ) . rca was hooked with a 3.5 judkin s right 6 f guiding catheter ( medtronic , usa ) . lesion was crossed with a 0.014 " 140 cm fielder fc wire with help of a finecross microcatheter ( asahi , japan ) ( fig . 3 ) . once parked distally , finecross was advanced and fielder fc was exchanged with a 0.014 " 140 cm bmw wire ( abott , usa ) . distal tip of bmw wire was not in typical distribution of rca but as we encountered , no resistance and movement of distal tip along with the feel was sufficient to say that it was in true lumen ( fig . we treated him with upstream tirofiban ( 10 g / kg/3 min ) and dilated with a 2 10 mm minitrak balloon ( abott , usa ) ( fig . contrast injection this time showed one large branch going beyond crux giving posterior descending artery and two parallel large coronary arteries distally . lesion was stented with a 3.5 23 mm xience prime drug - eluting stent ( abott , usa ) ( fig . 4c ) and post - dilated by a 3.5 10 minitrak nc balloon ( abott , usa ) achieving timi iii flow ( fig . control coronary angiogram demonstrated atypical double rca as there were two parallel coronary arteries distal to the occlusion ( fig . stay , complete heart block reverted to 2:1 atrioventricular block , and then went back to normal sinus rhythm on third day ( fig . he was discharged in stable condition with dual antiplatelets , statin , and beta blocker . ( a ) electrocardiogram showing complete heart block ; ( b ) 2:1 atrioventricular block ; ( c ) wenckebach phenomenon ; ( d ) normal sinus rhythm . ( a ) bmw guide wire parked distally after exchange with feider wire ; ( b ) lesion being predilated with 2 10 minitrak balloon ; ( c ) stent being deployed across the lesion ; ( d ) stent being post - dilated with non - compliant balloon . double rca is a very rare coronary anomaly , whose true definition and correct diagnosis remain controversial [ 2 , 3 ] . sometimes , it is very difficult to distinguish double rca with single orifice from rca which has a high take - off of a large right ventricular artery . right anterior oblique ( rao ) view may be helpful in differentiating double rca from a large right ventricular branch as it provides better demonstration of artery courses in such circumstances . sato et al have proposed that double rcas are defined when they supply the blood to the inferior left myocardium , thus both of the rcas should course downwardly to reach the interventricular sulcus whether or not they cross the crux . the first report about double rca anomaly in the literature was by barthe et al . after the origin of a conus artery and a ventricular branch , the most anterior rca descended toward the acute margin of the heart and terminated in a small posterior descending artery . the second rca terminated in a small posterior descending and posterolateral branches . in our cases , both rcas were almost identical in size and both gave rise to a pda . by using this reasonable classification , we diagnosed our case as atypical double rca . since the first report , this rare anomaly has been accepted as a benign entity . however , its involvement with atherosclerosis has also been reported , where revascularisation had been performed either by coronary artery by - pass surgery or elective percutaneous coronary intervention ( pci ) [ 7 , 8 ] . rohit et al have reported primary pci of double rca presenting with acute inferior wall infarction but there was no rhythm disturbance in their case . to the best of our knowledge and after extensive search in medical literature , we are reporting for the first time , double rca presenting with complete heart block with cardiogenic shock where primary pci was performed . rca maintains a course in the atrioventricular groove and forms the uppermost portion of the posterior descending branch . the length of each of the two posterior descending branches varies from patient to patient : in our patient , both the branches were large ; therefore , their occlusion was responsible for the symptoms .

double right coronary artery ( rca ) is an extremely rare coronary artery anomaly . we here report an atherosclerotic double rca which appeared after primary percutaneous intervention performed to treat a 34-year - old male presenting with acute inferior myocardial infarction , cardiogenic shock and complete heart block . this is an unusual case as double rca had been hidden by total atherosclerotic occlusion of the proximal part of the rca and complete restoration of patency led complete heart block back to normal sinus rhythm .

in the previous issue of critical care , rumpf and colleagues evaluated the potential contribution of measuring end - tidal carbon dioxide ( co2 ) for suspected pulmonary embolism ( pe ) in the prehospital setting . capnography has been studied for decades as a potential diagnostic tool for patients with suspected pe . indeed , pe is expected to create areas of reduced arterial flow with normal or increased alveolar ventilation , resulting in increased alveolar dead space volume and reduced global expired co2 . this should create a difference between arterial and end - tidal co2 values , as first demonstrated by robin and colleagues in 1959 . however , during the two following decades , several authors pointed out the numerous pitfalls and sources of errors in assessing the arterial to end - tidal co2 difference in the clinical suspicion of pe , and this test was finally abandoned until the nineties [ 3 - 5 ] . three elements explain the current resurgence of expired co2 measurement in the suspicion of pe . first , technical improvements now allow measuring co2 not only for monitoring purposes in intubated patients in operating rooms but also as a diagnostic tool in spontaneously breathing patients in the emergency department or even in the field . second , volumetric capnography , which displays expired co2 as a function of the expired volume of the patient , did much to renew interest in capnography because of its potential for better performance in diagnosing pe than the arterial to endtidal co2 difference , even though that expectation could not be confirmed by recent results . finally , in the era of non - invasive strategies for pe combining several tests of various types , such as clinical evaluation , biological tests , and imaging , the evaluation of a potential role for co2 measurement in combination with those other instruments made sense . numerous studies are available , and although none to date has been able to prove the safety of such a non - invasive strategy incorporating capnography with a high enough level of evidence to allow its recommendation in daily clinical practice , the venue remains interesting [ 7 - 11 ] . where then can we place the endeavor of rumpf and colleagues ? they included 131 consecutive patients suspected of pe who had an abnormal rapid point - of - care d - dimer result in a prehospital setting and evaluated them with a combination of clinical probability of pe ( two - level wells score ) and measurement of the end - tidal partial pressure of co2 ( pco2 ) . pe was diagnosed in the emergency department by a positive spiral computed tomography , a high - probability v / q scan , or a positive pulmonary angiogram . the combination of a normal end - tidal co2 value ( defined as higher than 28 mm hg based on a receiver operating characteristic analysis ) and an unlikely probability of pe had a 100% sensitivity and 100% negative predictive value ( 95% confidence interval [ ci ] 90% to 100% ) for ruling out pe . in contrast , the association of a low end - tidal co2 value ( less than 28 mm hg ) and a high clinical probability had only an 86% positive predictive value for pe , and further tests would certainly be required in such patients . clearly , those results are preliminary . this is a small series and it was designed to set the cutoff value for this particular capnography technique and assess its feasibility in the field . moreover , as acknowledged by the authors themselves , the clinicians who established the diagnosis were not blinded to either clinical assessment or capnography results . finally , the prevalence of pe is unusually high , although this would tend to bias the results toward lower , not higher , sensitivity . but the sheer simplicity of the technique used by rumpf and colleagues is appealing and certainly deserves validation in a large - scale prospective study . indeed , it emphasizes the use of expired co2 alone without associated arterial pco2 , and this is a pragmatic issue in modern emergency medicine . also , the use of capnography in the prehospital setting is interesting : there might be situations in which a rapid and rough evaluation of the patient 's expired co2 status would help emergency physicians in making vital decisions , such as starting thrombolysis for a suspected fulminant pe , as well as in monitoring the hemodynamic effect of thrombolysis in such patients . finally , the merit of the article by rumpf and colleagues is to remind us that clinical applications of capnography are still growing , especially amongst spontaneously breathing patients . physicians dealing with acute medicine should make every effort to become familiar with expired co2 measurement . inconclusive capnographic results related to tachypneic or apprehensive patients do not overcome the potential for expired co2 to be placed inside the diagnostic algorithm of a challenging disease like pe . co2 : carbon dioxide ; pco2 : partial pressure of carbon dioxide ; pe : pulmonary embolism .

capnography has been studied for decades as a potential diagnostic tool for suspected pulmonary embolism . despite technological refinements and its combination with other non - invasive instruments , no evidence to date allows recommending the use of expired carbon dioxide measurement as a rule - out test for pulmonary embolism without additional radiological testing . further investigations are , however , still warranted .

in a study of patients with sepsis , velissaris and colleagues showed that high mixed venous blood oxygen saturation ( svo2 ) levels do not exclude fluid responsiveness . svo2 is assumed to reflect the balance between arterial oxygen delivery ( do2 ) and oxygen consumption ( vo2 ) provided arterial blood oxygen saturation ( sao2 ) is normal . indeed , the modified fick equation states : svo2=sao2-vo2/cardiac output hb 1.34 where hb is the hemoglobin concentration . nevertheless , the interpretation of svo2 and its changes in shock states must be cautious for at least four reasons . first , in any shock state , oxygen demand exceeds vo2 by definition such that svo2 can not reflect the balance between do2 and oxygen demand , which is better assessed by markers of anaerobic metabolism such as the blood lactate level . second , as vo2/do2 dependency is a characteristic pattern of shock states , any increase in do2 during resuscitation will be associated with a simultaneous increase in vo2 and hence with no or only a small increase in svo2 until a critical do2 is reached . third , the tissue oxygen utilization is impaired in severe sepsis so vo2 may decrease relative to oxygen demand , even if do2 is normal or high . fourth , because of the hyperbolic relation ship between svo2 and cardiac output ( graphical representation of the modified fick equation ) , svo2 should not change much in response to an increase in cardiac output in cases of hyperdynamic shock states . for all these reasons , interest in svo2 monitoring in septic shock has been debated - although svo2 or its surrogate , central venous oxygen saturation , has been recommended as a major hemodynamic target of early resuscitation in septic shock . nevertheless , svo2 might still play an important role in the monitoring of septic shock by identifying the patients in whom do2 could be further augmented and then by guiding the therapy aimed at increasing do2 . this point is of particular importance since systematic maximization of do2 is not recommended in every patient with septic shock . velissaris and colleagues showed that a given value of svo2 can not be used to predict a positive response to fluid challenge . preload responsiveness is an intrinsic property of cardiac performance , indicating that the heart is operating on the steep ascending part of the frank - starling relationship . preload responsiveness is therefore by nature a concept that differs from the concept of global vo2/do2 balance and thus from svo2 . patients with low svo2 can be either fluid responsive in cases of hypovolemic shock or fluid unresponsive in cases of cardiogenic shock . in the study by velissaris and colleagues almost two - thirds of patients with a low svo2 ( < 60% ) were fluid nonresponders , suggesting that their heart was operating on the flat part of the frank - starling curve . this observation suggests that in the presence of low svo2 it is mandatory to obtain additional information to identify the cases where fluid administration should be considered the most logical therapeutic measure . cardiac filling pressures are not appropriate to make such a therapeutic decision , as confirmed by velissaris and colleagues . by contrast , dynamic tests ( pulse pressure variation , passive leg raising and endexpiratory occlusion tests ) are far more reliable to predict fluid responsiveness / unresponsiveness . in cases of low svo2 the presence of fluid responsiveness should incite infusing fluid , whereas its absence should rather incite consideration of other therapies ( for example , inotropes ) that enable one to increase cardiac output with the ultimate goal of decreasing tissue hypoxia . because septic shock is often characterized by high cardiac output and low extraction oxygen capacities , high values of svo2 or central venous blood oxygen saturation can be observed as confirmed in the study by velissaris and colleagues . one striking finding of their study is that an increase in cardiac output with fluid infusion occurred in more than 50% of patients who exhibited a high svo2 ( > 70% ) at baseline . this confirms that preload responsiveness can coexist with the presence of reduced oxygen extraction capacities and thus high svo2 . a reliable prediction of fluid responsiveness would also be important to obtain in cases of high svo2 . whether the presence of preload responsiveness should lead to the decision to infuse fluid , however , is still uncertain . one should anticipate that abnormally high svo2 is an indicator of profoundly decreased oxygen extraction capacities so that the additional increase in do2 can not be effectively distributed and/or utilized in the most injured peripheral tissues . in other words , one can reasonably postulate in cases of tissue hypoxia that the higher the svo2 , the less likely the correction of tissue hypoxia with fluid infusion , even in the presence of indicators of preload responsiveness . since the study by velissaris and colleagues was not designed to confirm this hypothesis , do2 : oxygen delivery ; hb : hemoglobin concentration ; sao2 : arterial blood oxygen saturation ; svo2 : mixed venous blood oxygen saturation ; vo2 : oxygen consumption . j - lt and xm are members of the medical advisory board of pulsion medical systems ( munich , germany ) .

real - time monitoring of mixed venous oxygen blood saturation ( svo2 ) or of central venous oxygen blood saturation is often used during resuscitation of septic shock . however , the meaning of these parameters is far from straightforward . in the present commentary , we emphasize that svo2 - a global marker of tissue oxygen balance - can never be simplistically used as a marker of preload responsiveness , which is an intrinsic marker of cardiac performance . in some septic shock patients , because of profound hypovolemia or myocardial dysfunction , svo2 can be low but obviously can not alone indicate whether a fluid challenge would increase cardiac output . in other patients , because of a profound impairment of oxygen extraction capacities , svo2 can be abnormally high even in patients who are still able to respond positively to fluid infusion . in any case , other reliable dynamic parameters can help to address the important question of fluid responsiveness / unresponsiveness . however , whether fluid administration in fluid responders and high svo2 would be efficacious to reduce tissue dysoxia in the most injured tissues is still uncertain .

such dislocations are usually caused by sports injuries , epileptic seizures , electrical shock , or electroconvulsive therapy . however , simultaneous bilateral anterior shoulder dislocation is very rare and usually is of traumatic in origin with only few cases described in literature . thorough clinical examination of the patient is mandatory in order to ensure that a bilateral dislocation is not missed . the following case report demonstrates a typical bilateral shoulder dislocation as a result of trauma in a 24-year - old male . a 24-year - old man presented to accident and emergency department with complaints of acute shoulder pain involving both shoulders after trying to prevent a fall . he tried to prevent falling backward by extending both arms behind his back . physical examination showed fullness over anterior aspect and bilateral squaring of his shoulders ( epaulet sign ) . both humeral heads were palpated in the anterior aspect of each joint and there was a global , painful restriction of range of motion in both shoulders , without any evidence of peripheral motor , sensory and vascular deficit . radiographs confirmed bilateral anterior glenohumeral dislocation with greater tuberosity fracture on left side [ figure 1 ] . reduction of both shoulders was obtained which was confirmed radiologically [ figure 2a and b ] . since the greater tuberosity fracture of left shoulder returned to its anatomical position after reduction , so it was decided to manage the fracture conservatively . radiographs demonstrating the bilateral anterior shoulders dislocation with fracture greater tuberosity left side ( a and b ) post - reduction x - ray showing congruent reduction of bilateral shoulder joint and anatomically reduced greater tuberosity fracture left side the patient received physical therapy as tolerated and no further episodes of instability ensued . at follow - up of two months the patient reported no pain and had returned to his normal activities of daily living with minimal discomfort . both shoulders had near normal range of motion with pain only present at the extremes of motion . radiographs showed an anatomical consolidation of greater tuberosity fracture of left shoulder joint . at the end of one year follow up , the fracture has united with no restriction of motion and the shoulders were defined as stable . bilateral shoulder dislocation was first described in 1902 in patient in whom excessive muscular contractions occurred as a result of camphor overdose . dunlop et al . , reported in 2002 of other cases in the literature , but most were associated with fractures . bilateral posterior shoulder dislocations occur mostly due to electrical shock , seizures or hypoglycaemic episodes , and these occur as a sequel of maximal involuntary muscle contractions . the weaker external rotating muscles are overpowered by the stronger internal rotators , resulting in adduction and internal rotation sufficient dislocate the humeral head posteriorly . unlike posterior dislocations , anterior dislocations occur more commonly following trauma . our patient had minor trauma after falling backwards with his arms extended behind his back . the dislocation mechanism in our case is a protective effort in an unbalanced position both created a typical shoulder dislocation mechanism . this is the first case reported of a patient dislocating both shoulder by this mechanism . cresswell and smith reported a case of bilateral anterior dislocation of the shoulder without any fractures in a bench - pressing athlete . singh and kumar reported a case of sequential bilateral anterior dislocation in which the left shoulder dislocated first due to trauma followed by atraumatic dislocation of the right shoulder . galois et al . early reduction and immobilisation should be followed by definite treatment , which may include active and passive physiotherapy or surgery in the younger , more active patient group . this poses obvious problems in the case of bilateral injuries when the patient may require remain in hospital for an extended period . a fracture of the greater tuberosity occurs in approximately 10% of dislocations and is usually associated with the humeral head in a subglenoid , low subcoracoid , or subclavicular position . in these cases , the greater tuberosity is displaced in the approximately 15% of all anterior shoulders dislocations of the shoulder . the diagnosis of a rotator cuff tear is almost sure when the fracture of the greater tuberosity is displaced . possible rotator cuff tears and other shoulder pathologies should be investigated by magnetic resonance imaging ( mri ) . mri was not used in our cases because of financial constraints and plan of conservative treatment . functional impairment is commonly seen if the greater tuberosity is not reduced anatomically . in our patient it is important to take accurate clinical history , a thorough clinical examination and adequate imaging in order to exclude this injury . this is especially of concern , since the reported rate of late diagnosis is greater than 10% . predisposition to bilateral dislocations may be higher in older age group because of balance problems .

shoulder dislocations are the most common major joint dislocations encountered in the emergency departments . bilateral shoulder dislocations are rare and of these , bilateral posterior shoulder dislocations are more prevalent than bilateral anterior shoulder dislocations . bilateral anterior shoulder dislocation is very rare . we present a case of 24-year - old male who sustained bilateral anterior shoulder dislocation following minor trauma , with associated greater tuberosity fracture on one side . prompt closed reduction followed by immobilization in arm sling and subsequent rehabilitation ensured a good outcome .

the paper entitled ' prolonged treatment with n - acetylcysteine delays liver recovery from acetaminophen hepatotoxicity ' by yang and colleagues , published in the previous issue of critical care , demonstrates that prolonged administration of n - acetylcysteine ( nac ) at 100 mg / kg in acetaminophen ( apap)-induced liver failure in mice potentially limits hepatocellular regeneration . activation of a transcription factor , nuclear factor - kappa - b ( nf-b ) , strongly linked to impairment of liver regeneration , is a putative mechanism for this . furthermore , the paper postulates that high doses of nac may interfere with normal metabolic processes of the liver , leading to impairment of its regenerative capacity . nac has been used since the 1970s , and it effectively manages apap poisoning by glutathione repletion if administered within 8 to 10 hours of ingestion of the overdose . in later years , clinical use of nac was extended to patients who present more than 10 hours after ingestion and to those with apap - induced acute liver failure ( alf ) , and patients in such categories are routinely on nac infusions for many days , even weeks . the putative protective mechanisms of nac in late - apap poisoning and apap - induced liver failure remain poorly characterised but include free - radical scavenging , hemodynamic , and cytokine effects . concern has been expressed relating to its extended use in late presenters with apap poisoning and apap - induced liver failure because of the possibility of changed kinetics of nac in liver injury , reduced efficacy , and adverse hemodynamic changes ( vasodilatation and increased cardiac index ) . this new study raises the issue of whether impairment of regeneration is also a clinical concern for extended nac use . a key issue in liver recovery after any acute injury is tissue repair and regeneration . such liver regeneration involves replication of mature parenchyma and non - parenchyma liver cells , which requires multiple cytokine and growth factor signalling pathways , including tumour necrosis factor - alpha , interleukin-6 , hepatocyte growth factor ( hgf ) , and transforming growth factor - alpha . inhibition of the transcription factor nf-b was shown to be associated with impaired liver regeneration and apoptosis of hepatocytes . nf-b is also demonstrated to be responsible for regulation of transcription of a cell cycle regulator cyclin d1 . this new study in a mouse model demonstrates that nac , in doses similar to those used therapeutically to treat apap poisoning in humans , impairs liver regenerative capacity and that the effect is more pronounced when administered for a longer duration ( that is , 72 versus 24 hours ) . the histopathological evidence of this effect was supported by the reduced nf-b dna binding in liver and decreased expression of cyclin d1 . it is noteworthy that nac acting on apap - treated human hepatoma - derived cell hepg2 cell cultures was shown to have a protective effect against apap - induced oxidative damage but not from apoptosis . this evidence does support the findings of yang and colleagues , despite the species differences that could contribute to apap and nac metabolic pathways . the current clinical literature recommends the prolonged administration of nac in patients with apap - induced alf and in those who present late for medical care until evidence of improvement of the international normalised ratio or transplantation takes place . in this backdrop , the evidence by yang and colleagues raises two issues with respect to prolonged use of nac : first , whether prolonged nac use is potentially harmful by reducing liver regeneration in patients presenting late with apap poisoning , especially in those with apap - induced alf , and second , the issue of appropriate dosing and duration of nac treatment . the concept of tailor - making nac therapy to the apap - poisoned patient has been raised recently in the literature , and differing protocols of nac infusion are starting to be evaluated , albeit with study limitations . future research on apap - induced alf patients could be in the direction of monitoring for biomarkers ( for example , sfas and hgf ) for liver regeneration or apoptosis in order to establish whether there is a ' tipping point ' of risk / benefit after which nac infusion might be stopped . further research is also required to fully evaluate the impact of nac on cytokine systems controlling hepatocellular recovery . in the management of late presenters with apap poisoning and apap - induced liver failure , clinicians may have to consider individual case scenarios in tailor - making duration and dose of nac therapy . alf : acute liver failure ; apap : acetaminophen ; hgf : hepatocyte growth factor ; nac : n - acetylcysteine ; nf-b : nuclear factor - kappa - b .

since the 1970s , n - acetylcysteine ( nac ) has shown proven efficacy as an antidote for acetaminophen ( apap ) poisoning and apap - induced liver failure for early presenters . the current evidence of benefits of nac for late presenters is controversial because of the poor understanding of the mechanism of late toxicity . in the previous issue of critical care , yang and colleagues use a mouse model to demonstrate that nac in doses similar to those used therapeutically to treat apap poisoning in humans impairs liver regenerative capacity and that the effect is more pronounced when administered for a longer duration . studies based on cell cultures support this evidence . cytokine and growth factor signalling pathways are recognised to be involved in the process of liver regeneration and apoptosis . this research paper generates several issues related to the future management of apap - induced liver failure and research into the mechanism of toxicity , especially of late toxicity .

carcinoma of the prostate is a common condition , with over 21 000 cases and over 10 000 deaths every year in the united kingdom alone . we describe two patients with known carcinoma of the prostate who presented with visual disturbance and papilloedema on examination . the first patient was a 76-year - old gentleman who presented to the urology service complaining of a poor stream . he re - presented to the urology service 30 months later with a serum psa of 378 g / l with macroscopic haematuria . a trans - rectal biopsy of the prostate was performed and poorly differentiated adenocarcinoma of the prostate was diagnosed . an mri scan was performed , which showed bony metastases in the occipital bone and oedema in the cerebellum ( figs 1 and 2 ) . the slightly hyper - intense signal in the superior sagittal sinus indicates that the thrombosis is between 5 and 15 days old and is due to the presence of methaemoglobin . the patient responded well to 20 gy ( in five fractions ) of radiotherapy , delivered to the occipital region . figure 1 t2w sagittal image of patient 1 , showing metastases in the occipital bone and oedema of the cerebellum.figure 2 t2w axial image of patient 1 , showing mixed signal in the sagittal sinus compatible with thrombosis . after treatment of the metastases with radiotherapy , follow - up imaging showed a return of a normal signal void . t2w sagittal image of patient 1 , showing metastases in the occipital bone and oedema of the cerebellum . t2w axial image of patient 1 , showing mixed signal in the sagittal sinus compatible with thrombosis . after treatment of the metastases with radiotherapy , follow - up imaging showed a return of a normal signal void . the second patient was a 62-year - old gentleman who was admitted to hospital with a history of recent onset of headaches , nausea , nocturia and macroscopic haematuria . positive findings on examination included bilateral papilloedema and a markedly ataxic gait with cerebellar ataxia . isotope bone scanning showed bony metastases in the thoracolumbar spine , the pelvis and the base of the skull . computed tomography ( ct ) of the brain did not demonstrate cerebral metastases but mri scanning did reveal bony metastases in the occiput ( fig . venous infarcts in the occipital lobes adjacent to the superior sagittal sinus were also demonstrated ( fig . figure 3 t2w axial image of patient 2 , showing metastases in the occipital bone and iso - intense signal in the occluded sagittal sinus . note the fluid around both optic nerves.figure 4 mrv ( 2d tof ) of patient 2 showing thrombus in the superior sagittal sinus.figure 5 coronal t1w image of patient 2 demonstrating high signal adjacent to the superior sagittal sinus compatible with haemorrhage . t2w axial image of patient 2 , showing metastases in the occipital bone and iso - intense signal in the occluded sagittal sinus . mrv ( 2d tof ) of patient 2 showing thrombus in the superior sagittal sinus . coronal t1w image of patient 2 demonstrating high signal adjacent to the superior sagittal sinus compatible with haemorrhage . the patient was commenced on cyproterone acetate and received 30 gy to the skull in 10 fractions over 14 days . papilloedema has been described in prostate carcinoma due to transverse sinus thrombosis , but this was a result of dural metastases at the torcula and not in the bone of the skull vault . bony metastases in the optic canal have also been described , causing painless visual loss . mri is effective at showing both bony metastases in carcinoma of the prostate and is the imaging modality of choice for cerebral venous sinus thrombosis . intravenous contrast - enhanced ct scanning may show filling defects in the superior sagittal sinus , but mri is more sensitive in the detection of superior sagittal thrombosis and venous oedema and of bone metastases . we would suggest that in a patient with visual disturbance , who is known to be suffering from a malignancy that may spread to bone , mri is the imaging modality of choice and the venous sinuses should be examined with mrv at the time of imaging .

carcinoma of the prostate is a common condition and often spreads to bone . we describe the imaging findings in two patients with known carcinoma of the prostate who presented with visual disturbance ( both had papilloedema on examination ) . mri showed occipital bone metastases and superior sagittal sinus thrombosis . we suggest that mri is the imaging modality of choice in patients suffering from prostate cancer who have visual disturbance and that mrv sequences should be included to detect venous sinus thrombosis .

microbes are the biggest reservoir of biodiversity in natural forests and are involved in nutrient transformations thereby maintaining the forest ecosystem . there are many natural forest types present in the north eastern region of india and many are still far from human understanding and any kind of anthropogenic interference . murlen national park is an undisturbed natural forest falling within the indo - burman biodiversity hotspot zone . this region contains diverse ecological niches with leading hotspots in terms of endemics and provides unique niches for the evolution of novel microorganisms although this ecologically important region has been poorly explored in terms of soil microflora . the ecology and functional role of most of the microbes are unknown due to their cultural constrains . a recent advance in molecular microbial ecology has provided means to identify microbial life in many ecosystems without the need to culture the microorganisms through a metagenomic approach , . next - generation sequencing technology has been successfully applied to study bacterial diversity in different environments such as bat guano , hot spring , lake , cave sediments , etc . n , 88 36 44.860 e ) in a sealed sterile container and the metagenomic dna was extracted separately using mp - biomedical soil kit and finally mixed to prepare a composite sample . v4 region of bacterial 16s rrna gene was amplified by pcr according to de mandal et al .. sequencing was performed on illumina miseq platform and the analysis was carried out by qiime data analysis package , . metagenome consisted of 151.81 mb data consisting of 302,416 reads with a g + c content of 56.48% . more than 85% of the sequence had a phred score > = q30 and individual sequence length was 251 bp ( supplementary table 1 ) . a total of 29 phyla were detected in our analysis and the dominant phyla were acidobacteria ( 39.45% ) followed by proteobacteria ( 26.95% ) , planctomycetes ( 7.81% ) , actinobacteria ( 7.18% ) , bacteroidetes ( 6.65% ) , chloroflexi ( 4.11% ) and nitrospirae ( 3.33% ) . however the analysis identified 100 bacterial orders dominated by iii115 ( 23.94% ) , rhizobiales ( 13.97% ) , actinomycetales ( 5.83% ) , solibacterales ( 5.06% ) , burkholderiales ( 4.83% ) , saprospirales ( 4.61% ) , nitrospirales ( 3.33% ) , gemmatales ( 3.40% ) , ellin6513 ( 2.94% ) , thermogemmatisporales ( 2.74% ) and acidobacteriales ( 2.55% ) . a total of 138 genus were detected and the most dominating among them were da101 ( 7.02% ) , followed by gemmata ( 1.03% ) , candidatus xiphinematobacter ( 1.02% ) , and rhodoplanes ( 0.92% ) . however , 84.44% reads were not identified at the genus level which suggested that the uniqueness and unidentified bacterial community structure might lead to reveal novel bacterial populations with some unique properties ( supplementary fig . our study , which is the first to study bacterial communities using high - throughput methods in murlen national forest soil , a pristine reserve forest , revealed the presence of diverse bacterial population . this will be helpful in cataloging and describing the bacteria diversity of the forests of mizoram that needs to be conserved and simultaneously could be the habitat for large number of economically important microbes . 1.bacterial community structure from phylum to species level of murlen national park metagenome can be visualized in this file using krona visualization tool.supplementary table 1 . .bacterial community structure from phylum to species level of murlen national park metagenome can be visualized in this file using krona visualization tool . .

paired end illumina mi - seq sequencing of 16s rrna gene amplicon was carried out to study the bacterial community in the soil of murlen national park located in indo - burman biodiversity hotspot region . metagenome consisted of 302,416 reads with 151.81 mb data and g + c content of 56.48% . more than 85% sequence was having a phred score > = q30 and individual sequence length was 251 bp . metagenome sequence data are available at ncbi under the bioproject database with accession no . srp057136 . community metagenomics revealed a total of 1802 species belonging to 29 different phyla dominated by acidobacteria ( 39.45% ) , proteobacteria ( 26.95% ) and planctomycetes ( 7.81% ) . our data detected a wide group of bacterial community which will be useful in further isolating and characterizing the economic importance of bacteria from this region .

we report on a 28-year - old woman , who presented two months postpartum after delivering twins with complaints of transient ischemic attack ( tia ) , dyspnea and chest pain . physical examination demonstrated jugular venous distention ( jvd ) and s3 gallop on cardiac auscultation along with minimal rales and pedal edema . her electrocardiogram ( ecg ) showed sinus tachycardia with lateral t wave inversion ( fig . laboratory work up revealed an elevation in her cardiac biomarkers with a peak troponin - i level of 10.2 ng / ml . the echocardiogram showed moderate left ventricular ( lv ) dilatation with severely reduced lv systolic function and left ventricular ejection fraction ( lvef ) < 15% associated with a 2.1 cm apical thrombus ( fig . 2 ) . given the chest pain , elevated cardiac biomarkers and ecg changes suggestive of ischemia , a coronary angiography was performed which revealed two filling defects in the distal segment of the second obtuse marginal artery with a hazy appearance consistent with thrombi ( fig . aspiration thrombectomy was performed with multiple passes at the site of thrombi and fresh clot was retrieved ( fig . post - procedure , the patient did well ; her troponin - i levels down - trended and her symptoms improved . she was started on oral anticoagulation for treatment for left ventricular apical thrombus and she was strongly counseled on avoidance of future pregnancies and tubal ligation . she was discharged on oral anticoagulation , and guideline directed heart failure medical therapy . two sequential thrombi in the distal segment of the obtuse marginal 2 ( om2 ) . repeat images demonstrating resolution of the stenosis in the obtuse marginal 2 ( om2 ) . peripartum cardiomyopathy ( ppcm ) is characterized by the development of heart failure during the last month of pregnancy or during the first five months of the post - partum period in the absence of any other identifiable causes of heart failure ( 1 , 2 ) . several risk factors have been identified with ppcm including ethnicity , age , pregnancy - induced hypertension or pre - eclampsia , multiparity , multiple gestations , obesity and chronic use of tocolytics ( 2 ) . in the case described , multiple gestations , pregnancy with twins , and african descent were identified as significant clinical risk factors . ppcm is known to increase the risk of thrombus formation and arterial emboli ( 3 , 4 ) . the risk of acute myocardial infarction is approximately three times higher in pregnant women compared to non - pregnant women of the same age ( 5 - 6 - 7 - 8 ) . in our case , the inherent hypercoaguable state that exists in pregnancy along with poor lv systolic function and resulting stasis of blood flow in dilated heart , likely provided an environment for the development of an intraventricular thrombus ( 3 , 4 ) . the findings of two intracoronary thrombi in the setting of otherwise normal coronary arteries , which were free of atherosclerotic disease , suggests embolism from lv mural thrombus as the primary mechanism of her coronary thrombi and myocardial infarction . upon review of available literature there are only two reported cases of embolic myocardial infarction in the setting of ppcm and an associated lv thrombus ( 9 , 10 ) . our case is unique in the aspect that catheter - based aspiration thrombectomy was performed safely for reperfusion therapy and was successful with the resolution of thrombus as documented angiographically ( fig . , we propose that it be considered as a treatment modality in future similar cases in the absence of contraindications .

acute coronary syndrome ( acs ) due to embolic phenomenon in the setting of peripartum cardiomyopathy ( ppcm ) and left ventricular mural thrombus is a rare occurrence . there have been two known cases described in medical literature . we present a unique case in which catheter - based aspiration thrombectomy was used to successfully treat a patient with acs due to coronary emboli in the setting of ppcmand left ventricular mural thrombus . we believe this to be the first report of the use of aspiration thrombectomy in such a clinical case .

a 13-year - old premenarchal girl presented with a 2 days history of gradually worsening right iliac fossa ( rif ) pain and vomiting . she had a background of gastroschisis which was corrected at birth with no further complications . on examination her abdomen was soft with localized tenderness and voluntary guarding of the rif . ultrasound scan of the abdomen revealed an enlarged and echogenic mass in the pelvis which was difficult to characterize sonographically ( fig.1 ) . the right ovary was necrotic and enlarged measuring 70 30 30 mm in size ( figs.2 and 3 ) . histopathology revealed no underlying ovarian lesion ; the ovary was engorged with massive edema and hemorrhage . findings at exploratory laparoscopy ( a ) right adnexal torsion ( arrow ) with moderate amounts of bloody fluid in the pelvis and ( b ) enlarged right ovary and distal fallopian tube pediatric ovarian torsion is an infrequent diagnosis and it often mimics acute appendicitis 1 . in children , it is most common around menarche 2 . if left untreated , ovarian torsion may result in tissue necrosis , loss of ovarian function , and may eventually cause infection and peritonitis 1,3 . the true incidence of pediatric ovarian torsion is unknown and most cases are due to underlying ovarian pathology 2 . emergency surgical exploration to salvage gynecological function is crucial in suspected ovarian torsion , however , children usually present too late after the onset of symptoms 3 .

key clinical messagepediatric ovarian torsion is an infrequent diagnosis and it often mimics acute appendicitis . most cases are due to underlying ovarian pathology and if left untreated , ovarian torsion may eventually cause peritonitis . emergency exploratory laparoscopy represents a valuable diagnostic and therapeutic tool in suspected ovarian torsion .

late adolescents phase is the most active periods of life because of double demand of activity and growth , as a result nutritional needs are extremely important at this phase of time . although snacking is a well - established eating pattern among adolescents and can be a source of needed nutrients and calories , it is important that they dont become a substitute for regular meal as it may further lead to cause the development of serious syndrome . night eating syndrome ( nes ) is one such very specific disorder where the affected individuals wake up several times during the night and is unable to fall back asleep unless they eat something . individuals with the disorder consume one third or more of their daily calories after their evening meal , sometimes rising from their beds once or twice a night to snack . when sleeping and eating behaviors are simultaneously affected , often there is spectrum of disease states that may result and often lead to nes . these unhealthy eating behaviors , faulty food habits such as omitting main meal , and frequent snacking prevalent among adolescents , are also the cause of faulty food habits causing nes . keeping the above in mind , the present study was undertaken to analyze the pattern of nes among the late adolescents . a sample of 380 adolescents ( 188 male and 192 female ) with in the age range of 18 - 22 years were randomly selected from the local five co - educational colleges of chandigarh and hostlers of the same college were also included in the study . questions regarding the respondents sleeping habit , reasons and duration of night snacking were asked from the studied respondents . mean , frequency , percentage and chi square test was used further for analysis of the data . looking at the nes perspective of the studied respondents , results indicated that out of total 380 adolescents , inadequate sleep was seen among more than half of the adolescents i.e. 55.8% , complaining with few brief awakenings at night . highly significant results were seen when chi square value was applied between hostlers and day scholars ( =79.14 and p value < 0.001 ) . these specific respondents also complained of nigh snacking and almost 52.3% respondents snacked at night , out of which the percentage of hostlers were ( 76.3% ) more than day scholars . further it was also found that 30.7% respondents snacked almost up to 50% their total calories after evening meal while 1% of studied respondents snacked up to 75% of total calories after dinner meeting up the criteria of nes . the results thus depicted that hostlers were highly involved in eating snacks after dinner than day scholars due to the reason that , hostlers have more fluctuating eating pattern as there is no one to take care of them , moreover late night sleeping and getting up late is also the reason behind late night snacking among adolescents . as seen in the present study , hostlers group were more seen to have night eating behaviors . as , the present study reveals , night snacking syndrome are associated with a number of harmful behaviors , physical and psychological consequences , including poor dietary quality and also skipping main meal and nibbling at night have led to significant changes seen in the eating pattern and life style of late adolescents , further under going night time snacking . as shown in the present study , these fluctuating and changed patterns together could force the youngsters at risk of various chronic illnesses further disrupting their health status and eating attitude , causing clinical eating disorders . so awareness regarding healthy eating is what needed to secure the health of youth and further improving the future generation of the country . moreover , snacks and fast food items should be used as food items of leisure and should not take over as items of regular meals . thus by educating youth we can build up strong nation , as youth are the strong foundation of the country and so it is important to identify strategies for the prevention of nes .

with the increase in the trend of social networking , celebrations , over a couple of decades weather in the hostel or at home . snacking has become an important aspect of activity . today teen prefer snacks more than a proper meal . skipping of meal and nibbling in between meal is a common practice . the main meals ( breakfast , lunch and dinner ) are missed and total proportions of calories are consumed from the snacks eaten . hence , this disordered eating behavior when continued may further lead to development of serious syndrome i.e. , night eating syndrome . a purposive random sample comprising 188 males and 192 females ( n=380 ) , adolescents ( 18 - 22 years ) were selected including hostlers and day scholars . the subjects were administered with self - organized questionnaire so to analyze the pattern of nes among them . out of total 380 respondents , the numbers of hostlers were 211 and day scholars 169 , while boys were 188 and girls were 192 in number . results indicated that nearly half the percentage of adolescents snacked at night , out of which very few respondents met the criteria of nes , in which the number of hostlers were quite more than the day scholars , i.e.,76.3% .

we report a case of acute adrenal insufficiency ( aai ) in a patient with antiphospholipid syndrome ( aps ) . a 44-year - old female patient presented to us with acute abdominal pain associated with recurrent vomiting and giddiness . on examination , her blood pressure was 80/50 mm hg . etiological work - up revealed prolonged activated thromboplastin time , which did nt correct with normal plasma , her anti - cardiolipin antibody and lupus anticoagulant were also positive . she was diagnosed to have aps with adrenal insufficiency and she was started on intravenous steroids and heparin infusion . aai due to the aps can present with acute abdominal pain followed by hypotension . a high index of suspicion is needed to make the correct diagnosis and to initiate appropriate treatment . the more common clinical features of aps include recurrent pregnancy loss and unexplained vascular thrombosis . to fulfill the diagnosis of aps , patients must have at least one clinical event ( vascular thrombosis / pregnancy complication ) and one laboratory criterion ( anti - cardiolipin immunoglobulin g ( igg ) or immunoglobulin m ( igm ) antibodies / lupus anticoagulant of the igg or igm class detected on two or more occasions ) . lupus anticoagulant antibodies are more specific and the anti - cardiolipin antibodies are more sensitive for diagnosis of aps . a 44-year - old female patient presented to us with acute abdominal pain associated with giddiness and vomiting . her initial serum cortisol was 20 g / dl ( normal 5 - 25 g / dl ) [ table 1 ] . repeat serum cortisol done 24 h later was 1.3 g / dl and concurrent plasma adrenocorticotropin hormone was 698 pg / ml ( normal 45 pg / ml ) . these feature confirmed the diagnosis of evolving acute adrenal insufficiency ( aai ) . computed tomography ( ct ) scan of the abdomen revealed , bilateral enlarged adrenal glands , the right adrenal showed good enhancement with contrast , whereas the left adrenal showed no contrast enhancement suggesting acute ischemia [ figure 1 ] . ct angiography repeated at 48 h showed that the previously enhancing right adrenal also failed to enhance with intravenous ( iv ) contrast . contrast computed tomography scan showed enlarged hypodense left adrenal gland with normally enhancing right adrenal gland computed tomography angiogram of the abdomen with contrast showed bilateral hypodense adrenal enlargement suggestive of adrenal infarct in view of the acute onset of adrenal insufficiency in an otherwise healthy female we initially considered the possibility of underlying vasculitis . thrombotic work - up revealed prolonged activated thromboplastin time , which did nt correct with the addition of normal plasma , indicating the presence of a circulating anticoagulant . her prothrombin time was normal , lupus anticoagulant was positive and anti - cardiolipin antibody level was mildly elevated , 30 gpl units ( normal < 25 gpl units ) . based on the above clinical and laboratory findings , this patient was diagnosed to have aps with bilateral infarction of the adrenal glands leading to aai . she was subsequently started on the oral warfarin and the dose was titrated to maintain the international normalized ratio between 2.5 and 3.0 . at discharge , the adrenal gland has multiple arterial supplies , but drains through a single vein making it susceptible for venous infarction . primary aps presenting as aai is indeed very rare and one needs to be alert to this possibility in a young lady presenting with abdominal pain and hemodynamic instability . our patient 's ct scan showed evolving venous infarction initially involving the left and later also involving the right adrenal gland . previously , published literature reveal reports of primary aps causing adrenal insufficiency at different stages of the disease . adrenal failure can be life - threatening in about 10 - 26% of these patients and can be the first presentation of underlying aps . the exact pathophysiological mechanism is not completely understood , but the hypercoagulable state in such patients may lead to venous infarction and destruction of the adrenals leading on to addison 's disease . it can be the first presentation of aps or it can happen later in a previously diagnosed case of aps . in all cases , a high index of suspicion is needed to make the correct diagnosis and to initiate appropriate treatment .

introduction : we report a case of acute adrenal insufficiency ( aai ) in a patient with antiphospholipid syndrome ( aps).case report : a 44-year - old female patient presented to us with acute abdominal pain associated with recurrent vomiting and giddiness . on examination , her blood pressure was 80/50 mm hg . systemic examination was normal . further evaluation revealed hypocortisolemia with elevated plasma adrenocorticotropin hormone indicative of primary adrenal insufficiency . her abdominal computed tomography scan showed features of evolving bilateral adrenal infarction . etiological work - up revealed prolonged activated thromboplastin time , which did nt correct with normal plasma , her anti - cardiolipin antibody and lupus anticoagulant were also positive . she was diagnosed to have aps with adrenal insufficiency and she was started on intravenous steroids and heparin infusion.conclusion:aai due to the aps can present with acute abdominal pain followed by hypotension . a high index of suspicion is needed to make the correct diagnosis and to initiate appropriate treatment .

natural killer / t - cell ( nk / t - cell ) lymphoma is a rare fast - growing lymphoma arising from the lining of the nose or upper airway . a 26-year - old young female presented with nasal obstruction , bloody discharge and swelling of the nasal skin and right lower eyelid . biopsy from the soft tissue seen in the nasal cavity revealed nk / t - cell lymphoma ( nasal type ) . patient was referred to a whole body 18 fluoride ( 18f)-fluoro - deoxy glucose ( fdg ) positron emission tomography - computed tomography ( pet - ct ) . 18f - fdg pet - ct performed showed intense fdg uptake in heterogeneously enhancing soft tissue in the right nasal cavity with extension into the skin of the cheek and right lower eyelid [ figure 1 : a - maximum - intensity projection , b - axial ct , c - fused pet - ct ] . intense fdg uptake was also noted in enhancing soft tissue bilateral adrenal masses [ d - axial ct ; e - fused pet - ct ] indicating disease involvement . a diagnosis of bilateral adrenal involvement by nk / t - cell lymphoma was made . 18 fluoride - fluoro - deoxy glucose positron emission tomography - computed tomography ( 18f - fdg pet - ct ) performed showed intense fdg uptake in heterogeneously enhancing soft tissue in the right nasal cavity with extension into the skin of the cheek and right lower eye lid ( a - maximum - intensity projection , b - axial ct , c - fused pet - ct ) . intense fdg uptake was also noted in enhancing soft tissue bilateral adrenal masses ( d - axial ct ; e - fused pet - ct ) indicating disease involvement morphologically , mature nk cells are large granular lymphoid cells , they are negative for surface cd3 but characteristically express cytoplasmic cd3 epsilon ( ) , cd56 , and cytotoxic molecules . there are two main categories of nk cell - derived neoplasms , namely , aggressive nk cell leukemia and extranodal nk / t - cell lymphoma , nasal type . nk / t - cell lymphoma of the nasal type accounts for 710% of all non - hodgkin lymphomas in asia and latin america , but only 1% of that amongst caucasians . the leukemic counterpart of nk / t - cell lymphoma , aggressive nk - cell leukemia is an uncommon disease . clinically , it is useful to classify nk / t - cell malignancies into two categories , namely , nasal nk - cell lymphomas , and nonnasal or extranasal nk / t - cell lymphomas , depending on the site of the lesions . nasal nk / t - cell lymphomas occur in the nose and the upper aerodigestive tract . bone marrow involvement occurs in < 10% of patients , and distant metastasis is unusual . extranasal or nonnasal nk / t - cell lymphomas occur outside the typical nasal region , and the common primary sites involved include the skin , gastrointestinal tract , salivary glands , spleen , and testis . unusual sites of involvement such as the muscle , the adrenal gland , and the female genital tract ( ovaries and uterus ) have been reported . occult nasal involvement should be ruled out with panendoscopy and multiple random biopsies in patients presenting with extranasal nk / t - cell lymphoma . disseminated nodal nhl can involve the adrenals in up to 25% of the cases . however , primary adrenal lymphoma is extremely rare with majority of the cases being b cell type . natural killer - cell lymphomas are fdg - avid and pet - ct offers more accurate definition of the extent of involvement by distinguishing lymphoma involvement from inflammatory masses . 18-fdg pet - ct is increasingly used both at diagnosis and for monitoring of response to therapy . pet changes the staging in up to 21% of the patients and alters the planned management strategy in 44% of the patients . pet parameters such as total lesion glycolysis , in addition to the international prognostic index , is useful in predicting prognosis of these patients . for the stage , i / ii nasal nk / t - cell lymphomas , radiotherapy is an important modality of treatment . recent evidence indicates radiation therapy alone is insufficient , and chemotherapy is also needed in these patients . nonnasal nk cell lymphomas tend to have advanced or disseminated disease at presentation , and the role of radiotherapy is often limited . for the stage iii / iv nasal nk / t - cell lymphomas , extranasal nk / t - cell lymphomas and aggressive nk - cell lymphoma / leukemia , chemotherapy is the primary treatment . l - asparaginase - containing regimens have shown promise as the tumor cells lack l - asparagine synthetase and are susceptible to l - asparaginase , which depletes l - asparagines in nk lymphoma cells .

natural killer / t - cell ( nk / t - cell ) lymphoma is a rare condition , which presents as necrotic , granulomatous lesions involving the nose and the upper respiratory tract . the condition usually has an aggressive clinical course . the predominant subtype of nk / t - cell lymphoma noted in asian population is the nasal type . we describe a case of biopsy - proven nk / t - cell lymphoma with bilateral adrenal involvement . adrenal involvement by lymphoma is usually of b - cell type and occurs in disseminated disease and often unilateral . bilateral adrenal involvement by t - cell lymphoma is extremely rare .

common sites of breast cancer metastases include regional lymph nodes , bones , liver , lungs and brain . metastatic breast and lung cancers are the most common non - traumatic causes of brachial plexopathy , after radiation induced fibrosis . because one of the major lymphatic drainage of the breast is through the apex of the axilla , it is not uncommon for metastatic breast cancer to invade the brachial plexus . a 56-year - old woman diagnosed with infiltrating ductal carcinoma of the left breast had undergone left modified radical mastectomy followed by radiotherapy and adjuvant chemotherapy . she presented to her oncologist with left para sternal chest wall recurrence with restriction of movement of the left upper limb . the patient was referred for 18f - fdg pet / ct to evaluate the extent of recurrent / metastatic disease . whole - body contrast enhanced pet / ct was acquired 1 hour following the intravenous injection of 296 mbq of 18f - fdg on pet ct discovery 600 , with 16 slice ct scanner . the scan showed ill - defined heterogeneously enhancing hypermetabolic soft tissue along left brachial plexus [ figure 1 ] with intra - spinal extension through neural foramina at c5-c6 and c6-c7 levels on the left side [ figure 2 ] along with few ill -defined intra - spinal enhancing lesions at d4-d5 , d7-d8 and d8-d9 levels [ figure 3 ] and heterogeneously enhancing extra - axial lesion in left c - p angle region [ figure 4 ] . the scan also showed heterogeneously enhancing ill - defined soft tissue lesion in subcutaneous plane in left para - sternal region in anterior chest wall at 1st intercostal space [ figure 5 ] along with soft tissue in antero - superior mediastinum extending along left proximal common carotid artery [ figure 6 ] . maximum intensity projection ( mip ) and coronal 18f - fdg pet - ct images show linear extension of tracer activity from superomedial aspect ( supra / infraclavicular ) to lateral aspect of the left axilla . ill - defined heterogeneously enhancing hypermetabolic soft tissue along left brachial plexus with intra - spinal extension through neural foramina at c5-c6 and c6-c7 levels on left side . fdg avid heterogeneously enhancing extra - axial lesion in left c - p angle region . fdg avid heterogeneously enhancing ill - defined soft tissue lesion in subcutaneous plane in left para - sternal region in anterior chest wall at 1st intercostal space . fdg avid soft tissue in antero - superior mediastinum extending along left proximal common carotid artery . the two major causes of brachial plexopathy in breast cancer patients are metastatic invasion of and radiation damage to the plexus . it is difficult to image because of complicated anatomy of the plexus and its immediate anatomical relationship to blood and lymphatic vessels . computerized tomography scanning has been used to assess the brachial plexus but it has several limitations . the neurovascular bundle of the axillary artery and brachial plexus may appear as a single structure when the administration of contrast medium is poorly timed . in a series of 46 patients with proven metastatic plexopathy a ahmad et al also had either normal ct or the appearance of minimal thickening of the brachial plexus in 6 cases out of the total 11 cases in their study . its superiority to ct scanning relates to its ability to differentiate more accurately nerves from surrounding vessels and soft tissues . review of the literature suggests that there is no doubt that mri can delineate both the normal and abnormal anatomy of the brachial plexus in more detail than ct scan . some studies have shown that tumor recurrence has a higher signal intensity than radiation fibrosis on t2-weighted images , although other authors have reported increased t2 signal in both metastatic and radiation plexopathy patients . fdg - pet is a useful imaging technique to study the brachial plexus in breast cancer patients and that it may be useful to monitor treatment efficacy as well . the current data is insufficient to suggest unequivocally that fdg - pet may be useful in distinguishing neoplastic from radiation plexopathy . maximum intensity projection ( mip ) and coronal 18f - fdg pet / ct images show linear extension of tracer activity from superomedial aspect ( supra / infraclavicular ) to lateral aspect of the axilla closely related to the subclavian / axillary vessels . dual time point imaging may have some role in this scenario and further work in this area may be proved useful .

we report a case of a 56-year - old woman diagnosed with infiltrating ductal carcinoma of the left breast , who had undergone left modified radical mastectomy followed by radiotherapy and adjuvant chemotherapy . fdg pet - ct showed metastatic brachial plexopathy with intra - spinal and extra - axial brain metastasis . metastatic brachial plexopathy along with brain and spinal metastasis is a rare condition with very less incidence . the scan also showed left para - sternal anterior chest wall recurrence with antero - superior mediastinal metastasis . 18fdg - pet scanning is a useful tool in evaluation of patients with suspected metastatic plexopathy . it may also be useful in distinguishing between radiation - induced and metastatic plexopathy . typical pattern of fdg uptake and dual time point imaging may increase specificity and require further evaluation .

a 25-year - old systemically healthy male patient presented with complaints of severe photophobia , redness , discharge , pain and severe swelling of the lids in the left eye , since two days . past history was significant for a boil on the lower eyelid , two days ago . on examination , the best - corrected visual acuity was 20/20 and 20/30 , in the right and left eyes respectively . the left eye showed severe lid edema with scales on the skin and associated kerato - conjunctivitis [ fig . photographic documentation of the anterior segment condition was impossible because of the severe photophobia . a conjunctival swab and a periorbital skin swab were sent for culture and sensitivity . the patient was seen by our infectious diseases expert and started on intravenous co - amoxiclav ( augmentin , glaxosmithkline ) 1 g twice daily , intravenous ceftriaxone ( ceftriaxone sodium , sandoz , novartis ) 1 g twice daily and oral metronidazole ( flagyl , searle ) 500 mg three times daily , pending sensitivity reports . topical loteprednol etabonate ( 0.5% ) ( alrex eye drops , bausch and lomb incorporated ) every three hourly and ciprofloxacin ( 0.3% ) ( ciplox eye drops , cipla ) six times a day were started , in the left eye . on follow - up two days later , the skin scabs had fallen off , revealing violaceous , sub - epidermal necrosis . the conjunctival inflammation had reduced and the corneal marginal infiltrates had almost disappeared [ fig . the culture plates for corneal infiltrates showed negative growth and were discarded after three weeks . five days later , the skin lesions had healed and the conjunctivitis had resolved . intravenous antibiotics were stopped and the patient was started on oral co - amoxiclav ( augmentin , glaxosmithkline ) , 625 mg thrice a day , for a week . on final follow - up a month later , periocular skin discoloration was the only sequalae noted [ fig . 2 ] . infections in the periocular region occur post surgical procedures , post trauma , furunculosis or even without any antecedent cause.2 ideally , a combination of intensive parenteral antimicrobial therapy and prompt surgical debridement of necrotic tissue should be done . intravenous pooled immunoglobulin and heparinization may also have beneficial roles by neutralizing super - antigen activity and aiding antibiotic perfusion.4 necrotizing fasciitis is a clinical diagnosis . necrotizing fasciitis limited to the eyelids looks and behaves differently from nf affecting other parts of the body , due to the excellent blood supply in the eyelid area.3 mild cases , especially those restricted to the eyelids alone may respond to medical therapy . the increased blood supply allows for delayed debridement , because the local vasculature allows for better access of the systemic antibiotics to the infected area . the marginal zone of tissue surrounding the infected area has better local blood supply and hence a higher chance of avoiding necrosis.3 we report the case of a 25-year - old male patient who presented with periocular nf associated with kerato - conjunctivitis . the paucity of literature regarding this entity , in association with staphylococcus - induced periocular nf probably stems from an under - reporting bias . these infiltrates are usually the result of an immunological reaction with staphylococcal antigens but in cases with severe infection as in our patient , the infiltrates need to be cultured for an infectious etiology . the patient responded to conservative medical management with systemic antibiotics , topical antibiotics and topical steroids . we report this case to highlight the successful conservative management of periocular nf and the hitherto unreported anterior segment involvement .

we report a 25-year - old systemically healthy male who presented with periocular necrotizing fasciitis ( nf ) in the left eyelid . this was associated with the presence of immunologically mediated marginal kerato - conjunctivitis , in the same eye . this potentially dangerous lid infection and the associated ocular surface infection resolved successfully , with medical management . we report this case to highlight the successful conservative management of periocular nf and the hitherto unreported anterior segment involvement .

the hernia sac passes through the obturator foramen , following the path of the obturator nerves and muscles . here we present a typical case of obturator hernia which was diagnosed by spiral ct preoperatively and the emergency operation was performed successfully . a 78-year - old woman was sent to our emergency department because of recurrent abdominal pain and constipation for 10 days . the colicky pain was getting worse in recent nearly six days , accompanied with nausea and vomiting . she also complained of intermittent right hip pain with radiation to the medial aspect of the thigh for several months , which worsened with extension , abduction , or internal rotation of right leg . the body weight was 38 kg . physical examination revealed a distended abdomen without tenderness or muscle guarding . the abdominal plain film revealed small intestine obstruction . enhanced ct scan demonstrated obvious intestinal obstruction with a low density mass in the right obturator canal area ( figure 1 ) the diagnosis of right obturaor hernia was confirmed and emergency laparotomy was performed . during the operation , a 10 cm loop of small intestine was revealed herniated into the right obturator canal ( figure 2 ) . the incidence is nearly 1% of all hernias 2 . with the nickname little old lady 's hernia , it usually occurs in multiparous and elderly emaciated women due to a wider pelvis and enlarged obturator canal . the patient had a positive howship - romberg sign , which was caused by the intermittent irritation of the obturator nerve . it was reported that 15~50% patients of obturator hernia may have positive howship - romberg sign 1 . in her early course the loss of the adductor reflex , named as hannington - kiff sign , was observed on the affected side , while the patellar tendon reflex was intact on the same side 3 . various imaging examinations have been applied to establish the diagnosis , including ultrasonography , herniography , ct scan and so on . among them , ct scan has superior sensitivity and accuracy 4 . in our case , preoperative diagnosis of obturator hernia was confirmed by spiral ct scan and emergent operation was performed . chang et al concluded that the duration of symptoms was one of the major factors affecting the rate of bowel resection . there are a variety of operative approaches including inguinal , retropubic and transperitoneal approach 6,7 . laparotomy via low midline incision was applied in this case because it had advantages of better exposure and facilitation of bowel resection when necessary . the advantages of laparoscopic surgery include less postoperative pain , shorter hospital stay and lower complications . however , it is usually reserved for the nonstrangulated hernia because of more challenging techniques and longer learning curve . methods of repair include simple suture closure , closure of the obturator with adjacent tissue , and mesh replacement during laparotomy 9 . many authors preferred a simple closure of the hernial defect with one or more interrupted sutures , in case of bowel resection 6 , 8 . in this case we did the simple suture and outcome was satisfying . in conclusion , it should be kept in mind that obturator hernia is a rare but significant cause of intestinal obstruction especially in emaciated elderly women .

obturator hernia is a rare pelvic hernia with incidence of 1% . it 's a significant cause of intestinal obstruction in emaciated elderly women . delayed diagnosis and surgical intervention contributed to its relatively high morbidity and mortality . we present a typical case of obturator hernia with positive howship - romberg sign and hannington - kiff sign . the diagnosis was confirmed by spiral ct preoperatively . during the emergency laparotomy , the incarcerated intestine was reduced and removed . obturator foramen was repaired by simple suture . the patient recovered uneventfully and no recurrence occurred during the follow - up . the obturator hernia should be included in the differential diagnosis if clinically suspected . early diagnosis and prompt surgical treatment are essential to reduce the morbidity and mortality associated with obturator hernia .

imaging findings , even with computed tomography ( ct ) , of such tumors are rarely described in literature . f-18 fluorodeoxy glucose positron emission tomography / computed tomography ( f-18 fdg pet / ct ) is emerging as a useful modality in assessment of genito - urinary malignancies . f-18 fdg pet / ct findings in penile leimyosarcoma have not been reported in literature . we present here a case of penile leiomyosarcoma with emphasis on findings on f-18 fdg pet / ct with histopathology correlation . a 47-year - old male presented with a palpable penile mass , with rapid growth over a period of 1 month . he was examined at an outside center and an incision biopsy of the tumor was done that revealed penile leiomyosarcoma . he was later referred to our institute , a tertiary care center , for further management . on examination of the patient at our institute , the patient was found to have 2 2 cm a typical nodular lesion in the proximal penile shaft . review of the histopathology examination after biopsy revealed tumor composed of spindle cells with hyperchromatic nuclei , inconspicuous nucleoli , and frequent mitoses . tumor cells also stained positive for smooth muscle antigen ( sma ) consistent with diagnosis of leiomyosarcoma of penis [ figures 1c and 1d ] . as a part of staging , the patient was subjected to f-18 fdg pet / ct examination 2 months after the biopsy ( this delay was due to late reporting of the patient to our institute from the peripheral center ) . the ct scan revealed moderate fdg uptake in the periphery of an ill - defined heterogeneously enhancing soft tissue lesion 2.9 2.2 cm in size involving corpora cavernosa on the left side of the distal penile shaft . this mass showed slightly thick , peripheral rim enhancement on the contrast - enhanced ct images corresponding to an area of increased f-18 fdg uptake , with an internal homogeneous region of low density , compared to the adjacent normal shaft of the penis , representing residual disease [ figures 1a and 1b ] . taking into consideration possible microscopic lymph node metastases total penectomy and bilateral inguinal lymphadenectomy was planned and the patient was counseled . however , the patient refused to undergo lymphadenectomy and only total penectomy was done . on follow - up after 8 months , the patient was found to be disease free . ( a ) contrast - enhanced axial ct through the penis demonstrates a low attenuating lesion in the corpora of the penis with peripheral enhancement . ( b ) f18-fdg pet image fused with corresponding ct demonstrates increased fdg uptake in the periphery of an ill - defined lesion within the corpora of the penis . ( c ) histopathological examination shows tumor composed of spindle cells with hyperchromatic nuclei , inconspicuous nucleoli with frequent mitoses ( d ) histopathological examination shows positivity for smooth muscle antigen penile cancer is a rare neoplasm and accounts for approximately 0.4% of all male malignancies . the most common primary malignant neoplasm of the penis is squamous cell carcinoma , constituting more than 95% of cases , followed by metastatic neoplasms of the prostate , bladder , rectum , kidney , and testis , as well as those spreading by direct extension from the adjacent structures . it accounts for 1020 % of all malignancies in males in asia , africa , south america , and it has a prevalence of only 1% in western countries . predisposing factors are phimosis , cigarette smoking , and human papilloma virus ( hpv ) infection . other tumors of the genitourinary tract include sarcoma , melanoma , basal cell carcinoma , and lymphoma . sarcomas are uncommon penile neoplasms , which include epithelioid sarcoma , kaposi sarcoma , leiomyosarcoma , and rhabdomyosarcoma . in general , very little literature exists that discusses the management of penile leimyosarcoma , due to the rarity of disease . role of routine lymphadenectomy is controversial as few authors have suggested that regional lymph node dissection is usually not indicated , since nodal metastases are uncommon . in our case lymphadenectomy was planned ; however , patient refused to undergo lymphadenectomy and was managed only with total penectomy . the ct findings of penile leiomyosarcoma are also rarely reported in literature in which the tumor may appear as a mass showing a relatively thick peripheral rim enhancement with internal regions of homogeneous low density , compared to the adjacent normal shaft of the penis , ( similar to findings in our case ) or as a soft tissue mass . fdg uptake has been described in penile squamous cell carcinomas and f-18 fdg pet / ct has been shown to be useful in detection of lymph nodal and distant metastases in penile carcinoma . f-18 fdg uptake has also been described in leiomyosarcomas and tumoral f-18 fdg uptake correlates well with the grade of the tumor in case of leiomyosarcomas . f-18 fdg pet / ct plays an important role in diagnosis , staging , treatment response monitoring , and follow - up in patients with sarcomas . this is the first case demonstrating f-18 fdg pet / ct findings in a case of penile leimyosarcoma .

penile cancer is a rare entity accounting for only 0.4% all male malignancies . penile leiomyosarcomas are even rarer with only around 35 cases reported in literature . we report a rare case of penile leiomyosarcoma illustrating f-18 fluorodeoxy glucose ( fdg ) positron emission tomography / computed tomography ( pet / ct ) features and histopathology correlation .

a patient with decreased vision underwent complete ophthalmologic examination , ultrasound biomicroscopy , fluorescein and indocyanine green ( icg ) angiography . the patient presented a nodule of the iris of the os and of the optic nerves of both eyes . fluorescein and icg angiography are the only objective exams to demonstrate the extent of ocular involvement in a patient with sarcoidosis . a 19-year - old black man noticed decreased vision in his os for approximately 2 months . at presentation best - corrected visual acuity measured with a standard snellen chart was 0.8 os and 1.0 od . slit - lamp examination revealed the presence of a granulomatous nodule of the iris of the os ( figure 1a ) , also detected by ultrasound biomicroscopy ( ubm ) ( figure 1b ) . fundus examination showed a voluminous granuloma of the optic nerve of os ( figure 2 ) and a granulomatous lesion of the od , more visible on fluorescein angiography ( figure 3a , b ) , which shows optic disc leakage of os and hyperfluorescence of od . multifocal choroidal lesions located in the posterior pole of the os only visible with indocyanine green ( icg ) were demonstrated ( figure 3c , d ) . systemic medical and laboratory work - up was performed in order to diagnose the granulomatous disease . chest computed tomography showed hilar adenopathy . a tissue biopsy obtained from the nose proved the presence of noncaseating granuloma . sarcoidosis is a chronic multisystemic granulomatous disorder thought to result from an exaggerated cellular immune response to a variety of self antigens or nonself antigens ( newman et al 1997 ) . the disease affects predominantly the lungs and thoracic lymph nodes , skin and eyes ( margolis 2007 ; chan et al 2007 ) . in this case report however , only the icg angiography was capable of demonstrating the widespread extent of choroidal involvement .

purposeto report a case with anterior and posterior nodules associated with systemic sarcoidosis.methodsa patient with decreased vision underwent complete ophthalmologic examination , ultrasound biomicroscopy , fluorescein and indocyanine green ( icg ) angiography.resultsthe patient presented a nodule of the iris of the os and of the optic nerves of both eyes . chest computed tomography and tissue biopsy established the diagnosis.conclusionsfluorescein and icg angiography are the only objective exams to demonstrate the extent of ocular involvement in a patient with sarcoidosis .

drug hypersensitivity syndrome ( dhs ) , also known as drug rash with eosinophilia and systemic symptoms ( dress ) , is a severe drug reaction . the syndrome can also be caused by other drugs , such as allopurinol , sulfonamides , beta - lactam antimicrobials , antidepressants , and nonsteroidal anti - inflammatory drugs . allopurinol hypersensitivity syndrome ( ahs ) is characterized by rash , fever , and internal organ involvement . we report a case of an exceptional presentation of agep as a manifestation of ahs . a 67-year - old male was admitted to the dermatology department with history of widespread skin eruption since 10 days . he was started on allopurinol ( 200 mg / day ) for hyperuricemia 8 weeks earlier . clinical examination showed maculopapular eruptions involving trunk , arms and legs , as well as pinhead - sized follicular and nonfollicular pustules on patient 's face and trunk . laboratory investigations revealed a white blood cell count of 13.2 10/l with atypical lymphocytes and hypereosinophilia ( eosinophil count 1.9 10/l ) . iu / l ( reference range 340 ) and alanine aminotransferase 409 iu / l ( 345 ) . barr virus , hepatitis b , c , hiv , parvovirus b19 and human herpesvirus 6 . skin biopsy showed subcorneal spongiform pustules and some single scattered necrolytic keratinocyte [ figure 1 ] . the superficial dermis was edematous , with mixed inflammatory infiltration , including numerous neutrophils and rare eosinophils consistent with the diagnosis of agep . subcorneal spongiform pustules and some single scattered necrolytic keratinocytes the patient improved markedly within 72 h on prednisone 30 mg daily ( dose of 0.5 mg / kg body weight ) . full dose corticosteroid therapy was continued for two weeks , and tapered by 2.5 mg every 57 days , with a total duration of 3 months . causality assessment by the naranjo probability scale showed that ahs had probable causal association with the adverse effect . allopurinol hypersensitivity syndrome is a rare adverse reaction characterized by a spectrum of cutaneous reactions and systemic manifestations . ahs is more frequently associated with chronic renal insufficiency and concurrent use of thiazide diuretics . the exact pathogenesis of this syndrome is yet unclear , but different hypothesis are proposed . it seems to be related to the accumulation of allopurinol or oxipurinol a ( major metabolite of allopurinol ) in patients with renal insufficiency . immunological factors , genetic factors , and human herpes virus - type 6 are also implicated . cutaneous manifestations of hypersensitivity syndrome are heterogeneous , ranging from mild morbilliform exanthema to severe toxic epidermal necrolysis and stevens johnson syndrome . pustules in dhs differ from the typical pattern of agep , in which pustules are more numerous and predominant in main body folds . we scored both the european registry of severe cutaneous adverse reaction ( regiscar ) criteria for dress and euroscar agep score . the score was 7 for dress indicating a definite case and 5 for agep indicating a probable case . the clinical features which most differentiated dress from agep in our patient were the delayed onset ( 8 weeks ) , protracted course and multi - organ involvement . the first case of ahs with generalized nonfollicular pustulosis was described in a 47-year - old man . the second is a 65-year - old man who developed ahs manifested as generalized follicular pustulosis mimicking agep . allopurinol directly inhibits the lymphocytes enzyme purine nucleoside phosphorylase and may affect certain components of the immune system with an alteration of cd4/cd8 rate . the concomitant release of several mediators from eosinophils and/or activation of neutrophils might be important for the clinical evolution of lesions , with appearance of pustules , or aggravation of skin detachment , as well as internal organ involvement in dress . a drug reaction leading to folliculitis and then pustule formation has also been proposed . clinicians should be observant of cutaneous manifestations of hypersensitivity syndrome that may be a nonfollicular and/or follicular pustular eruption as well as the more commonly associated maculopapular rash or erythroderma .

allopurinol hypersensitivity syndrome ( ahs ) is a severe drug reaction . it is characterized by rash , fever , and internal organ involvement . it may present in different clinical forms . we present a case of acute generalized exanthematous pustulosis occurring as a manifestation of ahs .

although tnf itself was not discovered until the 1970s , a physician named william coley first noted the phenomenon of tumor necrosis at the turn of the 20th century . the tumors of some of his cancer patients shrank after they had acquired streptococcal infections ( 1 ) . but the inherent dangers of injecting humans with a toxic soup of bacterial endotoxins prevented coley 's observation from being converted into an antitumor therapy . researchers , however , hoped to separate the tumor - blasting factor from the toxic mess . lloyd old and his team at the memorial sloan kettering cancer center ( new york , ny ) finally zeroed in on serum tnf from bacterium - primed , endotoxin - challenged mice in 1975 ( 2 ) . bruce beutler ( left ) and anthony cerami tnf was immediately included with the likes of interferon- , il-2 , and monoclonal antibodies as the next best hope in cancer treatment . by the mid-1980s tnf therapy not only failed to shrink tumors but also caused side effects . and just across the street from sloan kettering , a group from rockefeller university headed by anthony cerami would soon publish data that would put a further damper on the tnf - as - cure idea . his main interest was in understanding the basis of cachexia the weight loss associated with many chronic diseases , such as cancer and tuberculosis . in the 1970s , while testing drugs designed to rid cattle of the parasite trypanosoma , cerami noticed that the animals continued to waste away even though the parasites were dying off . the continued weight loss was not drug induced , as parasite - infested antelopes also responded to the drug but showed no further wasting . cachexia , cerami surmised , might be due to a host factor that was meant to fight the infection but became a threat when produced in amounts that overwhelmed the body . cerami soon found a reliable biochemical read - out for cachexia : lipaemia , the accumulation of lipids in the blood due to the suppression of a fat - metabolizing enzyme ( 3 ) . the hypothetical host factor , cerami realized , might be suppressing this enzyme , lipoprotein lipase ( lpl ) , thus triggering a fat storage problem and cachexia . he and a post - doctoral associate , masanobu kawakami , tested this hypothesis in a mouse model of endotoxin - induced cachexia . mice that were genetically susceptible to endotoxin had deficient lpl activity after an injection of bacterial lipopolysaccharide ( lps ) , whereas endotoxin - resistant mice had normal lpl activity . serum from lps - treated sensitive mice triggered lpl suppression in normally resistant mice , suggesting the presence of the cachexia - inducing host factor in the serum . the task of purifying this mystery protein was taken up by bruce beutler , another of cerami 's post - doctoral associate . the team had previously found that a macrophage cell line produced copious amounts of the lpl - suppressing factor when stimulated by endotoxin ( 4 ) . the macrophage prep was also a better starting point for protein purification compared with the messy mouse serum . beutler then took a year to purify the protein , which the team named cachectin . they published their discoveries in the journal of experimental medicine ( 5 , 6 ) . the team 's collaborators at the scripps institute ( la jolla , ca ) , however , found that cachectin shared the same biological activity with tnf . a comparison of cachectin 's sequence with that of the newly sequenced human tnf solidified the link . the team added this later discovery as a footnote to their already - accepted paper ( 5 ) . the identification of cachectin as the benign cytokine tnf created a furor in the field , especially as the other biological activities of cachectin mimicked the side effects seen in the tnf - treated cancer patients . everyone else was advocating for tnf to be given to patients , says cerami . we wanted to get rid of it . his team later found that blocking tnf activity using antibodies reduced infection - induced inflammation and endotoxin - induced lethality ( 7 ) . today , anti - tnf drugs are successfully used in the treatment of inflammatory diseases such as rheumatoid arthritis and psoriasis .

in the early 1980s , in search of the cytokine that triggers disease- associated weight loss and lethal shock , anthony cerami and bruce beutler purified cachectin . they soon found out that their malevolent cytokine already had another name tumor necrosis factor ( tnf)and was being lauded as a potential antitumor agent .

computed tomographic angiography ( cta ) is a non - invasive mean of investigating isolated third nerve palsy to exclude intracranial aneurysm . however , third nerve palsy can be also associated with dural carotid cavernous fistulae ( ccf ) with anterograde inferior petrosal sinus drainage , which may occur without cta features of superior ophthalmic venous dilatation and orbito - ocular congestion . here , we present two cases missed by cta . a 68-year - old woman with a history of hypercholesterolemia and on statin therapy presented with progressive ptosis and diplopia over five days . physical examination showed left painful complete third nerve palsy without orbito - ocular congestive signs . cta showed a 2.5 mm left internal carotid artery ( communicating segment ) outpouch but did not show any other vascular pathology . digital subtraction angiography ( dsa ) confirmed the above finding as a left internal carotid artery infundibulum and also showed left dural carotid cavernous fistulae with drainage into the right inferior petrosal sinus . follow - up magnetic resonance angiography ( mra ) at 5 months showed persistent carotid - cavernous fistulae . similarly , 63-year - old woman with no medical comorbidity presented with ptosis and diplopia over five days . physical examination showed right painful partial third nerve palsy with mydriasis and without orbito - ocular congestive signs . dsa was carried out and found right dural ccf ( figure 1a d ) . common causes of isolated third nerve palsies include diabetes mellitus and communicating segment internal carotid artery aneurysm . the above two cases illustrate that cta may not detect posterior - draining dural carotid cavernous fistulae when radiological signs of grossly engorged anterior cavernous sinus and a dilated superior ophthalmic vein are absent . in future , mra may act as a noninvasive diagnostic tool for these cta - negative posterior - draining dural carotid cavernous fistulae as illustrated by the first patient . embolization can also result in rapid and complete resolution of third nerve palsy in 88% of affected patients . figure 1digital subtraction angiography found right dural carotid cavernous fistulae fed by dural branches of bilateral internal carotid artery ( ica ) and drained through right inferior petrosal sinus . ( a ) right ica injection , ap projection ; ( b ) right ica injection , lateral projection ; ( c ) left ica injection , ap projection ; ( d ) left ica injection , lateral projection . digital subtraction angiography found right dural carotid cavernous fistulae fed by dural branches of bilateral internal carotid artery ( ica ) and drained through right inferior petrosal sinus . ( a ) right ica injection , ap projection ; ( b ) right ica injection , lateral projection ; ( c ) left ica injection , ap projection ; ( d ) left ica injection , lateral projection .

computed tomographic angiography ( cta ) is a well - established non - invasive investigation for this neurological presentation to exclude intracranial aneurysms . however , dural arteriovenous fistulae with anterograde venous drainage only can be missed by cta . here we reported two patients with painful complete third nerve palsy and dural carotid cavernous fistulae with anterograde venous drainage only missed by cta . the natural history and management option are discussed . in patients with persistent symptoms or without vasculopathic risk factors , magnetic resonance angiography ( mra ) or digital subtraction angiography ( dsa ) should be considered to exclude the diagnosis .

oesophageal perforations are associated with high morbidity and mortality , predominantly as a result of a mediastinal leakage frequently leading to septic shock . we report a patient on warfarin therapy presenting an intramural , intrathoracic eosophageal haematoma prior to oesophagus perforation ; a condition that to our knowledge is not previously reported . in our patient , an initial conservative approach was used in managing the haematoma and once perforated prompt surgical intervention was initated . a 84-year - old women presented to the emergency room after she slipped and fell causing blunt traumas to the chest and face . she was conscious , hemodynamically stable and had normal blood counts besides a low albumin of 34 g / l ( 3445 the patient was on warfarin treatment due to atrial fibrillation and a history of pulmonary embolisms , and suffered furthermore from recurrent urinary tract infections and pulmonary fibrosis . initial computed tomography ( ct ) revealed a 4 cm 6 cm 15 cm paraoesophageal haematoma located in the superior and posterior mediastinum ( fig . initially the haematoma was treated conservatively but during the course of hospitalization the patient developed increasing difficulty swallowing and on the 18th day , the patient 's condition rapidly deteriorated with fever , tachycardia , acidosis and leukocytosis . an immediate ct scan showed mediastinal leakage corresponding the known location of the haematoma ( fig . 2 ) . due to mediastinal leakage and unknown consequences of stent - treating a haematoma of this size this revealed no intra- or extramural necrosis but an extremely tense haematoma and further confirmed a 3 cm longitudinal oesophageal perforation . the perforation was directly sutured ; no reinforcements were applied . until recognition of the perforation the patient was on proton pump inhibitors and soft diet , and during the post - op stay antibiotics and parenteral nutrition . the patient began full diet 10 days prior to discharge . due to a complicated post - op stay with fungal and bacterial infection we report an intramural , intrathoracic esophageal haematoma with late rupture as a result of blunt trauma to the chest . earlier cases describe intramural small bowel haematomas in patients using warfarin but our case is extremely rare . our patient 's single complaint was chest pain and although anticoagulant therapy was discontinued , late complications to haematomas are possible . likely , the perforation might be due to ischemia from the pressure built up between the haematoma , vena azygos and the distal trachea ; or the oesophageal rupture was immediate present after the trauma and the haematoma walled it off until the patient became symptomatic . early diagnosis and management of oesophageal perforation is difficult but imperial in reducing morbidity and mortality . whether surgical or conservative treatment is indicated depends mainly on the general health of the patient , time elapsed and the size of the perforation . thoracic esophageal perforations are usually differentiated in those contained within the mediastinum and those noncontained that drain into the pleural space as with our patient . primary stent treatment for spontaneus esophageal perforations especially in iatrogenic perforations has proven effective but outcomes for stent treating haematomas are unknown and require close radiographic and endoscopic follow - up . as to our knowledge , no guidelines on traumatic blunt perforations with haematomas are available , and we believe as indicated by others , that stent treatment should be reserved for patients not fit to undergo major surgery like thoracotomy , or as 2nd line management in persistent leak or sepsis once a perforation is verified management should always include antibiotics , proton pump inhibitors and parenteral nutrition as vital therapeutic measures . if choosing to treate an oesophageal hematoma conservatively we advise to stop anticoagulants or lead strict control of international normalised ratio ( inr ) when prescribing vitamin - k - antagonists . to prevent esophageal lesions , it is advisable to refrain from gastric tubes and instead consider parenteral nutrition . as with our patient , chest pain is the most frequent symptom but other symptoms such as fever , dyspnoea and dysphagia might dominate . late , spontaneous , intrathoracic esophageal perforations due to blunt trauma is to our knowledge not described previously . such haematomas can be treated conservatively but if the esophageal wall ruptures prompt surgically management must be taken , especially if uncontained .

introductiontraumatic oesophageal perforation is a rare , life - threatening emergency that requires early recognition and prompt surgical management.presentation of casewe present an unusual case of a patient on warfarin treatment developed an intramural oesophageal haematoma following blunt thoracic trauma leading to perforation on the 18th day.discussionin treatment of oesophageal haematoma in patients on vitamin - k antagonists , strict control of the international normalized ratio ( inr ) is essential along with total parenteral nutrition therapy and refrainment through nasogastric tubes . three explanations postulated to be the cause for late perforation which might be due to esophageal wall ischemia from pressure built up between the hematoma , azygos vein and the lower part of thoracic trachea ; or could be an immediate rupture walled - off until the patient became symptomatic ; or the intramural hematoma gradually lysed and causing late perforation.conclusionalthough extremely rare , an oesophageal haematoma and late complications must be considered in patients on anti - coagulant therapy following blunt thoracic trauma and complaining only of chest pain .

paratesticular tumors are infrequent tumors that have a high incidence of malignancy ; they are either soft - tissue tumors or mesothelial neoplasms . paratesticular liposarcomas include all liposarcomas arising in the structures around the testis , including the lower end of the cord . it is felt to arise from the extra peritoneal fat that becomes continuous distally with the fatty tissue of the cord . they commonly present as painless , slowly growing masses that are usually diagnosed as being a lipoma or inguinal hernia . however , complete surgical resection offers the best chance of cure for these patients , and the established method for orchiectomy for testes / cord cancer is through an inguinal incision . a 65-year - old male patient presented with scrotal swelling of 2-year duration in both right and left hemiscrotum , which was gradually progressive in size and non - reducible . on examination , swelling was soft in consistency , testis was palpable posteriorly , and could not get above the swelling . intraoperative , a firm , well - defined tumor , about 20 14 5 cms on the left and 16 14 4 cms on the right side were found at the proximal spermatic cord [ figure 1 ] ; no hernia sac was noted at the inguinal canal . bilateral high inguinal orchiectomy was performed . the gross appearance of the specimen revealed a large , soft , well - circumscribed , multilobulated , fat - containing mass adhering to the spermatic cord and testis . the cut surface of the tumor [ figure 2 ] showed yellowish and myxoid areas , but without hemorrhage or necrosis . histopathological examination [ figures 3 and 4 ] showed sheets and nests of mature adipocytes , scattered atypical cells with hyper chromatic nuclei , and multivacuolated lipoblasts in between on a fibrous and myxoid background . he , however , refused further treatment because he did not have enough money to continue treatment . informed consent has been taken from the patient regarding the publication of the case report . gross specimen of the tumor mass measuring 20 14 5 cms on left and 16 14 4 cms on the right cut section of the specimen showing yellowish and myxoid areas microscopic examination of the mass revealed an encapsulated proliferation consisting of mature adipocytes accompanied by both spindle - shaped cells and multivacuolated lipoblasts microscopic photograph showing mature adipocytes , spindle - shaped cells with hyper chromatic nuclei within the stromal tissue and multivacuolated lipoblasts in between on a fibrous and myxoid background dreyfuss and lubash reported the first documented liposarcoma of the spermatic cord in a 54-year - old male in 1940 . liposarcomas are soft - tissue malignancies that are commonly found in the lower extremities and retroperitoneum . they are classified in four histology subtypes ( well differentiated , myxoid , pleomorphic , and dedifferentiated ) . paratesticular tumors have a high incidence of malignancy , which is estimated as 30% in the documented literature , mostly arising from the spermatic cord . most patients present with painless , slowly growing inguinal or scrotal masses , which are usually diagnosed as inguinal hernias or lipoma before surgical intervention . the majority of spermatic cord sarcomas begin their development just below the external inguinal ring and therefore , grows as a scrotal mass rather than as an inguinal mass . the homogenous fatty pattern of well - differentiated paratesticular liposarcomas being similar to lipomas or omentum in the hernia sac makes the differential diagnosis of a liposarcoma difficult through ultrasonograhic studies . hence , even though ultrasonography is the most helpful and commonly used diagnostic tool for differentiating cystic and solid lesions , an abdominal ct scan may be helpful . since they have the tendency for local recurrence after inadequate resection , complete resection , including high ligation of the spermatic cord , is indicated . an intralesional biopsy or surgery the role of adjuvant radiotherapy or chemotherapy remains controversial and is only limited in cases of metastatic tumors or in cases following incomplete resection . radiation therapy may be employed as an adjunct to surgical resection in an attempt to avoid local recurrence . the prognosis of paratesticular liposarcomas depends on the histological cell type , among well- differentiated , dedifferentiated pleomorphic , and myxoid / round cell types . the well - differentiated and myxoid / round cell types have a better prognosis , but they tend to have a high incidence of local recurrence . liposarcomas are the most radiosensitive of all sarcomas and in some cases remission has been achieved with radiotherapy alone . in conclusion , liposarcomas of the spermatic cord represent a rare type of tumors , which are often misdiagnosed preoperatively . being a rare disease and varied type of presentation , paratesticular liposarcoma should be considered as a possibility during the differential diagnosis of fat containing inguino - scrotal mass .

paratesticular liposarcomas are rare tumors and are often reported as isolated cases . patients usually present with a painless scrotal or inguinal mass , mimicking inguinal hernia . they refer to liposarcomas arising from the spermatic cord , testicular tunics , and epididymis . we report a case of bilateral scrotal swelling which was misdiagnosed as inguinal hernia . intraoperative diagnosis of testicular tumor was made . high inguinal orchiectomy was done . histopathological examination revealed it to be liposarcoma of the cord . to our knowledge , there is no reported case of bilateral paratesticular liposarcoma in english literature , hence we report this case .

in the previous issue of critical care hadian and colleagues compare the performances of the three best known examples of pulse contour systems - lidco plus , picco plus and flotrac - against thermodilution . an experimental design was used based on cardiac surgery patients in the first 4 hours after surgery , in which cardiac output was managed using four different therapeutic interventions - fluid bolus , vasoconstrictor , vasodilator and inotrope - which should have provided a vigorous test of trending ability when compared with the alternative of sampling at regular time intervals . the authors used a standard and now well - established statistical approach of bland and altman analysis , determining percentage errors and concordance trend analysis that included an exclusion zone ( changes < 0.5 l / minute ) . the results show that only the lidco plus system provided an acceptable level of agreement with thermodilution ( percentage limits none of the three systems provided satisfactory trending , however , with concordance rates ( 74% , 72% and 59% ) well below the required 90 to 95% for good trending . the reliability of the pulse contour method is known to be susceptible to changes in peripheral resistance and the study protocol involved vasoconstrictor and vasodilator drugs , which may explain these poor trending results . this study helps to confirm what is already suspected about the reliability of pulse contour devices ; that these devices do not track changes in cardiac output reliably . although there are many recent published studies evaluating pulse contour devices , the present one provides a very exacting examination and also compares the three main brands of pulse contour monitor . the study could be faulted , however , because a now out of date flotrac/vigeleo software version was used . the flotrac has been criticised for failing to compensate for low peripheral resistance states . in response , edwards lifesciences ( irvine , ca , usa ) produced a new third - generation software version ( for example , version 3.02 ) known as dynamic tone technology to overcome this limitation . the authors also used continuous cardiac output readings as their reference standard if a heated wire pulmonary artery catheter was in situ . validation should ideally be based on readings from single bolus thermodilution cardiac output measurements as these are said to be the most reliable . there are several studies that show continuous cardiac output to be as accurate as single bolus thermodilution . continuous cardiac output takes several minutes to stabilise and provide a valid reading , however , which makes it less reliable when measuring trends . one must therefore be cautious interpreting data from this study , as the bland and altman analyses and the concordance analyses may use reference data that have a wider spread than usual and thus wider acceptance criteria . the paper is made much harder to comprehend due to the many cross - comparisons , in the form of bland and altman and four - quadrant concordance plots , which show agreement between the three pulse contour methods . these comparisons do , however , suggest that these three pulse contour methods are not interchangeable . the reason given by the authors is the use of different proprietary algorithms , which measure different aspects of the pulse contour waveform - which is an interesting point . furthermore , nine out of 17 patients had femoral rather than radial arterial lines inserted . there is growing evidence that the site of puncture affects the shape of the arterial trace and thus pulse contour measurements . the more distal the puncture site , the greater the influence of acoustic reflections from vessel branching , and the extent of wave reflection also varies quite dramatically with blood vessel constriction and dilatation . the puncture site thus seems to be an important determinant of the success of pulse contour measurements and should be paid more attention . it is one of several recent clinical studies that show the pulse contour does not reliably reflect changes in cardiac output in haemodynamically unstable patients . excuses can be made that the thermodilution reference method is less reliable than the quoted 20% precision error , but that is another story . the study , however , does provide a rigorous test of the technology , does compare the performance of the three main pulse contour methods , albeit with now out of date flotrac software , and does add to the growing evidence that the pulse contour method is not the solution to providing reliable cardiac output monitoring at the bedside .

three pulse contour systems for monitoring cardiac output - lidco plus , picco plus and flotrac - were compared in postcardiac surgery patients . none of the three methods demonstrated good trending ability according to concordance analysis . pulse contour systems remain unreliable in the haemodynamically unstable patient .

true radial artery aneurysms are extremely rare , with no documented prevalence in the medical literature . in 1966 , the first recognition of this condition was introduced by thorrens , and since then some reports have been published . this paper describes a case of true radial artery aneurysm in a 65-year - old woman , and presents the clinical presentation , aetiologies , and diagnostic and therapeutic modalities . a 65-year - old woman presented to the outpatient clinic with a pulsatile mass at her right wrist . the patient denied history of trauma , surgeries or recurrent punctures , and there was no family history of aneurysms . upon physical examination , a mass of 2-by-3 cm found at the anatomical snuffbox area of the right hand , with no visible scars ( fig . 1 ) . later , ct angiography detected a local dilation at the distal part of the right radial artery ( figs 2 and 3 ) . complete body scan showed another aneurysm at the right common iliac artery measured 3-by-2.8 cm for which the patient was referred to a higher centre for possible endo - vascular intervention as it is not available in our hospital . figure 1:photo of the right hand of the patient shows a bulge at the snuffbox area . figure 2:transverse section of ct angiogram shows radial artery aneurysm at right hand ( arrow ) . figure 3:reconstructed three - dimensional image shows radial artery saccular aneurysm ( arrow ) . photo of the right hand of the patient shows a bulge at the snuffbox area . transverse section of ct angiogram shows radial artery aneurysm at right hand ( arrow ) . reconstructed three - dimensional image shows radial artery saccular aneurysm ( arrow ) . under local anaesthesia , the aneurysm site was incised . a saccular aneurysm of 2-by-1.5 cm appeared at the distal part of the radial artery . using vessel loops , a doppler examination was conducted and indicated positive signals over the thumb and digital arteries . later , the histopathology report showed a dilated arterial sac with a complete fibromuscular wall and an organized thrombus attached to its lumen ( fig . 5 ) . figure 4:the aneurysm with the radial artery controlled proximally and distally . figure 5:microscopic view of the aneurysmal wall shows the muscular layer . upper extremity arterial aneurysms are rare in surgical practice . ogeng'o et al . found that the prevalence of radial artery aneurysms is 2.9% of all aneurysms affect the upper limbs . many cases have been reported after thorrens , the majority reported traumatic pseudo - aneurysms and only few authors reported cases of true idiopathic aneurysms . a medline search was conducted using the terms radial artery and aneurysm and radial artery and pseudoaneurysm , and returned 68 and 46 articles , respectively , published until may 2013 . of these , radial artery cannulation , bone fractures , occupational injuries and traumas were the commonly reported causes . up to 15 other cases were reported as aneurysms induced by systemic pathologies . among all 102 reported cases , only 8 cases were reported as idiopathic true radial artery aneurysms . clinically , patients usually present with pulsatile swelling with or without pain which is usually due to the compression of the surrounding structures . the aneurysm has the potential to cause ischaemia due to laminar emboli or thrombus formation . moreover , traumatic rupture could occur due to the vulnerable location nonetheless ; spontaneous rupture is always a possibility . the diagnosis is initially clinical , but many imaging modalities could help in the diagnosis and in the management of such condition . duplex ultrasonography can be used first to differentiate the aneurysm from other masses with the help of colour doppler ; it is inexpensive and carries no risk to patients . ct angiography has the ability to delineate the aneurysms clearly , and it is ideal to scan the whole body to exclude the other aneurysms existence , although it carries the risk of contrast - induced nephropathy and is expensive . magnetic resonance angiography ( mra ) is another choice , but its higher cost makes it unpopular . in fact , the best treatment for radial artery aneurysms is still controversial ; however , the surgeon 's decision can be guided by taking some factors into consideration . the critical question is : is it the radial or the ulnar artery that carries the majority of blood supply to the hand ? currently there is no consensus about which non - invasive modality should be used to evaluate the circulation of the hand pre - operatively . many options are available with variable sensitivity and specificity ; for instance , allen 's test , modified allen 's test , digital plethysmography , digital doppler waveforms , and pressures and duplex ultrasonography . more reliable but invasive choices are available to assess the patency of the arteries and the development of the arterial arches , including ct angiography or conventional angiography . patient symptoms and the presence of thrombosis , distal emboli or infections are also important factors to determine the mode of management . technically , the management include the following choices : careful observation ; in case of small asymptomatic aneurysms , arterial ligation and aneurysm excision or arterial reconstruction ; whether by end end anastomosis or by vein graft in the case of aneurysmal dominant artery . in our patient , the decision to excise the aneurysm and ligate the artery was based on the results of ct angiography , modified allen 's test that clarified ulnar dominancy and the positive doppler signals over the dorsal digital artery of the thumb after radial artery clamping intra - operatively .

true aneurysms of hand arteries are rare . i present a case of a true saccular aneurysm of the distal radial artery in a 65-year - old woman with no history of trauma . the ct angiography , intraoperative features , operative procedure , histopathological examination and literature review are presented and discussed .

monocondylar tibia plateau fractures with non - comminuted fragments can be treated using percutaneous screws . currently indirect methods of reduction are used and thus the technique is limited to fragments with less than 5 mm depression . the first author has designed a device for direct elevation and reduction of the fragments thus potentially expanding the indications of percutaneous screws to fragments with > 5 mm depression a total of ten cases were treated by this method of percutaneous elevation of the depressed fractures of lateral condyles of the tibia using this device . the inner piston of the device in slowly hammered inside thus elevating the depressed fragment . the new device is able to elevate unicondylar tibia plateau fragments with no subsidence or loss of fixation in our series . a longer follow up in a larger sample will be needed to establish the technique . the tibial plateau fractures are still a challenging problem and demand an aggressive management as any other intraarticular fractures of the joints . before the advent of the recent advances conservative management was the treatment of choice resulting in joint stiffness which was very crippling to the patient . the thorough understanding of the classification the tibial plateau fractures based on the recent investigations , has opened the gates for better management . the amount of depression and the displacement of the condylar fractures , articular incongruity can be well assessed nowadays . schatzker classification is the most accepted classification currently and type i to iv fractures are associated with angulated or depressed fractures of either of the one condyle . in cases with large sinlge peripheral fractures most papers describe indirect method of reduction of these fragments via ligamentotaxis and thus limit themselves to depression < 5 mm . we designed a new device to achieve direct elevation of these fragments and thus use the percutaneous technique in depression > 5 mm . the present paper discusses the usefulness of the device in elevation of the depressed condyles with a small window ( very minimal incision ) . device : the device is designed by first author [ vsr ] indigenously with 316 ss alloy . the diameter of outer sleeve is 11 mm and the wall thickness of the sleeve is 1 mm . the diameter of the solid piston is 10 mm and it freely moves to and fro in the outer sleeve ( fig . the serrated edges of the sleeve help in insertion in the metaphyseal area surgical steps : ten male patients ( age between 25 - 40 years ) were operated using this device . first the direction elevation was assessed by a guide wire passed through a drill hole on the antero medial aspect of the upper one fourth of the tibial metaphysis ( fig . a bone window sufficient to accommodate the outer sleeve is made round the guide wire . then the piston was pushed into the sleeve and the piston was tapped towards the depressed fracture carrying a cylindrical cancellous plug of the bone to elevate the fracture condyle till plateau is congruous which was checked under the c - arm image in both views ( fig . next again under c - arm control a guide was passed perpendicular to the fracture line of the condyle keeping the piston in the intramedulary canal . a cancellous screw was threaded over the guide wire to fix the fracture ( fig . we had used two screws in majority of the cases with one screw used in one case , depending on size of the fragment . we were able to achieve good articular reduction in all our cases by use of this technique . weight bearing was allowed after the radiological union was present i.e after 8 weeks . in this buttressing with a plate was not needed as we felt the fixation achieve was stable enough and also weight bearing was delayed allowing for healing of the fracture . early results are encouraging with all cases achieving radiological union and good knee range of motion . there were no cases of loss of reduction or any other complications although a longer and more detailed prospective follow up will be required to establish the potential clinical importance of the device after elevation of the fragment another guidewire is passed through the fragment over which a 6 mm cannulated cancellous screw is passed percutaneously - d . percutaneous screw fixation in cases on monocondylar tibia fractures will prevent the morbidity associated with open procedure and is less expensive too . a lot of case series describe percutaneous screw fixation however these are based on indirect reduction techniques and are limited to depression less than 5 mm [ 1 - 6 ] . we felt a device which can directly help in elevating the fragment to achieve intraarticular reduction will definitely expand the indication of this minimally invasive technique . the solid inner rod compresses the metaphyseal cancellous bone thus compacting it below the subchondral area . we found this technique to be useful in 10 of our patients to achieve reduction . however most of our patients were young and were operated within a day or two of injury , thus usefulness of this device in older injuries and older patients ( with osteoporosis ) is yet to be defined . a long term follow up , a larger size sample and report of reproducability of this device by our peers will be essential to confirm the potential usefullness of this device .

introduction : monocondylar tibia plateau fractures with non - comminuted fragments can be treated using percutaneous screws . currently indirect methods of reduction are used and thus the technique is limited to fragments with less than 5 mm depression . the first author has designed a device for direct elevation and reduction of the fragments thus potentially expanding the indications of percutaneous screws to fragments with > 5 mm depressiontechnical note : a total of ten cases were treated by this method of percutaneous elevation of the depressed fractures of lateral condyles of the tibia using this device . device was inserted through a bony window on the anteromedial surface of tibia . the inner piston of the device in slowly hammered inside thus elevating the depressed fragment . elevation of fragment could be achieved in all the cases . the fractures were fixed with cancellous screws applied percutaneously . there were no cases with loss of fixation or subsidence of the fragment . all cases achieved radiological union and have good knee function at follow upconclusion : the new device is able to elevate unicondylar tibia plateau fragments with no subsidence or loss of fixation in our series . a longer follow up in a larger sample will be needed to establish the technique .

although typically thought to occur in older individuals , a hooked acromion causing shoulder impingement symptoms in younger populations is less recognized . this report illustrates a case of type iii acromial impingement in a younger athlete and the importance of early imaging in refining diagnosis . a 31-year - old right - hand dominant cross - fit personal trainer presented to an outpatient clinic complaining of left shoulder pain worsening over a 2-year period . the pain had become intermittently worse over the last 6 weeks , and was particularly flared the day following handstand push - ups and kipping . pain was reportedly worsened by shoulder abduction beyond 90 , bicep hammer curls and eccentric bench press . the patient perceived the left shoulder to be more elevated than the right at rest , and he had begun to note joint crepitus on circumduction . the pain was focal to the anterior aspect of the deltoid and upper biceps region with an occasional pulling sensation in the distolateral biceps . the patient was perplexed as to why the left shoulder was painful when he was right - handed . he described a 38/10 baseline daily pain , increasing to 10/10 with bicep curls and eccentric bench press . he pain with activities of daily living such as removing his shirt , lifting his 2-year - old child , and he was unable to sleep on his left side . despite the pain he took no medications , had no reported drug allergies or prior reactions to anesthesia . he was a non - smoker , and had been engaged in professional power lifting since 2008 . cervical spine ranges of motion were pain free and the spurling 's test with extension was negative . a painful arc was present upon left shoulder abduction with hitching a reported pain at 90. there was , however , no palpable or audible crepitus on left shoulder circumduction . however , there was a focal area of tenderness upon palpation 3 cm proximal to the left lateral epicondyle . mill 's & cozen 's tests were negative , and resisted muscle testing of the common extensor origin and extensor carpi radialis brevis was unremarkable . the left proximal biceps tendon and medial aspect of the left acromial - clavicular joint ( acj ) was focally tender on palpation . the initial diagnostic impression was of chronic left shoulder impingement ( query subacromial bursal effusion , early rotator cuff ( rc ) tear , down - sloped acromion ) , and mild acj osteoarthritis . although the physical examination was generally unremarkable , the history was indicative of some mild left extensor origin biceps tendonopathy . the patient was referred for a non - contrast magnetic resonance imaging ( mri ) of the left shoulder . the study reported high signal intensity within the belly of the supraspinatus muscle belly and tendon associated with a type iii downward - sloping acromion , which was interpreted to be causing a degree of impingement . there was also a small amount of fluid in the subacromial space raising the possibility of associated subacromial bursitis ( fig . the report of imaging findings and prognostic discussion convinced the patient of the importance to alter the intensity of his upper body training activities . by simply avoiding repetitive overhead activities and modifying the intensity of his upper body exercise program , impingement symptoms abated considerably over a period of several weeks . as the patient was responding to conservative management and there was no evidence of rc tear on imaging , surgical referral was postponed . there are several functional and potentially reversible causes of shoulder impingement syndrome . however , identifying the presence of bony impingement of the subacromial space may aid in a better understanding of predispositions to rc pathology . the original bigliani acromial morphology classification of type 1-flat , type ii - curved and type iii - hooked has more recently in updated by vanarthos and monu , to include a type iv - convex morphology ( fig . some studies have identified a significant association between type iii acromial morphology and full thickness rc tears . although type iii acromion ( t3a ) may be rare in asymptomatic young athletes , the incidence of in a general population of both young and older individuals is still not completely understood . typically , older patients are noted to have a high incidence of t2a and t3a ( 93% of those over 70 ) and both of full and partial - thickness rc tears were more commonly with these morphologies than type i . neer concluded that 95% of rc tears are caused by mechanical impingement , associating rc tears with extremely hooked ( > 43 ) anterior acromial slope . other studies have looked at the lateral extension and angulation of the acromial slope also being important in diagnosing and managing impingement pathologies . although thought to be associated with older populations , t2 down - sloped and t3 hooked acromial impingement may occur in younger populations such as overhead athletes . impingement may be manifested by pain with overhead activities , shoulder weakness and decreased range of motion . early shoulder x - rays including the outlet y view to define acromial morphology , or mri imaging may help to refine diagnosis , prevent inappropriate therapies , understand prognosis and expedite more effective management strategies . appropriate surgical referrals are patients with subacromial impingement syndrome refractory to 36 months of appropriate conservative treatment .

down - sloped or hooked acromion morphologies may cause bony encroachment on the soft tissues of the subacromial space , predisposing to shoulder impingement syndrome . of the latter , a hooked or type iii acromion ( t3a ) has also been linked to rotator cuff ( rc ) pathology . however , as bony acromial impingement is typically thought to occur over the age of 40 , its occurrence in younger shoulder athletes presenting with shoulder pain , impingement and rc pathology may be overlooked . this case serves to illustrate the occurrence of t3a in a younger shoulder athlete , and the importance of early imaging in achieving diagnostic accuracy . appropriate surgical referrals are patients with subacromial impingement syndrome refractory to 36 months of appropriate conservative treatment . surgery may be particularly beneficial in patients with a t3a .

canagliflozin ( invokana ) is a novel therapy for type 2 diabetes mellitus ( dm ) approved in a new class acknowledged as sodium - glucose co - transporter 2 ( sglt2 ) inhibitors . canagliflozin inhibits the glucose reabsorption by the kidney , increasing glucose elimination and reducing blood glucose levels in diabetic patients . acute pancreatitis is a very rare but severe side effect with an incidence < 1% . we report a case of a 50-year - old man who received a few doses of canaglifozin and developed pancreatitis - induced diabetic ketoacidosis requiring hospitalization in the intensive care unit . a 50-year - old white man presented to the emergency department with malaise , weakness , abdominal pain , and loss of vision that progressively worsened over 3 days . he has a history of a long - standing well - controlled type 2 dm treated with insulin , glyburide , and metformin . 4 days before admission his endocrinologist stopped his lantus ( insulin glargine ) and prescribed him on canagliflozin 100 mg oral daily along with glyburide and metformin . after 10 days of treatment , he developed malaise , weakness , abdominal pain that progressively worsened . on the day of the presentation , he developed blurry vision . blood test showed blood glucose of 506 mg / dl ; sodium of 125 , potassium 6.8 , chloride of 94 , total carbon dioxide < 5 and anion gap of 26 meq / l ; creatinine 2.0 mg / dl , trop i was negative ; amylase 643 , lipase 982 u / l , aspartate aminotransferase 18 u / l ; total bilirubin 0.9 mg / dl ; atrial blood gas ph 6.85 , partial pressure of carbon dioxide 11 mmhg , partial pressure of oxygen 149 mmhg , bicarbonate 1.9 mmol / l , and electrocardiogram showed normal sinus rhythm but no st - t change . he was diagnosed diabetic ketoacidosis induced by acute pancreatitis along with acute kidney injury from dehydration . computed tomography of abdomen demonstrated the evidence of acute inflammation of pancreas . the patient denied any history of recent alcohol use and his serum triglyceride level was normal at 95 mg / dl ( normal range , < 150 mg / dl ) . his serum creatinine , sodium , potassium , lipase , and amylase level returned to normal after 3 days , and we could stop insulin infusion after the anion gap returned to the normal range . the patient continues to do well at 2-month follow - up visit without any recurrent symptoms . canagliflozin is one of sglt2 inhibitors and has been approved by the food and drug administration for type 2 dm by inhibiting sglt2 in the proximal renal tubules . canagliflozin reduces the reabsorption of filtered glucose from the tubular lumen and lowers the renal threshold for glucose ( rtg ) . sglt2 is the main site of filtered glucose reabsorption ; reduction of filtered glucose reabsorption and lowering of rtg result in increased urinary excretion of glucose , thereby reducing plasma glucose concentrations . its safety and effectiveness were assessed in nine clinical trials involving over 10,285 patients with type 2 dm . the most common adverse effects described in the clinical trials were genital yeast infections , urinary tract infections , and increased urination . anaphylaxis , acute respiratory distress syndrome , or significant electrolyte abnormalities have not been demonstrated in the literature review . an ongoing trial , canagliflozin cardiovascular assessment study , will provide us more information on risks of malignancies , serious cases of pancreatitis , and other adverse events . in summary , our case demonstrates very rare but serious side - effect , acute pancreatitis in the use of canagliflozin . as the utility of canagliflozin expands

canagliflozin ( invokana ) is an innovative treatment for type 2 diabetes mellitus ( dm ) approved in a new class acknowledged as sodium - glucose co - transporter 2 inhibitors . acute pancreatitis is a very rare side effect with an incidence < 1% . a 50-year - old white male with dm type 2 presented to the emergency department with acute onset of abdominal pain after 4 days treatment with canagliflozin . he was successfully diagnosed with diabetic ketoacidosis induced by acute pancreatitis . canagliflozin was discontinued . his diabetic ketoacidosis was improved after aggressive intravenous fluid along with intravenous insulin infusion . our case demonstrates very rare but serious side effect , acute pancreatitis in the use of canagliflozin . as the utility of canagliflozin expands , physicians must be aware of this potentially fatal adverse effect . more specific details on potential candidates for this novel therapy are urgently needed .

as the global suicide rate increases by 60% in 50 years in the underdeveloped and developing countries , paraphenylenediamine ( ppd ) poisoning is emerging as an important etiological factor reported from india . ppd ingestion is a very common form of poisoning in india as this compound is a component of hair dyes and is easily available . it is brown or black colored solid substance , easily soluble in hydrogen peroxide and not in water . it is a good hydrogen donor and metabolized by electron oxidation to an active radical by cytochrome p450 peroxidase to form a reactive compound called benzoquinone diamine . this can be further oxidized to a trimer known as brandowaski 's base , a well known compound , reported to cause anaphylaxis and mutation . it is traditionally used for dyeing palms and soles along with henna and to dye the hairs . ingestion of ppd causes rapid development of edema of the face , neck , pharynx , tongue and larynx initially and rhabdomyolysis later . finally , an acute renal failure supervenes as renal tubular necrosis occurs due the deposits of the toxic metabolites of ppd . a 24-year - old young man who had ingested ppd pellets ( an exact amount could not be ascertained ) with suicidal intention . he developed generalized itching and intermittent lacrimation for a few days and was treated symptomatically by a nearby medical practitioner from whom he concealed the history of consumption of ppd pellets . he presented after 6 days with complaints of pain and stiffness of both lower limbs and passage of chocolate colored urine followed by anuria . his blood urea and serum creatinine were 210 mg / dl and 12.4 mg / dl , respectively . he was managed symptomatically with diuretics , phosphate binders , sodium bicarbonate , oral calcium and alkalization of urine . in view of his persistent oliguria and deranged metabolic parameters , myocarditis , myocardial rhabdomyolysis and shock have also been described in ppd poisoning . though the cervicofacial edema is also a common manifestation , it was not a prominent clinical feature in this case . the alteration in the prominent clinical features may be due to the symptomatic management in the initial stages . the major cause of mortality is respiratory distress due to edema , complications related to myocarditis and renal . the cause of acute tubular necrosis in ppd poisoning , independent of rhabdomyolysis is due to concentration of ppd in the renal tubules . this occurs due to aromatic structure of ppd , which makes it readily absorbable and concentrated in the tubules . gastric lavage with 2% sodium bicarbonate is also effective . due to low molecular weight and hydrophilic nature an acute renal failure is managed with adequate input and output charting , treating metabolic complications due to renal failure like hyperkalemia , hypocalcemia , hyperphosphatemia and metabolic acidosis by hemodialysis . renal biopsy may be done when there is undue delay in recovery of renal function . apart from an intentional or accidental excessive exposure to ppd , which results in above manifestations , routine use of this compound on regular basis for a long time can also lead to toxic effects . association between personal hair dye use and non - hodgkin 's lymphoma , multiple myeloma , leukemia and other bladder cancer have been reported but have not been consistently observed . however , the united states environmental protection agency has not classified ppd as a carcinogen . therefore , no warnings of toxicity are printed on boxes of hair dye . but , in view of an easy availability and potential toxicity , awareness about the toxic effects of this compound and adequate warnings for the users may be useful .

the commonest constituent of all hair dyes is paraphenylene diamine ( ppd ) . hair dye poisoning is emerging as one of the emerging causes of intentional self - poisoning to commit suicide . in this article , we report a case of ppd poisoning and the importance of clinical of hair dye poisoning . the lack of specific diagnostic tests , a specific antidote for paraphenylene diamine poisoning and the importance of early supportive treatment modalities are also discussed .

bone involvement in epithelial ovarian cancer is very unusual , with several series noting an incidence of < 2% [ 1 , 2 ] . a recently encountered ovarian cancer patient who was found to have significant bone involvement at the time of disease recurrence , after an extended treatment - free interval , emphasizes the potential risk of metastatic disease in such sites and suggests possible unique features associated with this event . a 60-year - old female with a history of epithelial ovarian cancer was seen for a second opinion concerning management . she had originally been diagnosed with , and treated for , this malignancy in 1998 . following initial surgery and chemotherapy , the patient remained without evidence of disease until 2007 when documented recurrence within the peritoneal cavity led to an attempt at secondary surgical cytoreduction . the patient experienced considerable bone marrow suppression from this regimen , presumably due ( at least in part ) to the residual effects of her prior chemotherapy . the patient subsequently remained well until the fall of 2010 when she developed both lower pelvic and back pain . a pelvic pet / ct scan revealed a pre - sacral mass with definite erosion of the cancer into the sacrum . the mass was felt to be unresectable and a decision was made to initially treat her with a platinum - based combination chemotherapy program ( carboplatin plus pegylated liposomal doxorubicin ) , and to then consider surgery or local radiation therapy ( depending on the impact of the response to the cytotoxic therapeutic regimen ) . one of the remarkable features of epithelial ovarian cancer is its localization in most patients to the peritoneal cavity during the majority of its natural history , despite potentially quite large tumor volumes contained within this region of the body . it has been hypothesized that successful spread of the malignancy requires a variety of essential specific growth factors and nutrients found within the peritoneal cavity and peritoneal fluid . however , it is also well recognized that women with advanced ovarian cancer who experience more prolonged survival have a greater likelihood of experiencing metastatic spread to additional locations , such as the central nervous system [ 1 , 2 ] . it is possible that late - developing malignant clones have lost the essential requirement for external growth factor support in order to become established in distant sites . it is also reasonable to hypothesize that these cancers have been present , but quiescent , in these regions of the body for long periods before they become clinically evident . the patient presented in this report was known to have had epithelial ovarian cancer for 12 years prior to the documentation of metastatic spread to the bone , an observation consistent with other reports of the development of bone involvement as a late metastatic event in the natural history of the malignancy [ 1 , 2 , 4 , 5 , 6 ] . it is relevant for clinicians caring for ovarian cancer patients to appreciate that although bone is a most unusual initial site of metastatic spread in this setting , bony involvement may become a more common feature in the increasing proportion of patients with this malignancy who are expected to experience extended survival ( > 45 years ) but who , unfortunately , are not expected to be cured of the disease process .

bone involvement is uncommon in epithelial ovarian cancer . in this report , a case of bone metastases from ovarian cancer is described and the potential risk factors for such a rare occurrence are discussed . it is possible that such an event will become more common in the future as patients with advanced ovarian cancer experience prolonged survival but the cancer is not eliminated .

autosomal dominant polycystic kidney disease ( adpkd ) is associated with several extra - renal manifestations including coronary artery aneurysm and ectasia as well as cerebral aneurysms , hepatic and pancreatic cysts , cardiac valve disease , aortic root dilatation and colonic diverticulae [ 15 ] . abnormalities in the polycystic kidney disease ( pkd ) gene manifested in arterial smooth muscle cells and myofibroblasts could explain the expression of these extra - renal complications of the disease . despite some case reports [ 15 ] the aim of this retrospective study was to determine the incidence of coronary artery aneurysms and ectasia in the adpkd population and to assess if the size of the coronary arteries was larger compared to a control population . we retrospectively reviewed all end - stage renal failure ( esrf ) patients on haemodialysis over a 10-year period ( 20002010 ) at westmead hospital using the australia and new zealand dialysis and transplant registry ( anzdata ) data . the study population had a diagnosis of adpkd and esrf at the time of coronary angiogram . the control group of 15 patients was selected from the hospital cardiology database if they had both a diagnosis of end - stage kidney disease not due to adpkd at the time of catheterisation . relevant clinical details including patient medical history , medications at the time of angiography and coronary risk factors were obtained from the case records . baseline heart rate , systolic blood pressure , diastolic blood pressure and mean arterial pressure were obtained from the coronary angiography report . angiograms were analysed offline by a single observer ( j.c . ) using computerised edge - detection software ( xcelera , philips healthcare , netherlands ) . the proximal left main coronary artery ( lmca ) , left anterior descending ( lad ) , left circumflex ( lcx ) and right coronary ( rca ) arteries were analysed . arterial segments were viewed in two orthogonal planes at end - diastole to maximise vessel diameter . the start and end points of a 5 mm segment of vessel were determined by the user . the average diameter within this 5 mm chosen segment was used to calculate the diameter of the proximal artery for each view . the start and end points were chosen by the user and the length of vessel measured was 5 mm . categorical data are reported in percentages and continuous data are represented as mean value sd . continuous variables were compared using the student s t - test and confirmed with a mann whitney test . the pearson chi - square or the fisher exact test was used as appropriate to compare categorical data . the baseline demographics , prevalence of cardiac risk factors and use of aspirin , clopidogrel , -blockers , calcium channel blockers , angiotensin - converting enzyme inhibitors and statins between the groups were not statistically different ( table 1 ) . the average diameters of the lmca , lad and rca were significantly larger in the adpkd group compared to the control group ( table 1 ) . demographics and mean coronary artery size in the adpkd and non - adpkd groupsa ace , angiotensin - converting enzyme . this retrospective study shows that subjects with adpkd have larger diameter coronary arteries independent of coronary risk factors and medication use . to our knowledge , this has not been demonstrated previously . our study showed that the esrf group with no history of adpkd had lmca , lad and rca vessel diameters similar to this normal range in contrast to the adpkd group whose average vessel diameter was larger . adpkd is associated with abnormalities in vascular smooth muscle and myofibroblasts as well as the extra - cellular matrix and collagen through defects in the pkd gene [ 6 , 8 ] . it is likely that polycystin has a role in maintaining the integrity of the arterial wall . dysfunction of polycystins regulate cell cell and cell matrix interactions in vascular cells , and in the vasculature , this may lead to abnormalities in endothelial function , vascular tone as well as vascular integrity . these pathophysiological abnormalities support that pkd gene mutations may contribute to coronary artery dilatation ; however , the mechanisms remain to be defined . it is thought that the presence of coronary aneurysmal segments leads to an increased risk of acute myocardial infarction and ischemia through the promotion of sluggish and turbulent blood flow in the relevant artery . it is possible that larger coronary arteries might precipitate coronary events due to a similar process ; however , this requires further study . further studies examining the change in vessel size and presence of aneurysms and ectasia in adpkd subjects at diagnosis and longitudinally over time using non - invasive imaging would be beneficial . in addition , it would also be of interest to examine the incidence of clinical events in the same population . a detailed understanding of the incidence and pattern of coronary artery disease in adpkd patients will allow us to determine the optimal time to screen patients for the presence of coronary artery disease and may assist in choosing the most appropriate treatment strategy , especially if the risk of arterial dissection is greater .

autosomal dominant polycystic kidney disease ( adpkd ) can affect several organs in addition to the kidney . there is paucity in the literature on the cardiac manifestations of this disease . this retrospective study aimed to assess whether adpkd was associated with a larger coronary artery diameter and to evaluate for the presence of coronary artery aneurysm and ectasia . this study shows that subjects with adpkd and end - stage renal failure have dilatation of coronary arteries independent of traditional coronary risk factors and medication use .

a 7-year - old female presented complaining of intermittent diplopia and blurred vision for 2 months . 1 ) . however , variable degrees ( 10 to 30 prism diopters [ pd ] ) of esodeviation and miotic pupils were evident only at near fixation ( fig . her esodeviation did not change with the addition of + 3.0 diopters ( d ) lenses . however , cycloplegic refraction revealed that both eyes were nearly emmetropic ( + 0.5 d ) . the patient also complained of frequent headaches and abdominal pain ; the results of all physical and neurological examinations were normal , including a brain magnetic resonance imaging with contrast . the patient was diagnosed with convergence spasms and was referred to the psychiatry department for her somatic complaints . plus lenses ( + 1.5 d ) for reading were prescribed for atropinization of her eyes . one month after prescribing atropine eyedrops and reading glasses , the patient 's best corrected visual acuity increased to 20/20 . she continued to complain of intermittent diplopia , but the frequency and duration were decreased . however , the patient 's mother did not bring her daughter to the psychiatric department ; the patient was again referred to the department of psychiatry . during a mental status examination at the department of psychiatry , the patient was given a psychiatric diagnosis of childhood emotional disorder owing to an emotionally unavailable mother suffering from major depressive disorder . ( antidepressants , selective serotonin reuptake inhibitor [ ssri ] ) and diazepam 2 mg p.o . ( anxiolytics , benzodiazepine ) for the patient . additionally , escitalopram 10 mg p.o . one month after initiation of the antipsychotic medications , the patient 's esodeviation at near fixation was resolved and all somatic complaints had ceased ( fig . the patient 's visual acuity was 20/20 without glasses and her refraction was nearly emmetropic ( + 0.5 d ) . as such , successful cessation of the atropinization of the patient 's eyes was achieved after only 2 months . after the patient and her mother finished 6 months of the antipsychotic medication regimen , no symptoms were evident of either convergence spasms or any other somatic disorders . most convergence spasm cases are caused by a functional disorder , such as hysteria or neurosis . . emotional instability may result in a variety of ocular manifestations besides convergence spasms , such as blurred vision , monocular diplopia , tunnel vision , blepharospasm , and nystagmus . emotional instability should be considered as a possible cause when patients present with these symptoms . if no signs of emotional problems are present , a thorough neurological work - up is recommended . there are several organic causes of convergence spasms , including encephalitis , tabes , labyrinthine fistulas , arnold chiari malformation , posterior fossa neurofibroma , trauma , and pituitary adenoma . some authors have reported positive outcomes from supportive psychotherapy and amytal interviews . however , the conventional therapy for convergence spasms consists of atropinization of the eyes and the prescription of plus lenses for near vision . it is useful to produce cycloplegia in an attempt to break the cycle of sustained maximal convergence and accommodative spasm . dilated pupils can lead to photophobia and blurred vision with near fixation and the wearing of reading glasses can cause discomfort . other adverse events may include allergic conjunctivitis and , rarely , fever and aggravation of asthma . in the present case , the successful cessation of the atropinization of the patient 's eyes was achieved only one month after the patient and her mother initiated antipsychotic medications . of course these events may occur early in treatment with a high dose ( > 100 mg ) of the drug or following the addition of drugs that inhibit the metabolism of ssris . in addition , some patients also experience ataxia ( < 2% ) and dizziness ( < 1% ) with benzodiazepines . however , most benzodiazepines , especially low potency benzodiazepines like diazepam , are generally well tolerated . the low dose and low potency of the antipsychotic medications given to the present patient did not elicit any of these side effects . we report a case of early resolution of convergence spasms after the addition of antipsychotic medications . additional treatment for childhood emotional disorder , which was the indirect cause of the patient 's convergence spasms , reduced the required duration of atropinization of the eyes from one year to 2 months . we recommend active referral and collaboration with psychiatrists when treating patients whose disease may be functional in origin .

we report a case of early resolution of convergence spasms following the addition of antipsychotic medications and present it as a possible alternative to the conventional treatment for convergence spasms . the cessation of atropinization of the eyes and the use of reading glasses was achieved after only 2 months following the initiation of antipsychotic medications for childhood emotional disorder .

granulocytic sarcoma or extramedullary myeloid tumor ( emmt ) is an uncommon neoplasm of immature hematopoetic cells . these tumors are reported in 3.1 - 9.1% of patients with myeloblastic leukemia and occur concomitantly with , after , or rarely before the onset of leukemia . we report a case with multiple tumors involving the lymph nodes , breast and orbit . the diagnosis was established on fine needle aspiration cytology ( fnac ) of the masses which subsequently led to the diagnosis of the underlying leukemia . a 15 year - old girl presented with bilateral , cervical lymphadenopathy , bilateral breast masses , and gradually developing proptosis of both eyes , in that order . nodes were firm to hard with restricted mobility and the breast masses were 4.5 cm ( left ) and 5.0 cm ( right ) along their maximum dimension . fine needle aspiration cytology ( fnac ) was done from the lymph nodes and breast masses . both wet - fixed and air - dried smears were prepared for papanicolaou and may - grnwald giemsa ( mgg ) staining respectively . smears from lymph nodes and the breast showed similar features with a polymorphous population of large atypical cells scattered in a background of mostly mature and a few reactive lymphoid cells [ figures 1 and 2 ] . cytoplasm was pale blue and a fair number of cells showed auer rods and a few fine granules ; the background showed lymphoglandular bodies . cell morphology from both sites was suggestive of myeloid blasts , so a diagnosis of granulocytic sarcoma / extramedullary myeloid tumor was made . smears from lymph node show infiltration by numerous myelomonoblasts ( mgg , 400 ) aspirate from breast with leukemic cells ( mgg , 400 ) the peripheral smear showed normocytic , normochromic anemia with leukocytosis . total leucocyte count ( tlc ) was 48000 cells / mm with the differential count showing 70% blasts , 2% promyelocytes , 8% myelocytes , 8% metamyelocytes , 2% band forms , and 10% lymphocytes . platelet count was adequate and the blasts were as described above with mostly indented nuclei and auer rods [ figure 3 ] . out of these , a considerable proportion showed monocytoid features ; the blasts were diffusely positive for sudan black b ( sbb ) and negative for periodic acid schiff ( pas ) . non specific enolase ( nse ) was noncontributory , based on which , a diagnosis of acute myeloid leukemia ( aml)-m4 was given . peripheral smear shows myeloblasts with auer rods and cells in mitosis ( giemsa , 1000 ) the patient was started on standard chemotherapy to which she responded well . granulocytic sarcoma or extramedullary myeloid tumor may be seen in association with chronic myeloid leukemia ( cml ) , myelodysplastic syndrome , ( mds ) , myeloproliferative syndrome ( mps ) , polycythemia vera , and essential thrombocytosis . emmt may be seen in known patients of aml or may occur ( rarely ) as the first manifestation of the disease . in other cases , it may be the first sign of systemic relapse of a case of treated aml . emmts may occur at any site in the body , common ones being the skin ( leukemia cutis ) , lymph nodes , and mediastinum . other sites such as epidural , uterus , ovaries , testis , and orbits have also been reported . a few case reports have described it in the breast[13 ] where it is often misdiagnosed as lymphoma . granulocytic sarcomas of the orbit have mostly been described as isolated masses which may precede systemic manifestations . the soft tissue counterparts may present months before the involvement of peripheral blood and bone marrow . they produce symptoms according to their anatomic location but they may be asymptomatic as well . problems in diagnosis arise when they are suspected in patients without a background of myeloprolifrative disease . they may often be misdiagnosed as non - hodgkin 's lymphomas , rhabdomyosarcomas , amelanotic melanomas , or undifferentiated carcinomas . light microscopy reveals collections of cells that can be usually recognised as being myeloid . undifferentiated or minimally differentiated blasts generally pose diagnostic problems and these are cases that are misdiagnosed as lymphoma . the cells in our case were positive for sbb and myeloperoxidase ; pas was negative . immunostaining with monoclonal antibodies against myeloperoxidase ; anti - cd43 , and anti - lysozyme are the most sensitive antibodies ; cd68 and cd20 are useful in differentiating it from lymphoma . it is regarded as a poor prognostic indicator by some , whereas others have not considered it as an independent prognostic factor . if they are diagnosed in patients previously treated for aml , they signify relapse whereas in a patient of chronic myeloproliferative disease , they may be indicative of an impending blast crisis . most tumors , whether detected prior to or during the therapy of leukemia , respond well to standard chemotherapeutic agents .

granulocytic sarcomas or extramedullary myeloid tumors represent the soft tissue counterpart of acute myeloid leukemia . the term is used for any solid collection of leukemic cells . there have been reports of these tumors occurring before the involvement of blood or bone marrow . our patient had simultaneous involvement of three sites , which was diagnosed on cytology . further confirmation was done on peripheral blood and bone marrow evaluation .

alopecia areata can affect any hair - bearing area . it is a lymphocyte cell - mediated inflammatory type of hair loss , although the exact pathogenesis is unclear . phenol , also known as carbolic acid , is well known as an antiseptic agent . it is a bactericide ( > 1% ) , fungicide ( > 1.3% ) , and a local anaesthetic . at concentrations over 80% , phenol coagulates proteins . pertaining to its easy availability and affordability , it finds great usefulness in being used in many office procedures in dermatology clinics . the mechanism of action is based on its irritating property that leads to tissue necrosis . phenol has the property of penetrating into the layers of skin , and this is inversely proportional to its concentration . the application of pure , undiluted 88% phenol to the skin causes rapid and complete coagulation of epidermal keratin protein and produces a partial blockade for further chemical penetration . the more dilute solution of 50% has greater penetration and , thus , peel potency than the full strength of 88% straight phenol preparation . there is a risk of systemic absorption leading to toxicity that can be averted by dividing the desired area into small areas and using a gap of 15 min while applying phenol to each of the affected areas . a 13 year old girl presented to us with diffuse hair loss over the scalp involving more than 50% of the scalp [ figure 1 ] for the past 6 months . she had consulted many dermatologists in the past 6 months since the onset of her complains , but none of the treatment brought relief . therefore , it was not only the disease entity that we needed to consider but also the financial and psychosocial impact on the patient . after taking a prior informed consent , phenolisation was done over the bald patches with 88% phenol until a uniform ivory white frost appeared . phenol was applied all over the bald patches , covering more than 50% of scalp surface ; 1 ml of phenol was taken in a container and applied to the scalp by dipping a bud in phenol . we assume that out of 1 ml , some amount of phenol was left in the bud . she began to show response to therapy after the 2 sitting when vellus hair regrowth was evident diffusely all over the bald patches . after five sessions done with 88% phenolisation and 4 pulses of dexamethasone intravenous therapy , she showed marked improvement with well - marked hair growth over the patches . phenol has been used for the treatment of various conditions like vitiligo , molluscum contagiosum , epidermal cysts , acne scars , and facial rejuvenation . the mechanism by which phenol acts in alopecia areata is unclear ; however , various mechanisms have been proposed such as the release of various growth factors during the wound repair process that stimulate the follicles . also , various cytokines released during wound healing neutralise the peribulbar infiltrates , causing re - growth of hair through immunomodulation . lastly most of the follicles in alopecia areata are in the telogen phase and thus lie in the dermis . therefore , it is proposed that phenol passes through the follicular opening and directly stimulates the germinal centre . alopecia areata is an organ - specific autoimmune disease directed against various cellular components of hair follicles , thus dexamethasone pulse has a profound but transient action on the perifollicular lymphocytes that restores normal hair cycle . use of phenol in the concentration of 20% alone or in combination with oral mini pulse with betamethasone or 2% minoxidil has been reported previously , and it was reported that combination therapy is better than use of single agent . this could probably be because concentration of phenol used was low as compared to that in this study . the rationale for combining phenol and dexa pulse is to get a fast and better result . the patient has shown marked improvement with 5 sessions of phenol and 4 monthly pulses of dexamethasone over a period of 4 months and has not shown any relapse even after 6 months of follow - up . keeping the safe limit in consideration ,

phenol is an aromatic hydrocarbon derived from coal tar or manufactured from monochlorobenzene . alopecia areata is a common non scarring autoimmune condition characterised by patchy loss of hair without atrophy . various treatment modalities have been proposed and used for the treatment of alopecia areata , which is indeed a difficult condition to treat . variable results have been documented using intralesional corticosteroid injections , topical minoxidil , topical anthralin ointment , topical contact sensitizers like diphencyprone , dinitrochlorobenzene or squaric acid dibutyl ester , and oral mini pulse with betamethasone . the use of 88% phenol for the treatment of alopecia areata has been documented in literature , but it has failed to secure a place in the priority list . herein we have reported a case of a young girl who was treated with short - time aggressive therapy using 88% phenol and dexamethasone pulse therapy and who responded well to the treatment with no recurrence in the last 6 months of follow - up .

although cerebral hyperperfusion syndrome ( chs ) is well documented after carotid endarterectomy and carotid artery stenting , only a few cases have been described after intracranial stenting . after the stenting versus aggressive medical therapy for intracranial arterial stenosis and vitesse stent ischemic therapy trials demonstrated the inferiority of intracranial stenting compared to aggressive medical treatment , this procedure has been largely abandoned . cerebral hyperperfusion is defined as a > 100% increase in cerebral blood flow ( cbf ) compared to the baseline and it is generally associated with postprocedural hypertension . chs has an estimated incidence of 0.4%2.7% after ce and usually presents with ipsilateral headache or migrainous phenomena , seizures , or intracerebral hemorrhage ( ich ) . i would like to report an unusual case of chs following middle cerebral artery ( mca ) stenting . a 71-year - old man presented to us with fluctuating motor aphasia of 3 h duration . magnetic resonance imaging of the brain showed multiple acute infarcts in the left mca territory and he was started on antiplatelets and statins . by the next day morning , he had developed global aphasia and transient right - sided weakness . his blood pressure ( bp ) was 150/90 mm hg and he was taken up for a four - vessel digital subtraction angiography which showed a possible dissection with a thrombus in the distal left mca [ figure 1 ] . after obtaining consent , a 4 mm 15 mm solitaire ab neurovascular modeling device ( ev3 , irvine , usa ) was placed across the lesion into the superior mca division with good recanalization . postprocedure , the patient was sedated and ventilated , but had severe hypertension , exceeding 240/140 mm hg which was difficult to control even with multiple antihypertensives . the next morning , a routine computed tomography ( ct ) brain ( 12 h later ) showed two discrete intracerebral hematomas ( ich ) in the left frontal and temporal areas [ figure 1 ] . transcranial doppler ( tcd ) showed elevated mean flow velocities of > 130 cm / s in the left mca . coagulation parameters were normal . on examination , now he had a dense right hemiplegia and global aphasia . two weeks later , a repeat ct showed resolution of the ich and no fresh infarcts . the patient had a residual wernicke 's aphasia and right hemiplegia at follow - up even 6 months later . ( a ) top left panel shows an irregularity in the left middle cerebral artery m1 segment , suggestive of dissection . ( c ) bottom panels ; computed tomography scan images showing left temporal and frontal intracerebral hematomas risk factors for chs include age > 75 years , preexisting hypertension , high - grade stenosis with poor collateralization , decreased cerebrovascular reactivity , and increased peak flow velocities . reperfusion of ischemic territories can also lead to reperfusion injury , wherein oxidant production , complement activation , and increased microvascular permeability result in an impaired blood chs is a devastating complication because of the high morbidity and mortality of nearly 60%80% associated with this condition . after cerebral revascularization , the advent of severe headache , seizures , or focal neurological deficits after cerebral revascularization should be presumed to signify chs unless proved otherwise . tcd studies are helpful in monitoring elevated peak systolic velocities in the intracranial arteries as a marker of impending chs . in about 15% of patients , in such patients , near - infrared spectroscopy may be a useful option to monitor cbf . all critical care physicians should be aware of this entity for better monitoring and prevention of this postprocedural complication in the icu .

cerebral hyperperfusion syndrome ( chs ) is a rare complication following cerebral revascularization . it presents with ipsilateral headache , seizures , and intracerebral hemorrhage . it has mostly been described following extracranial carotid endarterectomy and stenting and it is very unusual after intracranial stenting . a 71-year - old man with a stuttering stroke was taken up for a cerebral angiogram ( digital subtraction angiography ) , which showed a dissection of the distal left middle cerebral artery . this was recanalized with a solitaire ab stent . after 12 h , the patient developed a right hemiplegia and aphasia . computed tomography brain showed two discrete intracerebral hematomas in the left hemisphere . this is the first reported case of chs following intracranial stenting from india .

cage : cap analysis of gene expression , a method based on selection of rnas containing the 5 cap modification and obtaining short sequences or tags near the 5 end of these rnas . encode : encyclopedia of dna elements , an nhgri - sponsored project aimed at empirically identifying functionally important element in the human genome sequence , http://www.genome.gov/10005107 . genomic dark matter : usually refers to the portion of a genome that does not correspond to exons ( coding or non - coding ) of annotated mrnas . outward positioned primers to amplify toward the 5 and 3 end of an rna molecule from a point inside the molecule . rnaseq : a method to quantify and profile rna population in a cell based on massive sequencing of short ( typically less than 100 bases ) regions of a large number of rna molecules . typically , sequencing is conducted on cdna , rather than rna , thus cdnaseq would have been more appropriate . however , rnaseq is used for historical reasons . a note , since direct rna sequencing is now possible , a bona fide rnaseq analysis should somehow be distinguished from cdnaseq . single - molecule sequencing : a method where a single - molecule of a nucleic acid is sequenced directly as opposed methods that obtain sequence signal from a population of molecules . tiling array : a microarray platform designed to interrogate genomic sequence with a certain resolution set by the distance between the probes . opposite in concept to exon arrays where probes are designed only to the annotated regions of interest . vlinc : very long intergenic non - coding rna region , identified based on continuous rnaseq signal that spans genomic regions of 50 kb or longer ( often much longer ) in the area of genome where no annotated gene has been found . the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest .

the mysteries surrounding the 9798% of the human genome that does not encode proteins have long captivated imagination of scientists . does the protein - coding , 23% of the genome carry the 9798% as a mere passenger and neutral cargo on the evolutionary path , or does the latter have biological function ? on one side of the debate , many commentaries have referred to the non - coding portion of the genome as selfish or junk dna ( orgel and crick , 1980 ) , while on the other side , authors have argued that it contains the real blueprint for organismal development ( penman , 1995 ; mattick , 2003 ) , and the mechanisms of developmental complexity . thus , this question could be referred to without much exaggeration as the most important issue in genetics today .

a 57-year - old man was referred to samsung medical center with abrupt confusion , fever , and loss of vision in both eyes . the patient was in his usual state of health until two weeks prior , when he began to develop sudden loss of vision in his right eye . in another hospital , he was diagnosed with retinal vasculitis in his right eye and was prescribed oral prednisolone , 60 mg / day for three days , followed by 120 mg / day for three days . the retinal vasculitis did not respond to oral prednisolone , so he was treated with intravenous methylprednisolone , 1 g / day for five days . two days after initiation of intravenous methylprednisolone , he complained of decreased vision in his left eye . one week after initiation of intravenous methylprednisolone , he became drowsy and high fever occurred , and he was then referred to samsung medical center . on neurological examination , he was drowsy and confused to time and place orientation . his brain magnetic resonance imaging ( mri ) showed a hyper - intense lesion in the left medial temporal and bilateral medial occipital areas on t2-weight images , suggestive of hse ( fig . cerebrospinal fluid ( csf ) study revealed 11 cells / ml ( lymphocytes 90% ) , low protein ( 19.3 mg / dl ) , and normal range glucose concentration ( 63 mg / dl compared to 110 mg / dl in serum ) . an empirical antiviral agent one week later pcr of the csf was revealed to be positive for hsv-1 dna . on the night of admission , his electroencephalography showed sharp waves in left or right anterior temporal areas ( f7t7 , f8t8 maximum ) with a frequency of 1/min and diffuse slow waves . an antiepileptic drug ( phenytoin 300 mg / d ) was administered and no more epileptic seizure recurred . on the day of admission , his visual acuity was perception of light in both eyes . fundus examination showed retinal hemorrhage , confluent retinal necrosis affecting almost the whole retina , vascular sheathing involving both arterioles and venules , optic disc swelling , and exudative retinal detachment in both eyes ( fig . infectious retinitis including acute retinal necrosis was suspected , but in terms of the location of necrosis , his clinical features were not typical of arn diagnostic vitrectomy confirmed the presence of hsv-1 . after administration of intravenous acyclovir for 14 days , his systemic symptoms consistent with encephalitis slowly resolved , but his vision was not restored . on follow - up examination , retinal necrosis did not progress , but he still suffered from severe bilateral ocular pain with partial improvement of the exudative retinal detachment ( fig . 2c , d ) . thus , intravitreal ganciclovir injection ( 5,000/0.05 g / ml ) causes pain relief and decreased intraocular inflammation . atrophy was found six weeks later , thus vitrectomy with silicone oil tamponade was done in the right eye . cases with arn following hse have been uncommonly reported,59 and to our knowledge , this is the first report of the reverse situation , hse following arn , in even an immune - competent patient . arn associated with hse is known to be caused by axonal transmission of a reactivated latent virus from the brain to the retina , and retinitis occasionally occurs after the encephalitis . as shown by our patient , this is consistent with the finding that herpes virus uses bidirectional fast - axonal transport in neurons.11 arn usually presents as retinal necrosis with discrete borders located in the peripheral retina , rapid progression , circumferential spread , occlusive vasculopathy with arterial involvement , and a prominent inflammatory reaction in the vitreous and anterior chamber.3 our patient was initially diagnosed with retinal vasculitis and treated with a high - dose systemic corticosteroid , which was not effective . corticosteroids are known to affect cellular immunity and may promote viral replication . intraocular or systemic corticosteroids may induce retinal necrosis in patients with viral infection . thus , it is recommended that corticosteroids should be used in combination with antiviral agents or after beginning antiviral therapy.12 in this patient , the contralateral eye became infected , and hse occurred during initial corticosteroid therapy without antiviral medication . in cases with an unusual clinical course , especially in retinal vasculitis with arterial involvement , , arn may be a risk factor for hse , even in an immune - competent patient . the virus may reach the brain from the eye by a trans - axonal route . systemic steroid therapy may have exacerbated herpes viral infection in the retina , with subsequent spread to the contralateral eye and brain .

acute retinal necrosis ( arn ) , a viral retinal disease with poor visual prognosis , following herpes simplex encephalitis ( hse ) are uncommonly seen , and there has been no case yet reported of the reverse situation . we herein present the reverse situation , an immune - competent patient with hse following arn . a 57-year - old man who had been under steroid therapy for retinal vasculitis the prior two weeks , presented with abrupt confusion and high fever . his cerebrospinal fluid study and brain magnetic resonance imaging revealed typical hse . ophthalmic examination and polymerase chain reaction of the vitreous specimen revealed arn by herpes simplex virus type 2 . intravenous acyclovir treatment improved his encephalitis symptoms and retinal necrosis . this case implies that arn may be a risk factor for hse and the virus may reach the brain from the eye . inappropriate administration of a systemic steroid may exacerbate herpes viral infection in the retina , with subsequent spread to the brain .