Revised_E3C_EN_Test.tsv

we	O
present	O
a	O
case	O
of	O
a	O
77	O
-	O
year-old	O
caucasian	O
woman	O
with	O
obstructive	B-ety
jaundice	I-ety
.	O

laboratory	O
tests	O
revealed	O
that	O
she	O
had	O
elevated	B-ety
bilirubin	I-ety
and	I-ety
liver	I-ety
enzyme	I-ety
levels	I-ety
.	O

A	O
computed	O
tomographic	O
scan	O
showed	O
a	O
homogeneous	O
5	O
×	O
3	O
-	O
cm	O
mass	O
obstructing	O
the	O
common	O
bile	O
duct	O
.	O

the	O
results	O
of	O
brush	O
cytology	O
were	O
consistent	O
with	O
a	O
bile	O
duct	O
villous	B-ety
papilloma	I-ety
.	O

however	O
,	O
on	O
the	O
basis	O
of	O
the	O
tumor's	B-ety
radiological	O
features	O
,	O
a	O
preliminary	O
diagnosis	O
of	O
extrahepatic	B-ety
bile	I-ety
duct	I-ety
malignant	I-ety
tumor	I-ety
was	O
made	O
.	O

after	O
discussion	O
among	O
the	O
multidisciplinary	O
team	O
,	O
a	O
surgical	O
resection	O
of	O
the	O
bile	B-ety
duct	I-ety
tumor	I-ety
was	O
performed	O
.	O

histopathological	O
examination	O
confirmed	O
a	O
villous	B-ety
adenoma	I-ety
.	O

the	O
patient's	O
postoperative	O
course	O
was	O
uneventful	O
.	O

A	O
65	O
year-old	O
woman	O
with	O
hypertension	B-ety
and	O
parkinson's	B-ety
disease	I-ety
presented	O
with	O
sudden	O
onset	O
severe	O
chest	B-ety
pain	I-ety
.	O

electrocardiogram	O
showed	O
ischemic	O
st-segment	B-ety
elevation	I-ety
in	O
inferior	O
and	O
lateral	O
leads	O
.	O

urgent	O
cardiac	O
catheterization	O
revealed	O
focal	O
dissections	O
in	O
four	O
small	O
caliber	O
coronary	O
arteries	O
in	O
right	O
and	O
left	O
coronary	O
systems	O
including	O
right	O
posterior	O
decending	O
,	O
posterolateral	O
,	O
obtuse	O
marginal	O
and	O
septal	O
arteries	O
.	O

angiography	O
demonstrated	O
no	O
significant	O
atherosclerotic	B-ety
coronary	I-ety
artery	I-ety
disease	I-ety
.	O

the	O
patient	O
was	O
medically	O
managed	O
with	O
eptifibatide	O
,	O
aspirin	O
,	O
clopidogrel	O
and	O
beta	O
blocker	O
since	O
dissected	B-ety
vessels	I-ety
were	O
not	O
technically	O
suitable	O
for	O
percutaneous	O
coronary	O
intervention	O
.	O

antiparkinson	O
medications	O
were	O
held	O
as	O
a	O
potential	O
cause	O
of	O
dissection	O
.	O

she	O
responded	O
well	O
to	O
medical	O
management	O
.	O

A	O
45	O
year	O
old	O
indian	O
female	O
of	O
nordic	O
origin	O
presented	O
5	O
years	O
back	O
with	O
a	O
lump	B-ety
in	I-ety
the	I-ety
right	I-ety
breast	I-ety
and	I-ety
the	I-ety
axilla	I-ety
.	O

she	O
underwent	O
modified	O
radical	O
mastectomy	O
.	O

histophotomicrograph	O
of	O
the	O
excised	O
breast	B-ety
lesion	I-ety
showed	O
a	O
2.1	O
cm	O
duct	B-ety
carcinoma	I-ety
,	O
positive	O
for	O
ER	O
and	O
PR	O
with	O
1	O
out	O
of	O
25	O
lymph	B-ety
nodes	I-ety
positive	I-ety
for	I-ety
metastasis	I-ety
.	O

she	O
received	O
6	O
cycles	O
of	O
chemotherapy	O
with	O
cyclophosphamide	O
,	O
epirubicin	O
,	O
and	O
5	O
-	O
fluorouracil	O
.	O

this	O
was	O
followed	O
by	O
tamoxifen	O
20	O
mg	O
per	O
day	O
for	O
five	O
years	O
.	O

she	O
was	O
doing	O
well	O
on	O
follow	O
up	O
until	O
the	O
completion	O
of	O
fifth	O
year	O
of	O
her	O
disease	O
,	O
when	O
she	O
presented	O
with	O
complaints	O
of	O
mild	B-ety
fever	I-ety
and	O
weakness	B-ety
.	O

examination	O
revealed	O
generalized	B-ety
lymph	I-ety
node	I-ety
enlargement	I-ety
along	O
with	O
hepatomegaly	B-ety
.	O

hemogram	O
showed	O
mild	B-ety
anemia	I-ety
,	O
normal	O
platelet	O
count	O
and	O
a	O
leukocyte	O
count	O
of	O
1.2	O
x	O
10	O
(	O
11	O
)	O
/	O
L	O
.	O

peripheral	O
blood	O
examination	O
revealed	O
medium	O
sized	O
lymphoid	O
cells	O
,	O
constituting	O
almost	O
75%	O
of	O
total	O
nucleated	O
cell	O
population	O
.	O

immunophenotying	O
,	O
established	O
a	O
diagnosis	O
of	O
post	O
thymic	O
t-cell	B-ety
prolymphocytic	I-ety
leukemia	I-ety
.	O

contrast-enhanced	O
computed	O
tomography	O
of	O
the	O
chest	O
and	O
abdomen	O
was	O
done	O
which	O
revealed	O
an	O
anterior	B-ety
mediastinal	I-ety
mass	I-ety
with	O
destruction	O
of	O
sternum	O
along	O
with	O
multiple	O
small	O
nodular	O
shadows	O
in	O
bilateral	O
lung	O
fields	O
suggestive	O
of	O
lung	B-ety
metastasis	I-ety
.	O

fine	O
needle	O
aspiration	O
cytology	O
of	O
the	O
mass	O
showed	O
atypical	O
ductal	O
cells	O
with	O
nuclear	O
pleomorphism	O
,	O
which	O
were	O
positive	O
for	O
ER	O
,	O
PR	O
and	O
her2neu	O
protein	O
.	O

this	O
confirmed	O
a	O
co-existent	O
metastatic	B-ety
breast	I-ety
carcinoma	I-ety
.	O

she	O
was	O
started	O
on	O
chemotherapy	O
for	O
T-PLL	B-ety
along	O
with	O
hormonal	O
therapy	O
with	O
aromatase	O
inhibitor	O
.	O

unfortunately	O
,	O
both	O
her	O
malignancies	O
progressed	O
after	O
an	O
initial	O
stable	O
disease	O
of	O
two	O
months	O
.	O

A	O
male	O
,	O
63	O
years	O
old	O
,	O
complaining	O
about	O
a	O
""	O
wound	O
in	O
the	O
mouth	O
""	O
for	O
6	O
months	O
,	O
without	O
any	O
pain	B-ety
or	O
spontaneous	O
bleeding	B-ety
.	O

his	O
medical	O
history	O
was	O
free	O
of	O
disease	O
.	O

the	O
patient	O
was	O
a	O
smoker	B-ety
for	O
33	O
years	O
.	O

intraoral	O
examination	O
revealed	O
a	O
destructive	O
ulcerative	B-ety
lesion	I-ety
around	O
the	O
upper	O
left	O
first	O
and	O
second	O
molars	O
that	O
resembled	O
an	O
oral	B-ety
squamous	I-ety
cell	I-ety
carcinoma	I-ety
.	O

biopsy	O
of	O
the	O
ulcerative	B-ety
lesion	I-ety
was	O
performed	O
and	O
the	O
microscopic	O
features	O
showed	O
an	O
inflammatory	B-ety
infiltrate	I-ety
rich	O
in	O
plasma	O
cells	O
.	O

based	O
on	O
this	O
microscopical	O
finding	O
,	O
the	O
final	O
diagnosis	O
was	O
periodontal	B-ety
disease	I-ety
associated	O
with	O
a	O
proliferative	O
non-neoplastic	O
lesion	B-ety
.	O

the	O
patient	O
was	O
referred	O
to	O
a	O
specialized	O
dental	O
surgeon	O
and	O
underwent	O
periodontal	O
therapy	O
including	O
surgical	O
procedures	O
.	O

after	O
that	O
,	O
according	O
to	O
follow-up	O
with	O
the	O
patient	O
,	O
there	O
were	O
no	O
signs	O
of	O
disease	O
remission	O
.	O

the	O
lesion	B-ety
increased	O
in	O
size	O
,	O
although	O
the	O
patient	O
did	O
not	O
complain	O
of	O
any	O
symptoms	O
.	O

A	O
second	O
biopsy	O
was	O
performed	O
and	O
the	O
microscopic	O
features	O
again	O
showed	O
a	O
rich	O
inflammatory	B-ety
infiltrate	I-ety
with	O
mononuclear	O
cells	O
and	O
histiocytic	O
cells	O
,	O
characterized	O
by	O
pale	O
histiocytes	O
with	O
lobed	O
nuclei	O
,	O
resembling	O
a	O
bean	O
.	O

A	O
varying	O
number	O
of	O
eosinophils	O
also	O
were	O
observed	O
,	O
without	O
any	O
evidence	O
of	O
atypical	O
cells	O
present	O
in	O
this	O
infiltrate	O
.	O

an	O
immunohistochemical	O
staining	O
panel	O
was	O
done	O
to	O
determine	O
the	O
nature	O
of	O
this	O
inflammatory	B-ety
infiltrate	I-ety
by	O
using	O
antibodies	O
S	O
-	O
100	O
,	O
cd1a	O
,	O
CD	O
-	O
68	O
and	O
CD45RO	O
that	O
were	O
positive	O
.	O

these	O
immunohistochemical	O
findings	O
were	O
fundamental	O
for	O
the	O
final	O
diagnosis	O
of	O
LCH	B-ety
.	O

the	O
treatment	O
included	O
surgical	O
extraction	O
of	O
all	O
superior	O
teeth	O
,	O
radiation	O
and	O
systemic	O
corticoid	O
therapies	O
.	O

after	O
8	O
years	O
of	O
treatment	O
,	O
the	O
patient	O
is	O
free	O
of	O
disease	O
.	O

A	O
12	O
-	O
year-old	O
girl	O
was	O
referred	O
to	O
department	O
of	O
oral	O
surgery	O
,	O
with	O
a	O
complaint	O
of	O
pain	B-ety
and	I-ety
swelling	I-ety
in	I-ety
the	I-ety
left	I-ety
of	I-ety
maxilla	I-ety
that	O
appeared	O
3	O
months	O
ago	O
.	O

the	O
swelling	B-ety
was	O
slowly	O
progressive	O
,	O
associated	O
with	O
pain	B-ety
.	O

however	O
,	O
the	O
patient	O
did	O
not	O
refer	O
any	O
motor	O
or	O
sensory	O
deficit	O
.	O

there	O
was	O
no	O
family	O
history	O
of	O
similar	O
swelling	B-ety
.	O

physical	O
examination	O
revealed	O
a	O
left	O
maxillary	B-ety
swelling	I-ety
.	O

there	O
was	O
no	O
facial	B-ety
palsy	I-ety
.	O

no	O
cervical	O
lymph	O
node	O
enlargement	O
was	O
seen	O
.	O

the	O
oral	O
examination	O
showed	O
a	O
4	O
cm	O
x	O
5	O
cm	O
,	O
tender	O
,	O
compressible	O
mass	O
in	O
the	O
left	O
maxilla	O
,	O
from	O
the	O
lateral	O
incisor	O
to	O
the	O
second	O
premolar	O
teeth	O
.	O

the	O
tumor	B-ety
surface	O
was	O
smooth	O
and	O
red-purple	O
.	O

several	O
teeth	O
were	O
involved	O
and	O
displaced	O
in	O
the	O
tumor	B-ety
mass	I-ety
.	O

we	O
noted	O
the	O
absence	O
of	O
canine	O
.	O

vitality	O
tests	O
proved	O
negative	O
on	O
the	O
central	O
and	O
lateral	O
incisor	O
.	O

hight	O
mobility	O
of	O
lateral	O
incisor	O
was	O
noted	O
.	O

orthopantomography	O
and	O
occlusal	O
radiography	O
showed	O
a	O
wide	O
osteolytic	O
area	O
of	O
the	O
anterior	O
left	O
maxilla	O
,	O
extending	O
from	O
the	O
first	O
permanent	O
molar	O
to	O
the	O
central	O
incisor	O
.	O

the	O
canine	O
was	O
impacted	O
.	O

no	O
root	O
resorption	O
was	O
observed	O
.	O

the	O
radiolucency	O
was	O
closely	O
related	O
to	O
maxillary	O
sinus	O
and	O
involving	O
the	O
nasal	O
cavity	O
.	O

haematological	O
investigations	O
showed	O
normal	O
serum	O
calcium	O
,	O
phosphorus	O
and	O
parathormone	O
(	O
PTH	O
)	O
levels	O
.	O

the	O
provisional	O
diagnosis	O
of	O
benign	B-ety
tumor	I-ety
of	I-ety
the	I-ety
maxilla	I-ety
was	O
made	O
.	O

the	O
patient	O
underwent	O
excision	O
and	O
curettage	O
of	O
the	O
mass	O
with	O
extraction	O
of	O
the	O
canine	O
and	O
lateral	O
incisor	O
tooth	O
.	O

the	O
wound	O
was	O
closed	O
with	O
interrupted	O
sutures	O
.	O

the	O
post-operative	O
histopathological	O
report	O
revealed	O
multinuclear	O
giant	O
cells	O
scattered	O
randomly	O
throughout	O
the	O
cellular	O
and	O
fibrous	O
vascular-rich	O
tissue	O
.	O

new	O
bone	O
formation	O
and	O
granulation	O
tissue	O
rich	O
in	O
mononuclear	O
inflammatory	O
cells	O
was	O
revealed	O
.	O

the	O
giant	O
cells	O
were	O
multinucleated	O
with	O
bland-appearing	O
nuclei	O
,	O
and	O
the	O
background	O
stromal	O
cells	O
displayed	O
no	O
evidence	O
of	O
atypical	O
mitoses	O
.	O

A	O
diagnosis	O
of	O
giant	B-ety
cell	I-ety
tumor	I-ety
was	O
established	O
.	O

during	O
a	O
1	O
-	O
year	O
serial	O
clinical	O
and	O
radiological	O
follow-up	O
,	O
there	O
was	O
no	O
evidence	O
of	O
recurrence	O
.	O

the	O
facial	O
contour	O
and	O
masticatory	O
function	O
were	O
well-preserved	O
.	O

A	O
19	O
-	O
year-old	O
healthy	O
man	O
was	O
admitted	O
to	O
our	O
cardiology	O
department	O
following	O
a	O
syncopal	B-ety
episode	I-ety
.	O

his	O
past	O
medical	O
history	O
was	O
unremarkable	O
.	O

he	O
no	O
family	O
history	O
of	O
heart	B-ety
disease	I-ety
or	O
sudden	B-ety
death	I-ety
.	O

two-days	O
prior	O
the	O
syncope	B-ety
,	O
he	O
developed	O
chest	B-ety
pain	I-ety
and	O
an	O
influenza-like	B-ety
illness	I-ety
consisting	O
of	O
fevers	B-ety
,	O
rhinorrhea	B-ety
,	O
and	O
sore	B-ety
throat	I-ety
.	O

at	O
the	O
physical	O
exam	O
,	O
the	O
patient	O
was	O
febrile	B-ety
at	O
39	O
°	O
C	O
.	O

he	O
had	O
an	O
inflamed	O
throat	O
,	O
bradycardia	B-ety
at	O
cardiac	O
auscultation	O
and	O
there	O
were	O
no	O
signs	O
of	O
heart	O
failure	O
.	O

the	O
electrocardiogram	O
(	O
EKG	O
)	O
showed	O
grade	O
III	O
atrioventricular	O
(	O
AV	B-ety
)	O
bloc	O
with	O
a	O
ventricular	O
rate	O
of	O
38	O
beats	O
per	O
minute	O
.	O

laboratory	O
studies	O
were	O
remarkable	O
for	O
a	O
hs-troponin	O
level	O
181ng	O
/	O
L	O
,	O
a	O
white	O
blood	O
cell	O
count	O
of	O
14270	O
/	O
mm³	O
with	O
48%	O
lymphocytes	O
,	O
and	O
elevated	B-ety
c-reactive	I-ety
protein	I-ety
at	O
90mg	O
/	O
L	O
.	O

serum	O
electrolytes	O
,	O
kidney	O
and	O
liver	O
functions	O
were	O
within	O
normal	O
limits	O
.	O

A	O
chest	O
x-ray	O
showed	O
an	O
appropriate	O
cardiac	O
size	O
.	O

the	O
initial	O
transthoracic	O
echocardiography	O
(	O
TTE	O
)	O
showed	O
a	O
normal	O
global	O
left	O
ventricular	O
function	O
(	O
left	O
ventricular	O
ejection	O
fraction	O
(	O
LVEF	O
)	O
60%	O
)	O
and	O
wall	O
motion	O
abnormalities	O
(	O
anteroseptal	O
hypokinesia	B-ety
)	O
,	O
with	O
reduced	O
left	O
ventricular	O
global	O
longitudinal	O
strain	O
(	O
LV	O
GLS	O
=	O
-	O
14.1%	O
)	O
.	O

cardiac	O
magnetic	O
resonance	O
(	O
CMR	O
)	O
showed	O
increased	O
signal	O
intensity	O
at	O
the	O
mid-lateral	O
wall	O
on	O
T2	O
-	O
weighted	O
images	O
.	O

late	O
enhancement	O
revealed	O
a	O
patchy	O
subepicardial	O
hyperenhancement	O
of	O
the	O
medio-distal	O
segments	O
of	O
the	O
anterior	O
and	O
anterolateral	O
walls	O
which	O
confirm	O
the	O
diagnosis	O
of	O
myocarditis	B-ety
.	O

the	O
patient	O
was	O
treated	O
with	O
cefotaxime	O
and	O
doxycycline	O
.	O

all	O
serological	O
tests	O
(	O
chlamydia	O
,	O
coxiella	O
,	O
mycoplasma	O
,	O
rickettsia	O
,	O
lyme	O
and	O
bartonella	O
)	O
obtained	O
during	O
the	O
hospitalization	O
were	O
negative	O
.	O

five	O
days	O
later	O
,	O
the	O
patient	O
was	O
asymptomatic	O
.	O

the	O
24	O
hours	O
ECG	O
monitoring	O
showed	O
a	O
sinus	O
rhythm	O
.	O

the	O
TTE	O
revealed	O
a	O
normal	O
LVEF	O
and	O
an	O
improvement	O
in	O
the	O
LVGLS	O
with	O
segmental	O
reduced	O
values	O
concordant	O
with	O
the	O
CMR	O
abnormalities	O
.	O

at	O
one-month	O
follow-up	O
the	O
patient	O
made	O
a	O
full	O
recovery	O
without	O
any	O
recurring	O
cardiovascular	O
symptoms	O
or	O
abnormal	O
electrocardiographic	O
or	O
echocardiographic	O
findings	O
.	O

A	O
50	O
-	O
years-old	O
woman	O
,	O
hypertensive	B-ety
,	O
hospitalized	O
for	O
a	O
large	O
cervical	B-ety
mass	I-ety
appeared	O
30	O
years	O
ago	O
.	O

in	O
the	O
family	O
history	O
,	O
her	O
mother	O
,	O
sisters	O
and	O
cousins	O
underwent	O
a	O
surgery	O
for	O
MNG	B-ety
.	O

despite	O
of	O
the	O
large	O
volume	O
of	O
the	O
mass	B-ety
,	O
the	O
patient	O
never	O
described	O
signs	O
of	O
cervical	B-ety
compression	I-ety
whatsoever	O
respiratory	B-ety
,	I-ety
digestive	I-ety
,	I-ety
laryngeal	I-ety
,	I-ety
vascular	I-ety
or	I-ety
neurologic	I-ety
signs	I-ety
.	O

she	O
never	O
suffered	O
from	O
thyroid	B-ety
dysfunction	I-ety
.	O

her	O
neck	O
was	O
deformed	O
by	O
the	O
voluminous	O
formation	O
classified	O
grade	O
III	O
according	O
to	O
the	O
WHO	O
modified	O
classification	O
.	O

the	O
mass	B-ety
took	O
the	O
front	O
and	O
the	O
two	O
sides	O
of	O
the	O
neck	O
.	O

its	O
surface	O
was	O
embossed	O
and	O
covered	O
by	O
a	O
thin	O
normal	O
skin	O
.	O

there	O
were	O
some	O
veins	O
of	O
the	O
collateral	O
circulation	O
limited	O
to	O
the	O
neck	O
.	O

the	O
goiter	B-ety
measured	O
18	O
x	O
11	O
cm	O
.	O

the	O
mass	B-ety
was	O
firm	O
,	O
painless	O
,	O
and	O
mobile	O
with	O
the	O
swallowing	O
movements	O
.	O

lymphadenopathy	B-ety
research	O
was	O
difficult	O
and	O
found	O
no	O
palpable	O
lymph	O
nodes	O
.	O

the	O
laboratory	O
tests	O
(	O
T	O
3	O
,	O
T	O
4	O
and	O
TSH	O
)	O
were	O
normal	O
.	O

thoracic	O
radiography	O
showed	O
a	O
large	O
cervical	O
opacity	O
roughly	O
round	O
and	O
strewn	O
with	O
microcalcifications	B-ety
associated	O
with	O
a	O
right	O
eccentricity	O
of	O
the	O
trachea	O
.	O

cervical	O
and	O
chest	O
CT	O
revealed	O
the	O
presence	O
of	O
a	O
partially	O
calcified	O
thyroid	B-ety
mass	I-ety
slightly	O
plunging	O
in	O
the	O
anterior	O
mediastinum	O
.	O

it	O
took	O
heterogeneously	O
the	O
contrast	O
and	O
then	O
evocate	O
a	O
large	O
MNG	B-ety
.	O

the	O
trachea	O
was	O
surrounded	O
by	O
the	O
goiter	B-ety
,	O
slightly	O
narrowed	O
and	O
right	O
deviated	O
as	O
well	O
as	O
the	O
lower	O
part	O
of	O
the	O
larynx	O
.	O

the	O
right	O
and	O
left	O
vascular	O
axes	O
of	O
the	O
neck	O
(	O
carotid	O
artery	O
and	O
jugular	O
vein	O
)	O
were	O
deviated	O
backward	O
.	O

the	O
patient	O
underwent	O
a	O
surgery	O
for	O
her	O
enormous	O
MNG	B-ety
slightly	O
plunging	O
in	O
the	O
mediastinum	O
.	O

endotracheal	O
intubation	O
was	O
relatively	O
easy	O
by	O
the	O
laryngoscope	O
.	O

the	O
incision	O
performed	O
was	O
a	O
kocher	O
cervicotomy	O
.	O

there	O
was	O
a	O
multinodular	O
,	O
hypervascularized	O
goiter	O
.	O

its	O
lower	O
end	O
plunges	O
behind	O
the	O
sternal	O
manubrium	O
.	O

the	O
larynx	O
was	O
deviated	O
towards	O
the	O
right	O
side	O
.	O

the	O
total	O
thyroidectomy	O
was	O
performed	O
in	O
two	O
steps	O
:	O
initially	O
a	O
right	O
lobo-isthmectomy	O
,	O
then	O
the	O
left	O
lobectomy	O
.	O

the	O
retrosternal	O
part	O
of	O
the	O
goiter	B-ety
was	O
released	O
using	O
the	O
finger	O
by	O
the	O
same	O
incision	O
.	O

both	O
recurrent	O
laryngeal	O
nerves	O
(	O
RLN	O
)	O
were	O
not	O
identified	O
because	O
of	O
the	O
hemorrhage	B-ety
.	O

one	O
parathyroid	O
gland	O
was	O
accidently	O
devascularized	O
and	O
was	O
autotransplanted	O
to	O
the	O
ipsilateral	O
sternocleidomastoid	O
muscle	O
.	O

the	O
operation	O
was	O
finished	O
by	O
double	O
aspiration	O
drainage	O
.	O

in	O
the	O
first	O
hours	O
after	O
surgery	O
,	O
the	O
patient	O
developed	O
a	O
large	O
cervical	O
hematoma	B-ety
.	O

she	O
was	O
readmitted	O
to	O
the	O
operating	O
room	O
,	O
and	O
after	O
evacuation	O
of	O
the	O
hematoma	B-ety
there	O
was	O
no	O
vessels	O
bleeding	B-ety
.	O

the	O
operation	O
was	O
completed	O
with	O
a	O
double	O
suction	O
drainage	O
.	O

in	O
the	O
immediate	O
postoperative	O
period	O
,	O
the	O
patient	O
developed	O
hemodynamic	B-ety
collapse	I-ety
requiring	O
the	O
introduction	O
of	O
dobutamine	O
.	O

after	O
48	O
hours	O
of	O
hemodynamic	O
support	O
,	O
the	O
blood	O
pressure	O
stabilized	O
and	O
dobutamine	O
was	O
stopped	O
.	O

histological	O
study	O
concluded	O
in	O
multinodular	B-ety
colloid	I-ety
goiter	I-ety
.	O

the	O
patient	O
was	O
discharged	O
from	O
the	O
hospital	O
after	O
20	O
days	O
in	O
good	O
health	O
.	O

A	O
29	O
-	O
year-old	O
man	O
was	O
admitted	O
to	O
our	O
hospital	O
with	O
an	O
unidentified	O
fever	B-ety
.	O

he	O
was	O
diagnosed	O
with	O
malignant	B-ety
lymphoma	I-ety
(	O
extra-nodal	B-ety
NK	I-ety
/	I-ety
T	I-ety
cell	I-ety
lymphoma	I-ety
nasal	I-ety
type	I-ety
)	I-ety
,	O
and	O
chemotherapy	O
was	O
administered	O
.	O

after	O
chemotherapy	O
,	O
nodular	O
lung	B-ety
shadows	I-ety
along	O
with	O
new	O
brain	B-ety
,	I-ety
cervical	I-ety
,	I-ety
and	I-ety
myocardial	I-ety
abscesses	I-ety
appeared	O
,	O
despite	O
anti-bacterial	O
/	O
fungal	O
therapy	O
.	O

gene	O
analysis	O
of	O
the	O
cervical	O
abscess	O
biopsy	O
revealed	O
the	O
presence	O
of	O
aspergillus	B-ety
fumigatus	I-ety
species	O
,	O
and	O
the	O
transesophageal	O
echocardiogram	O
showed	O
a	O
mobile	O
mural	O
vegetation	B-ety
in	O
the	O
left	O
ventricle	O
(	O
22	O
×	O
8	O
mm	O
)	O
.	O

he	O
underwent	O
surgical	O
resection	O
of	O
this	O
mural	O
vegetation	B-ety
.	O

his	O
postoperative	O
course	O
was	O
uneventful	O
.	O

he	O
remains	O
healthy	O
at	O
28	O
months	O
after	O
surgery	O
with	O
continued	O
oral	O
antifungal	O
therapy	O
.	O

we	O
present	O
here	O
a	O
case	O
of	O
macrophage	B-ety
activation	I-ety
syndrome	I-ety
associated	O
with	O
griscelli	B-ety
syndrome	I-ety
type	I-ety
2	I-ety
in	O
a	O
3	O
-	O
years-old	O
male	O
born	O
of	O
consanguineous	O
parentage	O
.	O

his	O
birth	O
histories	O
,	O
his	O
familie	O
social	O
history	O
and	O
developmental	O
milestones	O
were	O
unremarkable	O
.	O

he	O
was	O
born	O
at	O
full	O
term	O
with	O
no	O
antenatal	O
or	O
perinatal	B-ety
complications	I-ety
,	O
he	O
was	O
on	O
exclusively	O
breast-fed	O
,	O
food	O
diversification	O
was	O
started	O
at	O
6	O
months	O
old	O
,	O
his	O
weight	O
,	O
length	O
and	O
psychomotor	O
development	O
were	O
within	O
the	O
normal	O
range	O
,	O
the	O
child	O
was	O
described	O
as	O
a	O
good	O
eater	O
,	O
was	O
on	O
a	O
normal	O
diet	O
and	O
was	O
thriving	O
appropriately	O
.	O

furthermore	O
the	O
boy	O
presented	O
a	O
progressive	O
abdominal	B-ety
distension	I-ety
since	O
birth	O
,	O
progressive	O
pallor	B-ety
and	O
recurrent	O
episodes	O
of	O
fever	B-ety
since	O
1	O
year	O
of	O
age	O
.	O

there	O
was	O
history	O
of	O
blood	O
transfusions	O
for	O
last	O
2	O
months	O
.	O

on	O
the	O
other	O
side	O
there	O
was	O
no	O
history	O
of	O
jaundice	B-ety
,	O
vomiting	B-ety
,	O
urinary	O
or	O
bowel	B-ety
complaints	I-ety
,	O
bleeding	B-ety
from	O
any	O
site	O
or	O
neurological	O
complaints	O
.	O

on	O
admission	O
,	O
he	O
was	O
very	O
pale	O
with	O
silvery	O
gray	O
scalp	O
hair	O
,	O
white	B-ety
eyelashes	I-ety
,	O
he	O
was	O
hypotonic	B-ety
,	O
tachycardic	B-ety
,	O
fever	B-ety
of	O
40	O
°	O
C	O
,	O
lymphoadenopathy	B-ety
and	O
hepato-splenomegaly	B-ety
.	O

the	O
blood	O
count	O
showed	O
pancytopenia	B-ety
;	O
1980	O
white	O
blood	O
cells	O
/	O
µl	O
(	O
VN	O
4000	O
-	O
13	O
500	O
/	O
µl	O
)	O
,	O
neutrophils	O
820	O
/	O
µl	O
,	O
910	O
cells	O
/	O
µl	O
,	O
hemoglobin	O
(	O
hb	O
)	O
6.3	O
g	O
/	O
dl	O
(	O
11.5	O
-	O
14	O
VN	O
,	O
5	O
g	O
/	O
dl	O
)	O
,	O
platelets	O
44	O
000	O
/	O
µl	O
(	O
VN	O
150	O
000	O
-	O
400	O
000	O
/	O
µl	O
)	O
,	O
there	O
were	O
no	O
giant	O
cytoplasmic	B-ety
granules	I-ety
in	O
leucocytes	O
.	O

the	O
liver	O
function	O
tests	O
were	O
normal	O
expect	O
low	B-ety
albumin	I-ety
(	O
2.1	O
mg	O
/	O
dl	O
)	O
and	O
increased	B-ety
alkaline	I-ety
phosphatase	I-ety
(	O
1196	O
mg	O
/	O
dl	O
)	O
with	O
low	B-ety
fibrinogen	I-ety
(	O
1.7g	O
/	O
l	O
)	O
.	O

serum	O
triglycerides	O
,	O
ferrintin	O
and	O
lactic	O
dehydrogenase	O
were	O
very	O
high	O
;	O
respectively	O
4.75g	O
/	O
L	O
;	O
2763µg	O
/	O
L	O
and	O
597U	O
/	O
L	O
.	O
the	O
C	O
reactive	O
protein	O
(	O
CRP	O
)	O
was	O
elevated	O
at	O
83mg	O
/	O
l	O
.	O

A	O
chest	O
x-ray	O
was	O
normal	O
while	O
the	O
abdominal	O
ultrasound	O
showed	O
a	O
hepatomegaly	B-ety
and	O
a	O
splenomegaly	B-ety
,	O
free	O
biliary	O
ducts	O
without	O
ascites	B-ety
.	O

because	O
of	O
hepato-splenomegaly	B-ety
,	O
pancytopenia	B-ety
,	O
hyperferritinemia	B-ety
and	O
hypofibrinogenemia	B-ety
the	O
diagnosis	O
of	O
macrophage	B-ety
activation	I-ety
syndrome	I-ety
was	O
evoked	O
indicating	O
a	O
bone	O
marrow	O
aspiration	O
that	O
showed	O
numerous	O
morphologically	O
benign	O
macrophages	O
with	O
haemophagocytic	O
activity	O
that	O
comforting	O
the	O
diagnosis	O
of	O
a	O
SAM	B-ety
according	O
to	O
ravelli	O
and	O
HLH	O
-	O
2004	O
criteria	O
.	O

blood	O
culture	O
,	O
urine	O
examination	O
,	O
malarial	O
serology	O
,	O
kala	O
azar	O
serology	O
,	O
viral	O
serologies	O
such	O
as	O
EBV	O
,	O
hepatitis	O
A	O
,	O
B	O
,	O
C	O
and	O
human	O
immunodeficiency	O
virus	O
HIV	O
,	O
serologies	O
of	O
rickettsia	O
,	O
syphilis	O
and	O
toxoplasmosa	O
were	O
negatives	O
.	O

serologies	O
of	O
CMV	O
and	O
rubella	O
showed	O
an	O
old	O
immunization	O
.	O

the	O
immunological	O
tests	O
such	O
as	O
antinuclear	O
antibodies	O
(	O
ANA	O
)	O
,	O
anti-lkm1	O
,	O
anti-mitochondria	O
and	O
anti-smooth	O
muscle	O
antibodies	O
were	O
negatives	O
.	O

because	O
of	O
the	O
consanguineous	O
family	O
,	O
notion	O
of	O
recurrent	B-ety
infection	I-ety
and	O
the	O
presence	O
of	O
silvery-gray	O
color	O
of	O
the	O
hair	O
and	O
eyebrows	O
,	O
diagnosis	O
of	O
griscelli	B-ety
syndrome	I-ety
was	O
evoked	O
directing	O
a	O
light	O
microscopy	O
examination	O
of	O
the	O
hair	O
that	O
showed	O
a	O
large	O
,	O
irregular	O
clumps	O
of	O
pigments	O
characteristic	O
of	O
griscelli	B-ety
syndrome	I-ety
.	O

the	O
molecular	O
biology	O
showed	O
mutation	O
in	O
RAB27A	O
gene	O
confirming	O
the	O
diagnosis	O
of	O
a	O
griscelli	B-ety
syndrome	I-ety
type	I-ety
2	I-ety
.	O

the	O
first-line	O
therapy	O
in	O
management	O
of	O
macrophage	B-ety
activation	I-ety
syndrome	I-ety
complicating	O
griscelli	B-ety
syndrome	I-ety
type	I-ety
2	I-ety
was	O
based	O
on	O
the	O
parenteral	O
administration	O
of	O
high	O
doses	O
of	O
corticosteroids	O
(	O
methylprednisolone	O
pulses	O
1g	O
/	O
0.73m	O
2	O
/	O
day	O
for	O
3	O
days	O
then	O
60mg	O
/	O
m	O
2	O
)	O
with	O
poor	O
response	O
;	O
persisting	O
with	O
involvement	O
of	O
the	O
3	O
cell	O
lines	O
in	O
the	O
blood	O
count	O
,	O
elevated	O
ferritin	O
and	O
triglycerides	O
.	O

given	O
the	O
lack	O
of	O
response	O
to	O
steroids	O
,	O
etoposide	O
was	O
started	O
for	O
3	O
days	O
associated	O
with	O
cyclophosphamide	O
,	O
the	O
evolution	O
was	O
good	O
with	O
improvement	O
of	O
count	O
blood	O
cells	O
,	O
ferritin	O
was	O
lessening	O
while	O
the	O
bone	O
marrow	O
showed	O
decreased	O
numerous	O
of	O
macrophages	O
with	O
low	O
haemophagocytic	O
activity	O
.	O

on	O
the	O
other	O
side	O
the	O
infectious	O
process	O
was	O
good	O
managed	O
by	O
perfusion	O
of	O
antibiotics	O
such	O
as	O
ceftazidim	O
in	O
combination	O
with	O
aminoside	O
.	O

the	O
patient	O
was	O
sent	O
home	O
with	O
prednisone	O
and	O
cyclosporine	O
,	O
he	O
was	O
placed	O
on	O
the	O
list	O
of	O
bone	O
marrow	O
transplantation	O
(	O
BMT	O
)	O
.	O

this	O
is	O
a	O
case	O
report	O
of	O
a	O
59	O
-	O
year	O
old	O
woman	O
with	O
a	O
5	O
-	O
year	O
clinical	O
history	O
of	O
perimenopausal	B-ety
uterine	I-ety
bleeding	I-ety
and	O
three	O
explorative	O
curettages	O
.	O

gynaecological	O
and	O
ultrasound	O
examinations	O
revealed	O
ovarian	B-ety
enlargement	I-ety
with	O
a	O
diameter	O
of	O
50	O
mm	O
with	O
hypoechoic	O
zones	O
suspected	O
of	O
benign	B-ety
teratoma	I-ety
.	O

the	O
diagnostic	O
test	O
such	O
as	O
ca	O
-	O
125	O
,	O
AFP	O
,	O
free-t4	O
and	O
TSH	O
was	O
in	O
normal	O
range	O
.	O

A	O
smooth	O
,	O
solid	O
right	O
ovarian	O
50	O
an	O
mm-size	O
tumour	B-ety
,	O
as	O
well	O
as	O
small	O
amount	O
of	O
fluid	O
in	O
the	O
douglas	O
pouch	O
,	O
was	O
found	O
during	O
the	O
total	O
abdominal	O
hysterectomy	O
,	O
bilateral	O
salpingo-oophorectomy	O
and	O
staging	O
biopsy	O
.	O

the	O
histopathology	O
revealed	O
teratoma	B-ety
with	O
strumal	B-ety
carcinoid	I-ety
tumour	I-ety
IA	O
stage	O
according	O
to	O
AJCC	O
2010	O
of	O
the	O
right	O
ovary	O
and	O
negative	O
cytopathology	O
of	O
the	O
fluid	O
from	O
the	O
douglas	O
pouch	O
.	O

on	O
the	O
postoperative	O
2	O
-	O
year	O
control	O
,	O
the	O
patient	O
was	O
tumour	O
free	O
,	O
and	O
ca	O
-	O
125	O
,	O
free-t4	O
and	O
TSH	O
were	O
in	O
normal	O
range	O
.	O

A	O
45	O
year	O
old	O
female	O
with	O
history	O
of	O
sickle	B-ety
cell	I-ety
disease	I-ety
presented	O
with	O
abdominal	B-ety
pain	I-ety
.	O

A	O
CT	O
scan	O
revealed	O
an	O
exophytic	O
renal	B-ety
mass	I-ety
measuring	O
2.9cm	O
x	O
2.0cm	O
x	O
2.1cm	O
located	O
on	O
the	O
antero-lateral	O
aspect	O
of	O
her	O
right	O
kidney	O
and	O
an	O
unremarkable	O
spleen	O
.	O

she	O
was	O
evaluated	O
by	O
urology	O
and	O
a	O
right	O
partial	O
nephrectomy	O
was	O
planned	O
,	O
however	O
on	O
the	O
day	O
of	O
the	O
procedure	O
,	O
the	O
patient's	O
preoperative	O
pregnancy	O
test	O
was	O
positive	O
.	O

the	O
procedure	O
was	O
post	O
postponed	O
until	O
after	O
she	O
delivered	O
and	O
interval	O
ultrasounds	O
were	O
obtained	O
throughout	O
her	O
pregnancy	O
to	O
monitor	O
the	O
renal	O
mass	O
.	O

the	O
lesion	B-ety
increased	O
minimally	O
in	O
size	O
.	O

two	O
months	O
after	O
caesarian	O
section	O
delivery	O
,	O
patient	O
underwent	O
an	O
unremarkable	O
right	O
laparoscopic	O
partial	O
nephrectomy	O
with	O
individual	O
artery	B-ety
and	I-ety
vein	I-ety
vascular	I-ety
occlusion	I-ety
at	O
the	O
level	O
of	O
the	O
renal	O
hilum	O
.	O

A	O
superficial	O
liver	B-ety
laceration	I-ety
caused	O
by	O
the	O
veress	O
needle	O
was	O
noted	O
at	O
the	O
beginning	O
of	O
the	O
procedure	O
and	O
effectively	O
managed	O
using	O
bipolar	O
cautery	O
.	O

the	O
patient's	O
post-operative	O
course	O
was	O
notable	O
for	O
marked	O
thrombocytosis	B-ety
with	O
her	O
platelet	O
count	O
increasing	O
for	O
her	O
baseline	O
of	O
300,000	O
to	O
a	O
zenith	O
of	O
1.3	O
million	O
.	O

she	O
was	O
started	O
on	O
aspirin	O
therapy	O
and	O
splenomegaly	B-ety
was	O
noted	O
on	O
abdomen	O
ultrasound	O
.	O

her	O
platelet	O
count	O
normalized	O
to	O
334,000	O
.	O

on	O
pathology	O
,	O
the	O
renal	O
mass	O
was	O
classified	O
as	O
a	O
papillary	B-ety
renal	I-ety
neoplasm	I-ety
consistent	O
with	O
a	O
translocation	O
carcinoma	B-ety
.	O

there	O
was	O
no	O
splenic	O
tissue	O
in	O
the	O
specimen	O
.	O

it	O
was	O
noted	O
that	O
the	O
complete	O
lack	O
of	O
staining	O
of	O
any	O
keratins	O
or	O
epithelial	O
membrane	O
antigens	O
was	O
not	O
consistent	O
with	O
a	O
usual	O
renal	B-ety
cell	I-ety
carcinoma	I-ety
and	O
hence	O
the	O
diagnosis	O
of	O
a	O
translocation	O
tumor	B-ety
was	O
made	O
.	O

the	O
patient	O
was	O
lost	O
to	O
follow	O
up	O
presenting	O
2	O
years	O
later	O
and	O
a	O
follow-up	O
CT	O
scan	O
noted	O
marked	O
splenic	B-ety
atrophy	I-ety
with	O
several	O
splenules	O
.	O

the	O
patient	O
was	O
completely	O
asymptomatic	O
and	O
at	O
the	O
time	O
received	O
all	O
the	O
post-splenectomy	O
vaccination	O
and	O
her	O
platelet	O
count	O
remained	O
within	O
normal	O
limits	O
.	O

A	O
3	O
years	O
old	O
boy	O
without	O
any	O
particular	O
diseases	O
history	O
,	O
admitted	O
to	O
the	O
emergency	O
room	O
for	O
a	O
bipolar	O
trauma	B-ety
with	O
a	O
left	O
hemicorporal	O
point	O
of	O
impact	O
following	O
a	O
domestic	O
accident	O
.	O

the	O
delay	O
to	O
consult	O
was	O
5	O
hours	O
after	O
the	O
incident	O
.	O

the	O
clinical	O
examination	O
at	O
admission	O
had	O
showed	O
a	O
deformed	O
left	O
superior	O
member	O
,	O
painful	B-ety
on	O
palpation	O
with	O
the	O
presence	O
of	O
the	O
humeral	O
pulse	O
and	O
a	O
right	O
inferior	O
member	O
shortened	O
and	O
flexed	O
,	O
the	O
thigh	O
slightly	O
in	O
adduction	O
,	O
internal	O
rotation	O
with	O
the	O
member	O
.	O

A	O
radiological	O
assessment	O
was	O
performed	O
immediately	O
;	O
including	O
a	O
standard	O
x-ray	O
of	O
the	O
pelvis	O
which	O
showed	O
a	O
dislocated	B-ety
head	I-ety
of	I-ety
the	I-ety
right	I-ety
femur	I-ety
,	O
completed	O
secondarily	O
by	O
a	O
CT	O
scan	O
of	O
the	O
hip	O
confirming	O
the	O
posterior	O
type	O
of	O
the	O
dislocation	O
isolated	O
from	O
any	O
fractures	B-ety
of	I-ety
the	I-ety
head	I-ety
of	I-ety
the	I-ety
femur	I-ety
.	O

the	O
standard	O
radiography	O
of	O
the	O
left	O
shoulder	O
showed	O
a	O
salter	O
I	O
epiphyseal	O
separation	O
of	O
the	O
humerus	O
.	O

after	O
one	O
hour	O
,	O
we	O
performed	O
an	O
orthopedic	O
reduction	O
of	O
the	O
dislocated	O
hip	O
monitored	O
under	O
scope	O
,	O
with	O
placement	O
of	O
a	O
pelvic	O
splint	O
for	O
an	O
analgesic	O
aim	O
to	O
be	O
kept	O
during	O
three	O
weeks	O
.	O

the	O
radiological	O
results	O
were	O
satisfactory	O
with	O
a	O
restored	O
bilateral	O
symmetry	O
of	O
the	O
articular	O
anatomy	O
.	O

the	O
salter	O
I	O
detachment	O
of	O
the	O
humerus	O
was	O
orthopedically	O
reduced	O
then	O
immobilized	O
by	O
a	O
thoracoabdominal	O
plaster	O
be	O
kept	O
during	O
a	O
month	O
.	O

the	O
child	O
has	O
been	O
discharged	O
the	O
next	O
day	O
.	O

revised	O
after	O
a	O
month	O
,	O
showed	O
a	O
stable	O
left	O
hip	O
on	O
the	O
clinical	O
examination	O
.	O

in	O
the	O
decline	O
of	O
2	O
years	O
,	O
we	O
haven't	O
noticed	O
any	O
recidivism	O
and	O
the	O
functional	O
results	O
were	O
good	O
;	O
on	O
the	O
radiography	O
we	O
do	O
not	O
have	O
any	O
signs	O
of	O
avascular	B-ety
necrosis	I-ety
no	O
changes	O
of	O
the	O
head	O
of	O
femur	O
,	O
of	O
the	O
acetabulum	O
or	O
the	O
joint	O
space	O
.	O

we	O
received	O
a	O
boy	O
3	O
-	O
year-old	O
boy	O
with	O
autistic	B-ety
disorder	I-ety
on	O
hospital	O
of	O
pediatric	O
ward	O
A	O
at	O
university	O
hospital	O
mohammed	O
VI	O
of	O
marrakesh	O
.	O

he	O
has	O
no	O
family	O
history	O
of	O
illness	B-ety
or	O
autistic	O
spectrum	O
disorder	O
.	O

the	O
history	O
revealed	O
that	O
at	O
2	O
years	O
of	O
age	O
.	O

the	O
child	O
was	O
diagnosed	O
with	O
a	O
‘	O
‘	O
severe	O
communication	B-ety
disorder	I-ety
,	O
'	O
'	O
with	O
social	B-ety
interaction	I-ety
difficulties	I-ety
and	O
sensory	O
processing	O
delay	O
.	O

A	O
composite	O
follow-up	O
of	O
all	O
previous	O
assessments	O
and	O
investigations	O
was	O
undertaken	O
.	O

blood	O
work	O
was	O
normal	O
(	O
thyroid-stimulating	O
hormone	O
(	O
TSH	O
)	O
,	O
hemoglobin	O
,	O
mean	O
corpuscular	O
volume	O
(	O
MCV	O
)	O
,	O
and	O
ferritin	O
)	O
.	O

genetic	O
testing	O
was	O
unremarkable	O
(	O
normal	O
karyotype	O
,	O
negative	O
for	O
fragile	O
X	O
)	O
and	O
the	O
magnetic	O
resonance	O
imaging	O
(	O
MRI	O
)	O
in	O
search	O
of	O
a	O
demyelinating	O
attack	O
of	O
the	O
white	O
matter	O
,	O
electroencephalography	O
(	O
EEG	O
)	O
,	O
optometry	O
assessment	O
were	O
also	O
normal	O
.	O

at	O
the	O
conclusion	O
of	O
this	O
composite	O
assessment	O
,	O
the	O
boy	O
was	O
given	O
a	O
primary	O
diagnosis	O
of	O
autistic	B-ety
spectrum	I-ety
disorder	I-ety
.	O

A	O
plan	O
was	O
instituted	O
including	O
speech-language	O
therapy	O
,	O
intensive	O
individualized	O
educational	O
programming	O
,	O
and	O
contact	O
was	O
encouraged	O
with	O
the	O
autism	O
society	O
.	O

for	O
that	O
purpose	O
,	O
the	O
parents	O
moved	O
to	O
morocco	O
to	O
be	O
surrounded	O
by	O
family	O
without	O
any	O
huge	O
improvement	O
.	O

upon	O
direct	O
questioning	O
at	O
initial	O
presentation	O
,	O
the	O
3	O
-	O
year-old	O
child	O
was	O
reported	O
by	O
the	O
parents	O
to	O
have	O
unexplained	O
fatigue	B-ety
,	O
gastrointestinal	B-ety
symptoms	I-ety
included	O
bloating	B-ety
,	O
constipation	B-ety
and	O
diarrhea	B-ety
.	O

psychiatric	O
symptoms	O
included	O
a	O
frequently	O
depressed	B-ety
mood	I-ety
,	O
disproportionate	O
anger	O
,	O
and	O
emotional	B-ety
lability	I-ety
.	O

on	O
exploring	O
his	O
history	O
,	O
the	O
child	O
was	O
born	O
from	O
yemenite	O
father	O
and	O
moroccan	O
mother	O
in	O
germany	O
at-term	O
weighing	O
3500	O
g	O
with	O
an	O
apgar	O
score	O
of	O
9	O
at	O
1	O
minute	O
and	O
10	O
at	O
5	O
minutes	O
after	O
an	O
uneventful	O
pregnancy	O
and	O
delivery	O
.	O

no	O
concerns	O
were	O
present	O
in	O
the	O
neonatal	O
period	O
.	O

development	O
in	O
the	O
first	O
24	O
months	O
of	O
life	O
appeared	O
fine	O
according	O
to	O
the	O
parents-his	O
motor	O
skills	O
seemed	O
to	O
progress	O
normally	O
and	O
he	O
achieved	O
expected	O
milestones	O
.	O

after	O
2	O
years	O
of	O
age	O
,	O
however	O
,	O
his	O
language	O
skills	O
slowly	O
began	O
to	O
regress	O
.	O

he	O
also	O
demonstrated	O
a	O
change	O
in	O
temperament	O
as	O
he	O
started	O
to	O
whine	O
repeatedly	O
and	O
to	O
scream	O
without	O
provocation	O
.	O

physical	O
examination	O
revealed	O
a	O
height	O
and	O
weight	O
normal	O
for	O
age	O
.	O

he	O
was	O
uncommunicative	O
,	O
restless	O
,	O
and	O
somewhat	O
agitated	O
.	O

general	O
examination	O
was	O
unremarkable	O
other	O
than	O
dark	O
rings	O
around	O
the	O
eyes	O
.	O

there	O
were	O
no	O
dysmorphic	O
features	O
evident	O
.	O

he	O
had	O
difficulty	O
maintaining	O
eye	O
contact	O
,	O
and	O
he	O
appeared	O
disinterested	O
in	O
what	O
was	O
taking	O
place	O
.	O

no	O
abnormality	O
was	O
found	O
on	O
abdominal	O
assessment	O
.	O

anti-tissue	O
transglutaminase	O
antibodies	O
levels	O
were	O
76	O
U	O
(	O
normal	O
<	O
10	O
)	O
.	O

the	O
patient	O
underwent	O
upper	O
endoscopy	O
as	O
duodenal	O
biopsy	O
to	O
confirm	O
a	O
celiac	B-ety
disease	I-ety
diagnosis	O
.	O

it	O
shows	O
a	O
total	O
villous	B-ety
atrophy	I-ety
corresponding	O
to	O
a	O
stage	O
4	O
of	O
marsh	O
classification	O
.	O

given	O
the	O
positive	O
screen	O
for	O
celiac	B-ety
disease	I-ety
(	O
positive	O
anti-tissue	O
transglutaminase	O
antibodies	O
and	O
results	O
of	O
duodenal	O
biopsy	O
)	O
,	O
dietary	O
intervention	O
was	O
immediately	O
commenced	O
.	O

all	O
gluten	O
was	O
eliminated	O
from	O
the	O
boy's	O
diet	O
.	O

within	O
1	O
month	O
,	O
the	O
boy's	O
gastrointestinal	B-ety
symptoms	I-ety
were	O
relieved	O
and	O
his	O
behavior	O
had	O
changed	O
.	O

the	O
mother	O
reported	O
that	O
her	O
boy	O
became	O
progressively	O
more	O
communicative	O
.	O

the	O
child	O
has	O
continued	O
on	O
the	O
gluten-free	O
diet	O
and	O
has	O
progressed	O
well	O
and	O
remained	O
healthy	O
over	O
the	O
following	O
6	O
months	O
.	O

A	O
seventy	O
two	O
years	O
old	O
male	O
presented	O
to	O
our	O
clinic	O
with	O
swelling	B-ety
,	I-ety
pain	I-ety
,	I-ety
and	I-ety
limitation	I-ety
of	I-ety
movement	I-ety
at	I-ety
knee	I-ety
joint	I-ety
.	O

the	O
patient's	O
history	O
revealed	O
swellings	B-ety
and	I-ety
pain	I-ety
at	I-ety
knee	I-ety
joint	I-ety
for	O
nearly	O
last	O
20	O
years	O
.	O

he	O
was	O
prescribed	O
nonsteroidal	O
anti-inflammatory	O
drugs	O
and	O
rest	O
.	O

but	O
pain	B-ety
didn't	O
relieve	O
and	O
limitations	O
in	O
range	O
of	O
motion	O
occurred	O
at	O
knee	O
joint	O
.	O

physical	O
examination	O
findings	O
included	O
a	O
solid	O
and	O
semi-mobile	O
mass	O
at	O
anterior	O
knee	O
region	O
.	O

knee	O
joint	O
range	O
of	O
motion	O
was	O
80	O
degrees	O
flexion	O
and	O
0	O
degrees	O
extension	O
.	O

there	O
wasn't	O
any	O
neurovascular	B-ety
pathology	I-ety
.	O

antero-posterior	O
and	O
lateral	O
knee	O
x-rays	O
showed	O
degenerative	B-ety
changes	I-ety
and	O
a	O
giant	O
,	O
irregular	O
,	O
calcific	O
mass	O
which	O
started	O
below	O
patella	O
and	O
extended	O
to	O
suprapatellar	O
area	O
.	O

knee	O
MRI	O
revealed	O
many	O
loose	O
bodies	O
(	O
consistent	O
with	O
synovial	B-ety
chondromatosis	I-ety
)	O
isointense	O
with	O
fatty	O
bone	O
marrow	O
at	O
all	O
sequences	O
at	O
the	O
level	O
of	O
right	O
knee	O
joint	O
.	O

scalloping	O
was	O
observed	O
at	O
tibial	O
and	O
femoral	O
surfaces	O
.	O

decision	O
for	O
a	O
surgical	O
intervention	O
was	O
made	O
and	O
after	O
informing	O
the	O
patient	O
,	O
consent	O
was	O
taken	O
.	O

under	O
spinal	O
anesthesia	O
,	O
a	O
tourniquet	O
was	O
applied	O
to	O
right	O
lower	O
extremity	O
.	O

right	O
knee	O
was	O
entered	O
with	O
an	O
anterior	O
longitudinal	O
incision	O
.	O

cutaneous	O
and	O
subcutaneous	O
tissues	O
were	O
passed	O
.	O

quadriceps	O
mechanism	O
was	O
opened	O
with	O
a	O
medial	O
parapatellar	O
incision	O
and	O
patella	O
was	O
toppled	O
to	O
left	O
side	O
.	O

intraarticular	O
mass	O
was	O
exposed	O
.	O

the	O
mass	O
was	O
released	O
from	O
surrounding	O
tissues	O
by	O
blunt	O
excision	O
and	O
excised	O
with	O
enucleation	O
.	O

then	O
synovial	O
tissue	O
was	O
excised	O
with	O
synoviectomy	O
.	O

surgical	O
area	O
was	O
irrigated	O
using	O
abundant	O
isotonic	O
solution	O
.	O

the	O
excised	O
mass	O
was	O
sent	O
to	O
pathology	O
laboratory	O
.	O

pathology	O
evaluation	O
showed	O
that	O
the	O
mass	O
was	O
consistent	O
with	O
synovial	B-ety
chondromatosis	I-ety
.	O

active	O
and	O
passive	O
exercises	O
were	O
started	O
at	O
an	O
early	O
period	O
after	O
surgery	O
.	O

recurrence	O
was	O
not	O
detected	O
at	O
his	O
last	O
control	O
visit	O
.	O

knee	O
movements	O
were	O
at	O
full	O
range	O
when	O
compared	O
with	O
the	O
other	O
knee	O
.	O

there	O
was	O
no	O
pain	B-ety
or	O
other	O
complaints	O
.	O

A	O
35	O
-	O
year-old	O
mentally	O
ill	O
man	O
was	O
transferred	O
from	O
a	O
local	O
psychiatric	O
hospital	O
after	O
attempted	O
suicide	O
by	O
fire	O
3	O
days	O
before	O
admission	O
.	O

he	O
acquired	O
full-and	O
partial-thickness	O
injury	O
in	O
approximately	O
38%	O
of	O
his	O
TBSA	O
,	O
including	O
face	O
and	O
neck	O
(	O
5%	O
)	O
,	O
both	O
upper	O
extremities	O
(	O
8%	O
)	O
,	O
right	O
thigh	O
(	O
4%	O
)	O
,	O
left	O
thigh	O
and	O
leg	O
(	O
3%	O
)	O
,	O
and	O
most	O
of	O
his	O
anterior	O
and	O
posterior	O
trunk	O
(	O
16%	O
)	O
.	O

the	O
patient	O
was	O
hospitalized	O
for	O
66	O
days	O
and	O
underwent	O
five	O
debridement	O
surgeries	O
.	O

the	O
psychiatric	O
diagnosis	O
was	O
schizophrenia	B-ety
type	O
ICD	O
10	O
F20.3	O
,	O
treated	O
with	O
haloperidol	O
1.5	O
mg	O
and	O
diazepam	O
5	O
mg	O
daily	O
.	O

the	O
patient	O
was	O
occasionally	O
restrained	O
due	O
to	O
rebellious	O
and	O
self-destruction	O
behavior	O
.	O

the	O
nutrition	O
management	O
of	O
this	O
patient	O
was	O
started	O
after	O
a	O
week	O
of	O
hospitalization	O
,	O
which	O
is	O
considered	O
late	O
.	O

in	O
the	O
initial	O
nutrition	O
assessment	O
,	O
the	O
patient	O
was	O
40	O
kg	O
weight	O
and	O
150	O
cm	O
tall	O
thus	O
the	O
body	O
mass	O
index	O
(	O
BMI	O
)	O
was	O
17,57	O
kg	O
/	O
m	O
2	O
or	O
underweight	O
.	O

gastrointestinal	O
symptoms	O
and	O
signs	O
were	O
not	O
found	O
.	O

information	O
regarding	O
the	O
patient's	O
dietary	O
intake	O
in	O
the	O
last	O
two	O
weeks	O
and	O
weight	O
change	O
within	O
the	O
last	O
6	O
months	O
could	O
not	O
be	O
obtained	O
,	O
but	O
his	O
mother	O
claimed	O
that	O
the	O
patient	O
seemed	O
to	O
lose	O
weight	O
because	O
he	O
refused	O
any	O
food	O
that	O
had	O
been	O
offered	O
to	O
him	O
;	O
he	O
only	O
smoked	O
and	O
drank	O
coffee	O
.	O

albumin	O
level	O
was	O
3.6	O
gr	O
/	O
L	O
with	O
imbalanced	O
electrolyte	O
levels	O
.	O

signs	O
of	O
fluid	B-ety
accumulation	I-ety
were	O
not	O
found	O
.	O

according	O
to	O
the	O
subjective	O
global	O
assessment	O
(	O
SGA	O
)	O
tool	O
,	O
the	O
patient	O
belonged	O
to	O
group	O
C	O
(	O
severely	O
malnourished	O
)	O
.	O

energy	O
and	O
protein	O
were	O
given	O
starting	O
from	O
30	O
kcal	O
/	O
kg	O
,	O
increasing	O
gradually	O
to	O
50	O
kcal	O
/	O
kg	O
,	O
and	O
2	O
gp	O
/	O
kg	O
divided	O
into	O
oral	O
nutrition	O
and	O
oral	O
nutrition	O
supplements	O
(	O
ONS	O
)	O
with	O
a	O
50	O
:	O
50	O
ratio	O
.	O

the	O
patient	O
was	O
also	O
given	O
micronutrient	O
supplementations	O
,	O
specifically	O
vitamin	O
A	O
100,000	O
units	O
for	O
the	O
first	O
week	O
,	O
vitamin	O
C	O
100	O
mg	O
3	O
times	O
a	O
day	O
,	O
and	O
zinc	O
20	O
mg	O
once	O
a	O
day	O
.	O

during	O
the	O
early	O
weeks	O
of	O
hospitalization	O
,	O
the	O
patient's	O
weight	O
loss	O
continued	O
.	O

at	O
the	O
end	O
of	O
the	O
second	O
week	O
,	O
his	O
body	O
weight	O
was	O
36	O
kilograms	O
while	O
his	O
serum	O
albumin	O
level	O
was	O
2.7	O
gr	O
/	O
L	O
.	O

on	O
the	O
28	O
th	O
day	O
,	O
the	O
patient's	O
body	O
weight	O
was	O
33	O
kilograms	O
while	O
his	O
serum	O
albumin	O
level	O
was	O
2.1	O
gr	O
/	O
L	O
.	O

energy	O
and	O
protein	O
intake	O
was	O
maintained	O
,	O
but	O
the	O
ratio	O
of	O
oral	O
intake	O
and	O
ONS	O
was	O
modified	O
to	O
70	O
:	O
30	O
.	O

during	O
the	O
treatment	O
,	O
the	O
patient's	O
appetite	O
was	O
unstable	O
.	O

the	O
patient	O
was	O
also	O
hardly	O
cooperative	O
with	O
enteral	O
access	O
.	O

the	O
patient	O
often	O
writhed	O
in	O
pain	B-ety
and	O
became	O
more	O
aggressive	O
.	O

the	O
patient	O
did	O
not	O
respond	O
well	O
to	O
analgesics	O
and	O
sedations	O
.	O

partially	O
parenteral	O
nutrition	O
(	O
PN	O
)	O
enriched	O
with	O
branched-chain	O
amino	O
acid	O
(	O
BCAA	O
)	O
was	O
administered	O
to	O
support	O
protein	O
needs	O
.	O

however	O
,	O
his	O
BMI	O
continued	O
to	O
decline	O
,	O
and	O
on	O
the	O
42	O
nd	O
day	O
,	O
his	O
body	O
weight	O
dropped	O
to	O
32	O
kilograms	O
with	O
a	O
serum	O
albumin	O
level	O
of	O
2	O
gr	O
/	O
L	O
.	O

on	O
the	O
66	O
th	O
day	O
,	O
granulation	O
tissues	O
appeared	O
on	O
the	O
wound	O
bed	O
.	O

considering	O
the	O
mental	O
and	O
nutrition	O
status	O
of	O
the	O
patient	O
,	O
it	O
was	O
decided	O
not	O
to	O
continue	O
with	O
the	O
skin	O
graft	O
surgery	O
.	O

the	O
patient	O
had	O
lost	O
24%	O
of	O
body	O
weight	O
(	O
BMI	O
11.96	O
kg	O
/	O
m	O
2	O
)	O
and	O
the	O
serum	O
albumin	O
level	O
was	O
2.5	O
gr	O
/	O
L	O
.	O

the	O
patient	O
displayed	O
severe	O
muscle	B-ety
wasting	I-ety
and	O
subcutaneous	B-ety
fat	I-ety
loss	I-ety
.	O

however	O
,	O
the	O
general	O
and	O
mental	O
condition	O
was	O
relatively	O
better	O
.	O

the	O
patient	O
was	O
discharged	O
from	O
the	O
hospital	O
.	O

mrs	O
B.S	O
.	O
28	O
years	O
old	O
multiparous	O
that	O
we	O
had	O
received	O
02	O
hours	O
after	O
a	O
vaginal	O
delivery	O
of	O
a	O
newborn	O
alive	O
weighing	O
2750	O
grams	O
in	O
a	O
peripheral	O
maternity	O
3	O
km	O
away	O
.	O

it	O
was	O
referred	O
for	O
postpartum	B-ety
hemorrhage	I-ety
.	O

his	O
medical	O
history	O
was	O
featureless	O
.	O

on	O
admission	O
,	O
she	O
presented	O
hypovolemic	B-ety
shock	I-ety
with	O
blood	O
pressure	O
76	O
/	O
44	O
mmhg	O
,	O
regular	O
tachycardia	B-ety
at	O
136	O
beats	O
per	O
minute	O
,	O
polypnea	B-ety
to	O
39	O
cycles	O
per	O
minute	O
.	O

the	O
obstetrical	O
examination	O
objectified	O
an	O
involuted	B-ety
uterus	I-ety
,	O
an	O
absence	O
of	O
vaginal	O
and	O
perineal	O
cervical	O
lesions	O
,	O
a	O
fluid	O
and	O
red	O
blood	O
originating	O
of	O
endouterine	O
.	O

furthermore	O
,	O
there	O
was	O
purpura	B-ety
.	O

we	O
therefore	O
concluded	O
a	O
significant	O
postpartum	B-ety
hemorrhage	I-ety
complicated	O
by	O
coagulopathy	B-ety
.	O

resuscitation	O
measures	O
were	O
taken	O
and	O
an	O
transfusion	O
1120	O
ml	O
whole	O
blood	O
,	O
red	O
cell	O
pellets	O
350	O
ml	O
and	O
860	O
ml	O
fresh	O
frozen	O
plasma	O
have	O
helped	O
to	O
management	O
coagulopathy	B-ety
and	O
anemia	B-ety
.	O

blood	O
count	O
at	O
admission	O
highlighted	O
severe	B-ety
thrombocytopenia	I-ety
23	O
0000	O
platelets	O
and	O
hemoglobin	O
levels	O
of	O
3.9	O
g	O
/	O
dl	O
.	O

the	O
post	O
natal	O
care	O
was	O
also	O
administered	O
.	O

after	O
seven	O
days	O
of	O
hospitalization	O
,	O
she	O
was	O
going	O
after	O
an	O
amendment	O
to	O
the	O
clinical	O
symptoms	O
and	O
normal	O
laboratory	O
tests	O
.	O

twenty	O
five	O
days	O
later	O
,	O
she	O
returned	O
to	O
obstetric	O
emergencies	O
for	O
significant	O
bleeding	B-ety
with	O
severe	B-ety
anemia	I-ety
with	O
hemoglobin	O
9	O
g	O
/	O
dl	O
without	O
signs	O
of	O
hypovolemic	B-ety
shock	I-ety
.	O

the	O
gynecological	O
examination	O
was	O
normal	O
.	O

the	O
balance	O
sheet	O
of	O
the	O
coagulation	O
was	O
normal	O
including	O
prothrombin	O
to	O
92%	O
and	O
a	O
normal	O
activated	O
partial	O
thromboplastin	O
time	O
.	O

the	O
treatments	O
were	O
based	O
on	O
oxytocin	O
,	O
tranexamic	O
acid	O
,	O
etamsylate	O
and	O
strict	O
regular	O
monitoring	O
.	O

transvaginal	O
ultrasound	O
coupled	O
doppler	O
was	O
normal	O
.	O

in	O
the	O
absence	O
of	O
arterial	O
embolization	O
,	O
she	O
was	O
going	O
with	O
ambulatory	O
monitoring	O
.	O

two	O
weeks	O
later	O
she	O
presented	O
again	O
rebleeding	B-ety
requiring	O
hospitalization	O
resulting	O
in	O
a	O
total	O
hysterectomy	O
after	O
conditioning	O
of	O
the	O
patient	O
.	O

histological	O
examination	O
of	O
the	O
surgical	O
specimen	O
objectified	O
in	O
the	O
cervix	O
and	O
uterine	O
body	O
the	O
presence	O
of	O
arterial	O
vessels	O
proliferation	O
homes	O
large	O
and	O
small	O
caliber	O
associated	O
with	O
tissue	O
hemorrhage	B-ety
.	O

the	O
postoperative	O
course	O
was	O
simple	O
.	O

A	O
20	O
years	O
old	O
man	O
presented	O
with	O
fever	B-ety
,	O
myalgias	B-ety
,	O
arthralgias	B-ety
,	O
retro-orbital	B-ety
pain	I-ety
,	O
vomiting	B-ety
and	O
gum	O
bleeding	O
during	O
a	O
large	O
dengue	O
outbreak	O
in	O
lahore	O
,	O
pakistan	O
.	O

on	O
7th	O
day	O
of	O
illness	O
patient	O
became	O
afebrile	O
,	O
but	O
he	O
developed	O
severe	O
headaches	B-ety
,	O
unconsciousness	B-ety
followed	O
by	O
altered	B-ety
behavior	I-ety
.	O

on	O
9th	O
day	O
of	O
illness	O
patient	O
developed	O
painful	O
neck	B-ety
swelling	I-ety
accompanied	O
by	O
fever	B-ety
,	O
tremors	B-ety
,	O
palpitations	B-ety
,	O
hoarseness	B-ety
of	I-ety
voice	I-ety
and	O
odynophagia	B-ety
.	O

examination	O
revealed	O
acutely	O
swollen	B-ety
,	O
tender	B-ety
thyroid	I-ety
gland	I-ety
along	O
with	O
features	O
of	O
hyperthyroidism	B-ety
.	O

laboratory	O
evaluation	O
revealed	O
stable	O
hematocrit	O
,	O
thrombocytopenia	B-ety
and	O
leukopenia	B-ety
.	O

patient	O
had	O
seroconverted	O
for	O
anti-dengue	O
igm	O
antibodies	O
on	O
the	O
10th	O
day	O
of	O
illness	O
.	O

A	O
non-contrast	O
computed	O
tomogram	O
(	O
CT	O
)	O
of	O
the	O
brain	O
showed	O
right	O
frontal	O
lobe	O
hematoma	B-ety
.	O

thyroid	O
profile	O
showed	O
increased	O
free	O
T3	O
and	O
T4	O
and	O
low	O
TSH	O
.	O

technetium	O
thyroid	O
scan	O
showed	O
reduced	B-ety
tracer	I-ety
uptake	I-ety
.	O

he	O
was	O
diagnosed	O
as	O
having	O
subacute	B-ety
thyroiditis	I-ety
and	O
treated	O
with	O
oral	O
prednisolone	O
and	O
propranolol	O
.	O

follow	O
up	O
CT	O
brain	O
showed	O
resolving	O
hematoma	B-ety
.	O

patient's	O
recovery	O
was	O
uneventful	O
.	O

A	O
28	O
-	O
year-old	O
female	O
patient	O
presented	O
to	O
outpatient	O
dental	O
clinics	O
for	O
full	O
mouth	O
rehabilitation	O
.	O

on	O
physical	O
examination	O
,	O
the	O
patient	O
was	O
awake	O
,	O
alert	O
,	O
oriented	O
,	O
and	O
her	O
blood	O
pressure	O
,	O
temperature	O
and	O
heart	O
rate	O
were	O
within	O
normal	O
limits	O
.	O

upon	O
taking	O
medical	O
history	O
the	O
patient	O
revealed	O
that	O
was	O
diagnosed	O
with	O
thymoma	B-ety
MG	I-ety
and	O
on	O
medication	O
including	O
pyridostigmine	O
bromide	O
60	O
mg	O
,	O
azathioprine	O
50	O
mg	O
and	O
prednisone	O
20	O
mg	O
.	O

intraoral	O
examination	O
showed	O
fair	O
oral	O
hygiene	O
multiple	O
fixed	O
prosthodontic	O
restorations	O
and	O
multiple	O
carious	B-ety
teeth	I-ety
,	O
multiple	O
remaining	O
roots	O
and	O
lipomatous	O
tongue	B-ety
atrophy	I-ety
.	O

the	O
patient	O
was	O
referred	O
to	O
her	O
neurologist	O
to	O
provide	O
a	O
detailed	O
history	O
about	O
her	O
medical	O
condition	O
and	O
to	O
coordinate	O
with	O
him	O
regarding	O
the	O
steroid	O
dose	O
take	O
to	O
avoid	O
any	O
complication	O
during	O
patient	O
management	O
.	O

A	O
consultation	O
letter	O
had	O
been	O
received	O
from	O
her	O
neurologist	O
explaining	O
the	O
patient	O
medical	O
condition	O
which	O
starts	O
with	O
difficulty	B-ety
in	I-ety
breathing	I-ety
,	I-ety
chewing	I-ety
and	I-ety
swallowing	I-ety
,	O
there	O
was	O
no	O
external	O
ocular	O
weakness	O
,	O
motor	O
weakness	O
,	O
sphincter	O
dysfunction	O
,	O
sensory	B-ety
deficits	I-ety
,	O
muscle	B-ety
wasting	I-ety
and	O
no	O
signs	O
of	O
diplopia	B-ety
,	O
dizziness	B-ety
,	O
double	O
vision	O
,	O
ptosis	B-ety
or	O
any	O
difficulty	O
in	O
maintaining	O
balance	O
.	O

patient	O
underwent	O
chest	O
CT	O
scan	O
with	O
contrast	O
which	O
show	O
evidence	O
of	O
thymoma	B-ety
benign	I-ety
tumor	I-ety
of	O
the	O
thymus	O
that	O
has	O
been	O
the	O
possible	O
causes	O
of	O
MG	B-ety
.	O

diagnosis	O
was	O
confirmed	O
with	O
measuring	O
serum	O
level	O
of	O
acetylcholine	O
receptor	O
antibodies	O
,	O
later	O
treatment	O
plan	O
had	O
been	O
formulated	O
including	O
drugs	O
to	O
control	O
the	O
condition	O
and	O
then	O
thymectomy	O
to	O
avoid	O
sever	O
complication	O
to	O
the	O
patient	O
.	O

before	O
proceeding	O
to	O
the	O
dental	O
management	O
of	O
the	O
case	O
;	O
CBC	O
and	O
blood	O
chemistry	O
had	O
been	O
requested	O
form	O
the	O
patient	O
.	O

creatinine	O
level	O
was	O
below	O
normal	O
(	O
42.23	O
umol	O
/	O
l	O
)	O
,	O
with	O
normal	O
levels	O
of	O
albumin	O
,	O
urea	O
,	O
uric	O
acid	O
,	O
AST	O
,	O
ALT	O
,	O
cholesterol	O
,	O
triglycerides	O
and	O
bilirubin	O
.	O

patient	O
had	O
elevated	O
WBC	O
“	O
12.52	O
x	O
10	O
9	O
/	O
L	O
”	O
and	O
platelet	O
“	O
453	O
x	O
10	O
9	O
/	O
L	O
”	O
with	O
reduction	O
in	O
RBC	O
“	O
4.4	O
x	O
10	O
9	O
/	O
L	O
”	O
and	O
eosinophil	O
count	O
“	O
0.07	O
”	O
.	O

consultation	O
with	O
patient	O
neurologist	O
regarding	O
the	O
steroid	O
dose	O
to	O
reduce	O
the	O
susceptibility	O
of	O
developing	O
adrenal	O
crisis	B-ety
.	O

A	O
13	O
-	O
year-old	O
boy	O
diagnosed	O
with	O
WHO	O
diagnostic	O
criteria	O
of	O
probable	O
NS	B-ety
was	O
referred	O
from	O
atanga	O
HC	O
III	O
in	O
pader	O
district	O
where	O
he	O
was	O
enrolled	O
and	O
undergoing	O
care	O
at	O
the	O
nodding	B-ety
syndrome	I-ety
treatment	O
center	O
;	O
he	O
came	O
with	O
a	O
history	O
of	O
progressive	O
swelling	B-ety
and	I-ety
pain	I-ety
in	I-ety
the	I-ety
right	I-ety
lumbar	I-ety
region	I-ety
.	O

the	O
swelling	B-ety
was	O
associated	O
with	O
a	O
high	O
grade	O
fever	B-ety
which	O
was	O
constant	O
and	O
only	O
partially	O
relieved	O
by	O
analgesics	O
.	O

these	O
symptoms	O
were	O
not	O
associated	O
with	O
vomiting	B-ety
,	O
constipation	B-ety
,	O
yellow	B-ety
eyes	I-ety
,	O
loss	B-ety
of	I-ety
appetite	I-ety
or	O
weight	B-ety
loss	I-ety
.	O

the	O
patient	O
reported	O
a	O
history	O
of	O
falling	O
from	O
a	O
tree	O
during	O
one	O
of	O
the	O
nodding	B-ety
episodes	O
in	O
october	O
2012	O
and	O
hit	O
his	O
abdomen	O
onto	O
a	O
tree	O
branch	O
.	O

on	O
further	O
probe	O
on	O
his	O
childhood	O
history	O
,	O
his	O
mother	O
reported	O
that	O
he	O
was	O
born	O
normally	O
at	O
home	O
by	O
a	O
traditional	O
birth	O
attendant	O
(	O
TBA	O
)	O
in	O
one	O
of	O
the	O
internally	O
displaced	O
peoples	O
(	O
IDP	O
)	O
camps	O
in	O
2000	O
.	O

she	O
reported	O
that	O
there	O
was	O
an	O
uneventful	O
pregnancy	O
which	O
was	O
carried	O
to	O
term	O
and	O
delivery	O
by	O
spontaneous	O
vaginal	O
delivery	O
(	O
SVD	O
)	O
.	O

she	O
reported	O
that	O
during	O
her	O
pregnancy	O
,	O
she	O
had	O
exclusive	O
feeding	O
on	O
the	O
relief	O
food	O
provided	O
by	O
WFP	O
(	O
beans	O
,	O
yellow	O
posho	O
and	O
cooking	O
oil	O
)	O
during	O
the	O
IDP	O
camps	O
and	O
denies	O
history	O
of	O
ingestion	O
of	O
herbs	O
or	O
medications	O
which	O
caused	O
adverse	O
events	O
during	O
and	O
after	O
the	O
pregnancy	O
.	O

she	O
reported	O
that	O
her	O
child	O
had	O
a	O
normal	O
physical	O
,	O
cognitive	O
and	O
social	O
childhood	O
development	O
before	O
the	O
onset	O
of	O
nodding	B-ety
which	O
began	O
in	O
may	O
27th	O
2011	O
immediately	O
after	O
returning	O
home	O
from	O
IDP	O
camps	O
.	O

the	O
child	O
was	O
enrolled	O
in	O
atanga	O
treatment	O
centre	O
and	O
was	O
being	O
managed	O
with	O
carbamazepine	O
,	O
multivitamins	O
and	O
ivermectin	O
.	O

she	O
reported	O
that	O
in	O
spite	O
of	O
these	O
medications	O
the	O
child	O
continued	O
to	O
have	O
seizures	B-ety
and	O
nodding	B-ety
at	O
least	O
twice	O
a	O
day	O
and	O
had	O
since	O
dropped	O
out	O
of	O
school	O
.	O

on	O
general	O
examination	O
,	O
he	O
was	O
dehydrated	B-ety
,	O
febrile	B-ety
and	O
moderately	O
wasted	O
.	O

there	O
was	O
a	O
right	O
lumbar	O
region	O
mass	O
,	O
tender	O
,	O
indurated	O
and	O
non-fluctuant	O
.	O

the	O
spleen	O
and	O
liver	O
were	O
not	O
palpable	O
.	O

there	O
was	O
no	O
renal	O
or	O
supra-pubic	O
tenderness	O
.	O

the	O
rectum	O
was	O
full	O
of	O
faecal	O
material	O
which	O
was	O
of	O
normal	O
colour	O
and	O
consistency	O
.	O

the	O
anal	O
tone	O
was	O
normal	O
and	O
there	O
was	O
no	O
blood	O
on	O
examining	O
fingure	O
.	O

haematological	O
investigations	O
were	O
conducted	O
and	O
showed	O
neutrophilia	B-ety
,	O
lympocytosis	B-ety
,	O
monocytosis	B-ety
,	O
and	O
eosinophilia	B-ety
.	O

there	O
were	O
immature	O
granulocytes	O
and	O
atypical	B-ety
lymphocytes	I-ety
seen	O
on	O
the	O
peripheral	O
film	O
report	O
.	O

other	O
laboratory	O
results	O
including	O
liver	O
function	O
tests	O
(	O
ALT	O
,	O
AST	O
)	O
were	O
elevated	O
while	O
serum	O
protein	O
levels	O
were	O
low	O
;	O
renal	O
functions	O
tests	O
(	O
serum	O
creatinine	O
,	O
blood	O
urea	O
and	O
nitrogen	O
level	O
)	O
,	O
and	O
serum	O
electrolytes	O
(	O
K	O
+	O
,	O
na	O
+	O
,	O
cl	O
-	O
,	O
HC03	O
-	O
)	O
which	O
were	O
within	O
normal	O
ranges	O
.	O

abdominal	O
ultrasound	O
showed	O
inflamed	O
internal	O
and	O
external	O
oblique	O
muscles	O
of	O
the	O
anterior	O
abdominal	O
wall	O
.	O

the	O
patient	O
underwent	O
incision	O
and	O
drainage	O
at	O
gulu	O
hospital	O
and	O
wound	O
left	O
open	O
for	O
14	O
days	O
and	O
thereafter	O
secondary	O
wound	O
closure	O
was	O
conducted	O
.	O

he	O
received	O
supplementary	O
food	O
rehabilitation	O
and	O
his	O
seizure	O
medication	O
was	O
changed	O
to	O
sodium	O
valproate	O
200mg	O
once	O
a	O
day	O
under	O
direct	O
observation	O
therapy	O
(	O
DOTS	O
)	O
and	O
close	O
monitoring	O
of	O
the	O
vital	O
signs	O
.	O

the	O
patient	O
continued	O
to	O
have	O
regular	O
follow	O
up	O
in	O
the	O
surgical	O
ward	O
;	O
seizures	B-ety
and	O
nodding	B-ety
stopped	O
completely	O
from	O
the	O
time	O
of	O
intervention	O
in	O
the	O
hospital	O
.	O

with	O
these	O
interventions	O
for	O
over	O
one	O
month	O
the	O
child	O
had	O
no	O
seizures	B-ety
nor	O
nodding	B-ety
and	O
the	O
child	O
returned	O
to	O
normal	O
life	O
.	O

A	O
subsequent	O
review	O
of	O
the	O
haematological	O
and	O
clinical	O
chemistry	O
findings	O
2	O
weeks	O
later	O
showed	O
that	O
renal	O
function	O
tests	O
,	O
serum	O
electrolytes	O
were	O
normal	O
except	O
the	O
liver	O
enzymes	O
level	O
were	O
elevated	O
and	O
were	O
still	O
high	O
.	O

A	O
3	O
years	O
old	O
girl	O
born	O
from	O
non-consanguineous	O
parents	O
,	O
without	O
any	O
neonatal	O
suffering	O
;	O
with	O
good	O
psychomotor	O
development	O
,	O
from	O
a	O
popular	O
district	O
in	O
one	O
of	O
our	O
cities	O
,	O
without	O
any	O
obvious	O
contact	O
with	O
dogs	O
;	O
presented	O
with	O
exophthalmia	B-ety
associated	O
with	O
unilateral	B-ety
blindness	I-ety
evolving	O
rapidly	O
within	O
3	O
months	O
.	O

clinical	O
examination	O
showed	O
a	O
non-pulsatile	O
,	O
painless	O
,	O
axial	O
,	O
irreducible	O
exophthalmia	B-ety
with	O
no	O
sign	O
of	O
conjunctivitis	B-ety
or	O
keratitis	B-ety
,	O
and	O
right	O
monocular	B-ety
blindness	I-ety
,	O
right	B-ety
ptosis	I-ety
;	O
and	O
fundal	O
examination	O
had	O
objectified	O
right	O
papillary	O
oedema	O
.	O

the	O
rest	O
of	O
the	O
clinical	O
examination	O
was	O
normal	O
.	O

brain	O
and	O
orbital	O
magnetic	O
resonance	O
imaging	O
(	O
MRI	O
)	O
revealed	O
an	O
extra-connal	B-ety
right	I-ety
orbital	I-ety
lesion	I-ety
near	O
the	O
orbital	O
apex	O
,	O
measuring	O
28	O
x	O
18mm	O
,	O
of	O
oval	O
shape	O
,	O
it	O
appeared	O
hypo-signal	O
in	O
T1	O
and	O
hyper-signal	O
in	O
T2	O
,	O
limited	O
by	O
a	O
thin	O
wall	O
which	O
took	O
contrast	O
product	O
,	O
this	O
lesion	B-ety
compressed	O
the	O
optic	O
nerve	O
towards	O
the	O
nasal	O
region	O
.	O

chest	O
x-ray	O
and	O
abdominal	O
ultrasound	O
did	O
not	O
reveal	O
any	O
other	O
localization	O
.	O

the	O
patient	O
was	O
operated	O
by	O
performing	O
a	O
right	O
extra-dural	O
frontal	O
approach	O
,	O
a	O
cyst	O
puncture	O
was	O
done	O
in	O
the	O
first	O
intention	O
because	O
the	O
cyst	B-ety
was	O
adherent	O
to	O
the	O
neighbouring	O
structures	O
making	O
its	O
complete	O
removal	O
impossible	O
,	O
then	O
a	O
microscopic	O
extirpation	O
of	O
the	O
cystic	O
membrane	O
,	O
combined	O
with	O
abundant	O
washing	O
by	O
hypertonic	O
serum	O
to	O
sterilize	O
the	O
cystic	O
sit	O
and	O
reduce	O
chances	O
of	O
dissemination	O
.	O

histological	O
examination	O
was	O
in	O
favour	O
of	O
intra-orbital	O
hydatidosis	B-ety
.	O

postoperatively	O
,	O
the	O
patient	O
was	O
given	O
an	O
antihelminthic	O
treatment	O
of	O
albendazole	O
at	O
a	O
dose	O
of	O
10mg	O
per	O
kilogram	O
per	O
day	O
in	O
3	O
doses	O
separated	O
by	O
2	O
weeks	O
;	O
the	O
evolution	O
was	O
marked	O
by	O
the	O
significant	O
regression	O
of	O
the	O
exophthalmia	B-ety
and	O
the	O
gradual	O
improvement	O
of	O
the	O
visual	O
acuity	O
.	O

the	O
patient	O
however	O
still	O
retains	O
a	O
right	O
unilateral	O
nasal	O
hemianopia	B-ety
after	O
two	O
years	O
of	O
follow-up	O
.	O

an	O
MRI	O
done	O
in	O
the	O
same	O
period	O
shows	O
a	O
cure	O
of	O
the	O
patient	O
by	O
a	O
complete	O
disappearance	O
of	O
the	O
cyst	B-ety
.	O

A	O
21	O
-	O
year-old	O
male	O
was	O
referred	O
to	O
the	O
gastroenterology	O
clinic	O
for	O
incidental	O
findings	O
of	O
severe	O
chronic	B-ety
pancreatitis	I-ety
on	O
cross-sectional	O
imaging	O
but	O
no	O
associated	O
symptoms	O
of	O
pancreatitis	B-ety
.	O

he	O
had	O
presented	O
to	O
the	O
emergency	O
department	O
for	O
abdominal	B-ety
pain	I-ety
consistent	O
with	O
prior	O
episodes	O
of	O
renal	B-ety
colic	I-ety
.	O

computed	O
tomography	O
scan	O
confirmed	O
the	O
presence	O
of	O
renal	B-ety
calculi	I-ety
that	O
passed	O
with	O
conservative	O
management	O
.	O

an	O
incidental	O
finding	O
on	O
the	O
imaging	O
showed	O
marked	O
pancreatic	B-ety
atrophy	I-ety
with	O
multiple	O
sub-centimeter	O
calcifications	B-ety
consistent	O
with	O
severe	O
chronic	B-ety
pancreatitis	I-ety
.	O

remarkably	O
,	O
he	O
did	O
not	O
report	O
having	O
any	O
symptoms	O
associated	O
with	O
pancreatic	B-ety
insufficiency	I-ety
including	O
epigastric	B-ety
pain	I-ety
,	O
vomiting	B-ety
,	O
steatorrhea	B-ety
and	O
weight	O
loss	O
.	O

he	O
denied	O
having	O
any	O
prior	O
episodes	O
of	O
acute	B-ety
pancreatitis	I-ety
and	O
had	O
no	O
history	O
of	O
alcohol	O
use	O
.	O

his	O
laboratory	O
tests	O
were	O
all	O
within	O
normal	O
range	O
,	O
including	O
complete	O
blood	O
count	O
,	O
liver	O
function	O
tests	O
,	O
amylase	O
and	O
lipase	O
.	O

his	O
family	O
history	O
was	O
significant	O
as	O
his	O
father	O
had	O
an	O
isolated	O
episode	O
of	O
pancreatitis	B-ety
which	O
required	O
abdominal	O
surgery	O
.	O

magnetic	O
resonance	O
cholangiopancreatography	O
(	O
MRCP	O
)	O
showed	O
severe	O
parenchymal	B-ety
atrophy	I-ety
and	O
pancreatic	B-ety
ductal	I-ety
stones	I-ety
with	O
ductal	O
dilation	O
to	O
9mm	O
.	O

due	O
to	O
his	O
young	O
age	O
and	O
atypical	O
presentation	O
,	O
he	O
was	O
referred	O
for	O
genetic	O
testing	O
and	O
counselling	O
.	O

he	O
underwent	O
genetic	O
testing	O
for	O
various	O
genes	O
known	O
to	O
cause	O
hereditary	B-ety
pancreatitis	I-ety
:	O
CASR	O
,	O
CFTR	O
,	O
CTRC	O
,	O
PRSS1	O
,	O
SPINK1	O
.	O

he	O
tested	O
positive	O
for	O
homozygous	O
variant	O
of	O
SPINK1	O
(	O
N34S	O
)	O
mutation	O
.	O

reflex	O
testing	O
of	O
at-risk	O
relatives	O
confirmed	O
that	O
both	O
of	O
his	O
parents	O
were	O
heterozygous	O
carriers	O
of	O
the	O
same	O
SPINK1	O
(	O
N34S	O
)	O
mutation	O
and	O
a	O
review	O
of	O
their	O
extended	O
pedigree	O
revealed	O
that	O
they	O
were	O
distant	O
cousins	O
.	O

given	O
his	O
asymptomatic	O
clinical	O
course	O
,	O
he	O
remains	O
under	O
close	O
follow-up	O
without	O
requiring	O
any	O
specific	O
treatment	O
for	O
pancreatic	B-ety
insufficiency	I-ety
.	O

due	O
to	O
the	O
severity	O
of	O
pancreatitis	B-ety
noted	O
on	O
imaging	O
and	O
long	O
expected	O
lifespan	O
,	O
he	O
was	O
counselled	O
about	O
the	O
increased	O
risk	O
of	O
pancreatic	B-ety
malignancy	I-ety
and	O
is	O
undergoing	O
regular	O
cross-sectional	O
imaging	O
for	O
the	O
detection	O
and	O
prevention	O
of	O
cancer	B-ety
.	O

A	O
21	O
year	O
old	O
female	O
patient	O
with	O
the	O
diagnosis	O
of	O
SWS	B-ety
suffering	O
from	O
headaches	B-ety
admitted	O
to	O
our	O
clinic	O
.	O

she	O
had	O
a	O
2	O
year	O
history	O
of	O
frequent	O
non-pulsating	O
headaches	B-ety
.	O

her	O
headache	B-ety
was	O
relieving	O
with	O
non-steroidal	O
anti-inflammatory	O
drugs	O
and	O
was	O
not	O
worsening	O
with	O
physical	O
activity	O
.	O

there	O
was	O
no	O
nausea	B-ety
or	O
aura	B-ety
like	O
symptoms	O
accompanying	O
the	O
headache	B-ety
.	O

headaches	B-ety
were	O
lasting	O
for	O
hours	O
.	O

the	O
pain	B-ety
was	O
bilateral	O
,	O
generalized	O
and	O
pressing	O
in	O
quality	O
.	O

the	O
family	O
history	O
for	O
headache	B-ety
was	O
negative	O
.	O

she	O
had	O
a	O
history	O
of	O
seizures	B-ety
occurring	O
in	O
the	O
fifteenth	O
day	O
of	O
life	O
described	O
as	O
attacks	O
of	O
tonic	O
clonic	O
contractions	O
and	O
that's	O
when	O
she	O
was	O
diagnosed	O
with	O
SWS	B-ety
.	O

at	O
the	O
age	O
of	O
6	O
she	O
had	O
a	O
history	O
of	O
callosotomy	O
to	O
control	O
her	O
seizures	B-ety
.	O

at	O
the	O
age	O
of	O
18	O
during	O
a	O
laser	O
treatment	O
done	O
in	O
order	O
to	O
get	O
rid	O
of	O
her	O
port	B-ety
wine	I-ety
birthmark	I-ety
she	O
had	O
her	O
first	O
seizure	B-ety
since	O
callosotomy	O
.	O

after	O
that	O
she	O
was	O
prescribed	O
carbamazepine	O
400	O
mg	O
at	O
daily	O
dose	O
and	O
never	O
had	O
a	O
seizure	B-ety
since	O
then	O
.	O

according	O
to	O
the	O
story	O
taken	O
from	O
her	O
parents	O
even	O
though	O
she	O
had	O
a	O
normal	O
development	O
at	O
infancy	O
she	O
barely	O
graduated	O
from	O
elementary	O
school	O
and	O
she's	O
hardly	O
literate	O
.	O

there	O
was	O
nothing	O
significant	O
on	O
her	O
family	O
history	O
except	O
for	O
her	O
elder	O
sister's	O
port	B-ety
wine	I-ety
stain	I-ety
on	O
her	O
face	O
.	O

the	O
elder	O
sister	O
had	O
no	O
feature	O
of	O
SWS	O
and	O
no	O
researches	O
were	O
done	O
regarding	O
her	O
stain	O
.	O

she	O
was	O
inscribed	O
daily	O
doses	O
of	O
ketiapin	O
25	O
mg	O
for	O
anxiety	B-ety
disorder	I-ety
and	O
venlafaxine	O
75	O
mg	O
for	O
both	O
anxiety	B-ety
disorder	I-ety
and	O
the	O
chronic	B-ety
headaches	I-ety
.	O

she	O
was	O
also	O
inscribed	O
NSAID	O
drugs	O
.	O

after	O
the	O
first	O
week	O
of	O
this	O
treatment	O
her	O
headaches	B-ety
were	O
slightly	O
decreased	O
by	O
heaviness	O
but	O
the	O
frequency	O
was	O
the	O
same	O
.	O

at	O
her	O
physical	O
examination	O
a	O
facial	B-ety
nevus	I-ety
-	O
occurred	O
due	O
to	O
choroid	O
angioma-on	B-ety
the	O
right	O
forehead	O
,	O
right	O
eyelid	O
,	O
nasal	O
wing	O
and	O
the	O
cheek	O
was	O
observed	O
.	O

intra	O
oral	O
examination	O
showed	O
a	O
right	O
sided	O
overgrowth	B-ety
of	I-ety
gingiva	I-ety
.	O

gingival	B-ety
overgrowth	I-ety
was	O
bright	O
red	O
in	O
color	O
and	O
showed	O
blanching	O
on	O
applying	O
pressure	O
suggesting	O
angiomatous	O
enlargement	O
.	O

on	O
her	O
extremities	O
a	O
mild	O
asymmetry	O
was	O
visible	O
.	O

her	O
left	O
arm	O
and	O
leg	O
was	O
slightly	O
smaller	O
in	O
portions	O
and	O
showed	O
hemiparesis	B-ety
both	O
in	O
the	O
upper	O
and	O
lower	O
extremities	O
of	O
the	O
same	O
size	O
.	O

on	O
her	O
ophthalmological	O
evaluation	O
she	O
was	O
diagnosed	O
with	O
glaucoma	B-ety
of	I-ety
the	I-ety
right	I-ety
eye	I-ety
.	O

on	O
her	O
psychiatric	O
examination	O
she	O
showed	O
signs	O
of	O
anxiety	B-ety
disorder	I-ety
.	O

her	O
neurological	O
examination	O
was	O
not	O
remarkable	O
except	O
for	O
her	O
hemiparesis	B-ety
.	O

cranial	O
CT	O
scans	O
showed	O
diffuse	B-ety
atrophy	I-ety
in	O
the	O
right	O
hemisphere	O
and	O
irregular	O
double-contoured	O
gyriform	O
cortical	B-ety
calcifications	I-ety
in	O
the	O
right	O
occipital	O
area	O
.	O

gadolinium	O
enhanced	O
brain	O
MRI	O
revealed	O
multiple	O
dilated	O
pial	O
venous	O
vascular	O
structures	O
on	O
right	O
hemisphere	O
also	O
with	O
the	O
diffuse	B-ety
atrophy	I-ety
on	O
the	O
same	O
side	O
.	O

axial	O
T1	O
weighted	O
cranial	O
MRI	O
shows	O
right	O
calvarial	O
thickness	O
compared	O
to	O
the	O
left	O
and	O
right	O
hemisphere	O
is	O
asymmetrically	O
smaller	O
than	O
the	O
left	O
.	O

in	O
addition	O
to	O
that	O
,	O
T2	O
weighted	O
MRI	O
shows	O
extensive	O
venous	O
formations	O
around	O
corpus	O
of	O
right	O
lateral	O
ventricle	O
and	O
at	O
gallen	O
vein	O
localization	O
and	O
widespread	O
vascular	O
formations	O
are	O
seen	O
at	O
perivascular	O
space	O
,	O
anterior	O
to	O
third	O
ventricle	O
at	O
willis	O
polygon	O
localization	O
and	O
at	O
right	O
temporooccipital	O
area	O
at	O
quadrigeminal	O
cistern	O
localization	O
.	O

she	O
was	O
performed	O
a	O
proteus	O
intelligence	O
test	O
in	O
which	O
she	O
had	O
75	O
points	O
and	O
accepted	O
as	O
mildly	B-ety
mentally	I-ety
retarded	I-ety
.	O

proteus	O
intelligence	O
test	O
in	O
which	O
she	O
had	O
75	O
points	O
and	O
accepted	O
as	O
mildly	O
mentally	O
retarded	O
.	O

A	O
33	O
-	O
year	O
man	O
working	O
in	O
gulf	O
,	O
presented	O
with	O
hemetemesis	B-ety
15	O
days	O
ago	O
in	O
the	O
month	O
of	O
february	O
this	O
year	O
.	O

this	O
was	O
preceeded	O
by	O
low	O
grade	O
fever	B-ety
,	O
bone	B-ety
pain	I-ety
,	O
generalised	B-ety
bodyache	I-ety
,	O
low	B-ety
back	I-ety
ache	I-ety
and	O
generalised	B-ety
macular	I-ety
skin	I-ety
rashes	I-ety
.	O

there	O
was	O
no	O
history	O
of	O
abdominal	B-ety
pain	I-ety
,	O
jaundice	B-ety
or	O
features	O
of	O
chronic	B-ety
liver	I-ety
disease	I-ety
.	O

he	O
gave	O
history	O
of	O
intake	O
of	O
analgesics	O
for	O
backache	B-ety
.	O

after	O
symptomatic	O
treatment	O
he	O
returned	O
back	O
.	O

he	O
came	O
to	O
our	O
OPD	O
with	O
complete	O
blood	O
count	O
which	O
showed	O
a	O
haemoglobin	O
of	O
8g	O
/	O
dl	O
,	O
total	O
count	O
6700	O
/	O
mm3	O
platelet	O
count	O
24000	O
/	O
mm3	O
and	O
ESR	O
55mm	O
/	O
hr	O
.	O

on	O
examination	O
patient	O
was	O
pale	O
with	O
non	O
pruritic	O
macular	B-ety
rashes	I-ety
and	O
mild	O
splenomegaly	B-ety
.	O

residing	O
in	O
middle	O
east	O
with	O
background	O
history	O
of	O
fever	B-ety
,	O
backache	B-ety
,	O
skin	B-ety
rash	I-ety
,	O
splenomegaly	B-ety
and	O
a	O
low	O
platelet	O
count	O
possibility	O
of	O
atypical	O
infection	B-ety
like	O
brucellosis	B-ety
with	O
NSAID	O
induced	O
gi	B-ety
bleed	I-ety
was	O
considered	O
.	O

he	O
was	O
admitted	O
for	O
further	O
evaluation	O
and	O
endoscopy	O
done	O
showed	O
a	O
nodular	B-ety
ulcerative	I-ety
lesions	I-ety
in	O
the	O
antrum	O
of	O
stomach	O
and	O
histopathologic	O
examination	O
confirmed	O
adenocarcinoma	B-ety
of	I-ety
stomach	I-ety
.	O

liver	O
function	O
tests	O
showed	O
a	O
high	O
ALP	O
(	O
1536	O
U	O
/	O
l	O
)	O
,	O
elevated	O
INR	O
(	O
2.15	O
)	O
though	O
bilirubin	O
,	O
transaminases	O
and	O
serum	O
proteins	O
were	O
normal	O
.	O

brucella	O
agglutination	O
test	O
was	O
negative	O
.	O

xray	O
chest	O
was	O
normal	O
.	O

ultrasound	O
of	O
abdomen	O
showed	O
normal	O
echotexture	O
of	O
liver	O
,	O
no	O
SOL	O
,	O
normal	O
portal	O
vein	O
and	O
no	O
IHBRD	O
.	O

CT	O
scan	O
of	O
the	O
abdomen	O
revealed	O
gross	O
pylorus	B-ety
thickening	I-ety
with	O
regional	O
lymphadenopathy	B-ety
and	O
skeletal	O
metastasis	B-ety
with	O
sclerotic	O
foci	O
involving	O
vertebrae	O
and	O
pelvic	O
bones	O
and	O
lytic	O
areas	O
in	O
bilateral	O
iliac	O
blades	O
with	O
no	O
liver	B-ety
metastasis	I-ety
or	O
ascites	B-ety
.	O

A	O
skeletal	O
survey	O
was	O
done	O
which	O
showed	O
lytic	B-ety
lesions	I-ety
in	O
the	O
iliac	O
and	O
femoral	O
bones	O
.	O

bone	O
marrow	O
aspirate	O
showed	O
decreased	O
red	O
cells	O
and	O
platelets	O
and	O
marrow	O
biopsy	O
done	O
was	O
reported	O
as	O
metastasis	B-ety
from	O
adenocarcinoma	B-ety
.	O

coagulation	O
profile	O
done	O
was	O
suggestive	O
of	O
DIC	B-ety
due	O
to	O
the	O
raised	O
levels	O
of	O
FDP	O
(	O
5,170	O
ng	O
/	O
dl	O
)	O
and	O
a	O
low	O
fibrinogen	O
\	O
(	O
152mg	O
/	O
dl	O
)	O
.	O

he	O
was	O
transferred	O
to	O
medical	O
oncology	O
department	O
for	O
subsequent	O
management	O
and	O
was	O
treated	O
with	O
chemotherapy	O
.	O

he	O
succumbed	O
to	O
his	O
illness	O
within	O
10	O
months	O
of	O
diagnosis	O
.	O

our	O
patient	O
was	O
an	O
87	O
-	O
year-old	O
african-american	O
woman	O
who	O
was	O
a	O
nursing	O
home	O
resident	O
,	O
with	O
a	O
history	O
of	O
diabetes	B-ety
mellitus	I-ety
type	I-ety
2	I-ety
and	O
subarachnoid	B-ety
hemorrhage	I-ety
leading	O
to	O
aphasia	B-ety
,	O
hemiplegia	B-ety
,	O
seizures	B-ety
and	O
dysphagia	B-ety
requiring	O
percutaneous	O
gastric	O
feeds	O
.	O

while	O
at	O
the	O
nursing	O
home	O
,	O
she	O
had	O
recurrent	O
aspiration	B-ety
pneumonia	I-ety
and	O
large	O
tube-feed	O
residuals	O
consistent	O
with	O
a	O
diagnosis	O
of	O
underlying	O
gastroparesis	B-ety
.	O

her	O
management	O
included	O
metoclopramide	O
and	O
reduced	O
tube-feeding	O
rates	O
,	O
which	O
improved	O
her	O
symptoms	O
.	O

however	O
,	O
within	O
months	O
the	O
aspiration	B-ety
and	O
increased	O
residuals	O
returned	O
.	O

after	O
trials	O
of	O
different	O
medication	O
therapies	O
without	O
success	O
,	O
she	O
started	O
mirtazapine	O
and	O
her	O
residual	O
volume	O
and	O
aspirations	B-ety
decreased	O
with	O
a	O
dose	O
of	O
15mg	O
nightly	O
.	O

A	O
3	O
-	O
day-old	O
boy	O
from	O
kosovo	O
with	O
dextro-transposition	B-ety
of	I-ety
the	I-ety
great	I-ety
arteries	I-ety
who	O
developed	O
progressive	B-ety
heart	I-ety
failure	I-ety
required	O
an	O
emergency	O
arterial	O
switch	O
operation	O
.	O

because	O
of	O
persistent	O
pulmonary	B-ety
edema	I-ety
after	O
completion	O
of	O
the	O
arterial	O
switch	O
operation	O
at	O
our	O
institution	O
,	O
the	O
patient	O
could	O
not	O
be	O
weaned	O
off	O
mechanical	O
ventilation	O
.	O

transthoracic	O
echocardiography	O
revealed	O
an	O
anomalous	O
accelerated	O
flow	O
,	O
indicating	O
an	O
anomalous	O
systemic	O
pulmonary	O
shunt	O
.	O

arterial	O
catheterization	O
revealed	O
an	O
abnormal	B-ety
bronchial	I-ety
artery	I-ety
originating	O
from	O
the	O
left	O
subclavian	O
artery	O
and	O
bifurcating	O
to	O
both	O
lungs	O
.	O

the	O
anomalous	B-ety
ectatic	I-ety
bronchial	I-ety
artery	I-ety
was	O
successfully	O
occluded	O
by	O
coil	O
embolization	O
.	O

the	O
improvement	O
of	O
the	O
patient's	O
hemodynamic	O
status	O
resulted	O
in	O
an	O
uneventful	O
post-operative	O
course	O
.	O

A	O
43	O
-	O
year-old	O
non-diabetic	O
indian	O
male	O
reported	O
to	O
our	O
outpatient	O
department	O
with	O
chief	O
complaints	O
of	O
cough	B-ety
with	O
expectoration	O
,	O
chest	B-ety
pain	I-ety
,	O
reduced	B-ety
appetite	I-ety
,	O
fever	B-ety
with	I-ety
chills	I-ety
,	O
and	O
night	B-ety
sweats	I-ety
for	O
two	O
weeks	O
.	O

he	O
also	O
complained	O
of	O
breathlessness	B-ety
on	O
exertion	O
and	O
had	O
two	O
episodes	O
of	O
blood	B-ety
in	I-ety
his	I-ety
sputum	I-ety
.	O

the	O
patient	O
explained	O
that	O
the	O
cough	B-ety
was	O
continuous	O
and	O
was	O
relieved	O
after	O
taking	O
cough	O
syrup	O
.	O

he	O
also	O
mentioned	O
that	O
the	O
episodes	O
of	O
fever	B-ety
were	O
initially	O
intermittent	O
and	O
then	O
daily	O
for	O
the	O
last	O
two	O
weeks	O
and	O
were	O
relieved	O
after	O
taking	O
paracetamol	O
.	O

the	O
chest	B-ety
pain	I-ety
was	O
localized	O
to	O
the	O
middle	O
of	O
the	O
chest	O
and	O
was	O
aggravated	O
on	O
exertion	O
.	O

he	O
was	O
a	O
businessman	O
by	O
profession	O
with	O
no	O
history	O
of	O
smoking	O
,	O
alcoholism	O
,	O
or	O
any	O
other	O
substance	O
abuse	O
.	O

also	O
,	O
there	O
was	O
no	O
history	O
of	O
any	O
contact	O
of	O
TB	B-ety
or	O
COVID	B-ety
-	I-ety
19	I-ety
in	O
the	O
family	O
or	O
close	O
contacts	O
.	O

and	O
there	O
was	O
no	O
history	O
of	O
foreign	O
travel	O
in	O
the	O
recent	O
past	O
.	O

but	O
he	O
had	O
reported	O
having	O
traveled	O
by	O
a	O
domestic	O
airline	O
about	O
twenty	O
days	O
back	O
.	O

there	O
was	O
no	O
history	O
of	O
weight	O
loss	O
or	O
any	O
other	O
major	O
illness	O
in	O
the	O
past	O
.	O

on	O
examination	O
his	O
vitals	O
were-pulse	O
-	O
108	O
/	O
minute	O
,	O
arterial	O
BP	O
-	O
130	O
/	O
80	O
mm	O
of	O
hg	O
,	O
respiratory	O
rate	O
of	O
30	O
breaths	O
/	O
minute	O
,	O
sp02	O
-	O
899%	O
on	O
room	O
air	O
,	O
temperature	O
-	O
101	O
-	O
degree	O
centigrade	O
.	O

his	O
sp02	O
fell	O
by	O
70%	O
on	O
room	O
air	O
after	O
waking	O
.	O

on	O
auscultation	O
,	O
there	O
was	O
crepitation	B-ety
on	O
the	O
bilateral	O
middle	O
lobes	O
of	O
the	O
lungs	O
.	O

also	O
,	O
dyspnea	B-ety
on	O
exertion	O
was	O
noted	O
.	O

the	O
rest	O
of	O
the	O
systemic	O
examination	O
was	O
within	O
normal	O
limits	O
.	O

considering	O
this	O
as	O
a	O
probable	O
case	O
of	O
TB	B-ety
with	O
COVID	B-ety
-	I-ety
19	I-ety
he	O
was	O
advised	O
a	O
chest	O
radiograph	O
with	O
sputum	O
microscopy	O
(	O
ziehl	O
neelsen	O
(	O
ZN	O
)	O
staining	O
for	O
acid-fast	O
bacilli	O
)	O
,	O
cartridge-based	O
nucleic	O
acid	O
amplification	O
test	O
(	O
CBNAAT	O
)	O
of	O
the	O
sputum	O
and	O
other	O
routine	O
investigations	O
.	O

to	O
check	O
for	O
the	O
COVID	B-ety
-	I-ety
19	I-ety
he	O
was	O
advised	O
qualitative	O
polymerase	O
chain	O
reaction	O
(	O
PCR	O
)	O
test	O
from	O
the	O
oropharyngeal	O
swab	O
.	O

the	O
results	O
were	O
surprising	O
with	O
mycobacterium	B-ety
tuberculosis	I-ety
detected	O
on	O
sputum	O
fluorescent	O
microscopy	O
and	O
were	O
also	O
confirmed	O
by	O
the	O
CBNAAT	O
.	O

however	O
,	O
there	O
was	O
no	O
resistance	O
to	O
rifampicin	O
.	O

the	O
results	O
of	O
the	O
PCR	O
were	O
positive	O
for	O
RNA	O
specific	O
to	O
sars-cov	B-ety
-	I-ety
2	I-ety
.	O

besides	O
,	O
the	O
chest	O
radiograph	O
pa-view	O
was	O
suggestive	O
of	O
bilateral	O
consolidations	B-ety
on	I-ety
the	I-ety
middle	I-ety
lobes	I-ety
of	I-ety
lungs	I-ety
with	O
ill-defined	O
borders	O
.	O

the	O
other	O
investigations	O
revealed	O
a	O
low	B-ety
lymphocyte	I-ety
count	I-ety
(	O
1x	O
10	O
9	O
/	O
L	O
)	O
and	O
increased	B-ety
levels	I-ety
of	I-ety
c-reactive	I-ety
protein	I-ety
(	O
CRP	O
)	O
(	O
57	O
mg	O
/	O
L	O
)	O
,	O
lactate	O
dehydrogenase	O
(	O
LDH	O
)	O
(	O
580	O
U	O
/	O
L	O
)	O
,	O
and	O
erythrocyte	O
sedimentation	O
rate	O
(	O
ESR	O
)	O
(	O
70	O
mm	O
in	O
the	O
1	O
st	O
hour	O
)	O
.	O

also	O
,	O
a	O
sample	O
for	O
liquid	O
culture	O
(	O
MGIT	O
BACTEC	O
)	O
was	O
sent	O
to	O
the	O
intermediate	O
reference	O
laboratory	O
(	O
IRL	O
)	O
which	O
revealed	O
the	O
growth	O
of	O
mycobacterium	B-ety
tuberculosis	I-ety
.	O

computed	O
tomography	O
was	O
not	O
performed	O
as	O
the	O
diagnosis	O
was	O
established	O
by	O
other	O
cheaper	O
and	O
faster	O
methods	O
and	O
also	O
the	O
patient	O
was	O
unwilling	O
for	O
the	O
same	O
.	O

all	O
the	O
other	O
routine	O
investigations	O
were	O
within	O
normal	O
limits	O
.	O

he	O
was	O
referred	O
to	O
the	O
nearest	O
designated	O
COVID	O
-	O
19	O
management	O
center	O
,	O
where	O
he	O
was	O
managed	O
as	O
per	O
national	O
guidelines	O
.	O

besides	O
,	O
he	O
was	O
also	O
started	O
on	O
an	O
antitubercular	O
treatment	O
of	O
four	O
drugs	O
as	O
per	O
the	O
national	O
tuberculosis	B-ety
elimination	O
program	O
(	O
NTEP	O
)	O
guidelines	O
.	O

he	O
was	O
advised	O
follow-up	O
post	O
completion	O
of	O
his	O
stay	O
at	O
the	O
designated	O
COVID	O
-	O
19	O
center	O
,	O
but	O
he	O
has	O
not	O
yet	O
reported	O
back	O
for	O
follow-up	O
.	O

written	O
informed	O
consent	O
was	O
obtained	O
from	O
the	O
patient	O
for	O
using	O
clinical	O
data	O
and	O
images	O
for	O
publication	O
in	O
this	O
study	O
.	O

A	O
23	O
year	O
old	O
female	O
patient	O
(	O
weight	O
67kg	O
,	O
height	O
171cm	O
,	O
BMI	O
22.91kg	O
/	O
cm	O
2	O
)	O
presented	O
to	O
emergency	O
department	O
with	O
fever	B-ety
(	O
39.4oc	O
)	O
,	O
tachycardia	B-ety
(	O
116	O
bpm	O
)	O
,	O
hypotension	B-ety
(	O
95	O
/	O
45	O
mmhg	O
)	O
,	O
tachypnoea	B-ety
(	O
25	O
breaths	O
/	O
min	O
)	O
,	O
sore	B-ety
throat	I-ety
,	O
neck	B-ety
pain	I-ety
,	O
diffuse	B-ety
pain	I-ety
and	O
tissue	O
oedema	B-ety
in	O
the	O
right-side	O
gluteal	O
region	O
.	O

she	O
was	O
appointed	O
to	O
hospital	O
by	O
a	O
private	O
outpatient	O
surgical	O
center	O
where	O
she	O
had	O
undergone	O
perineal	O
abscess	O
drainage	O
a	O
week	O
before	O
.	O

recent	O
medical	O
history	O
included	O
also	O
endometrial	O
curettage	O
for	O
ERPC	O
a	O
month	O
before	O
and	O
conservative	O
therapy	O
for	O
hemorrhoids	B-ety
15	O
days	O
after	O
.	O

past	O
medical	O
history	O
included	O
henoch-schönlein	B-ety
purpura	I-ety
during	O
childhood	O
.	O

social	O
history	O
included	O
smoking	O
(	O
11	O
pack-years	O
)	O
,	O
family	O
history	O
was	O
non-contributory	O
.	O

she	O
had	O
no	O
known	O
drug	O
allergies	O
.	O

complete	O
blood	O
count	O
revealed	O
marked	O
neutrophilic	B-ety
leukocytosis	I-ety
(	O
WBC	O
23.400	O
/	O
lt	O
)	O
.	O

A	O
CT	O
scan	O
revealed	O
small	O
bilateral	B-ety
pleural	I-ety
effusions	I-ety
,	O
small	O
hepatic	B-ety
enlargement	I-ety
,	O
gerota's	O
fascia	O
thickening	O
,	O
perineal	O
soft	O
tissue	O
stranding	O
with	O
fascial	O
thickening	O
and	O
small	O
bubbles	O
of	O
air	O
.	O

fournier's	B-ety
gangrene	I-ety
was	O
set	O
as	O
working	O
diagnosis	O
(	O
calculated	O
FGSI	O
8	O
,	O
UFGSI	O
10	O
and	O
LRINEC	O
7	O
)	O
and	O
the	O
patient	O
was	O
transported	O
to	O
operation	O
room	O
for	O
immediate	O
radical	O
surgical	O
debridement	O
of	O
necrotic	O
tissue	O
.	O

blood	O
and	O
surgical	O
material	O
was	O
taken	O
for	O
microbiologic	O
analysis	O
.	O

due	O
to	O
the	O
extent	O
of	O
the	O
surgical	O
debridement	O
,	O
the	O
patient	O
was	O
admitted	O
postoperatively	O
to	O
the	O
ICU	O
(	O
SOFA	O
score	O
6	O
,	O
APACHE	O
II	O
score	O
12	O
)	O
;	O
where	O
sedation	O
(	O
midazolam	O
30	O
mcg	O
/	O
kg	O
/	O
hr	O
c.iv	O
)	O
,	O
analgesia	O
(	O
fentanyl	O
3	O
mcg	O
/	O
kg	O
/	O
min	O
c.iv	O
)	O
,	O
triple	O
antibiotic	O
regimen	O
with	O
meropenem	O
2gr	O
q8h	O
i.v	O
.	O
,	O
clindamycin	O
600mg	O
q	O
6h	O
i.v	O
.	O
and	O
daptomycin	O
500mg	O
q.d	O
.	O
i.v	O
.	O
,	O
gastroprotective	O
and	O
antithrombotic	O
prophylaxis	O
were	O
initiated	O
.	O

during	O
the	O
next	O
3	O
days	O
a	O
second	O
CT	O
and	O
an	O
obstetrical	O
consultation	O
were	O
conducted	O
with	O
no	O
significant	O
findings	O
.	O

human	B-ety
immunodeficiency	I-ety
virus	I-ety
and	O
diabetic	B-ety
screen	O
were	O
also	O
negative	O
.	O

yet	O
,	O
the	O
patient	O
remained	O
febrile	B-ety
.	O

microbiology	O
cultures	O
from	O
material	O
taken	O
from	O
the	O
surgical	O
trauma	O
area	O
revealed	O
candida	O
albicans	O
,	O
staphylococcus	O
epidermidis	O
and	O
klebsiella	O
pneumonia	O
;	O
hence	O
antibiotic	O
regimen	O
was	O
modified	O
and	O
antimycotic	O
treatment	O
(	O
caspofungin	O
100mg	O
q.d	O
.	O
i.v	O
.	O
)	O
was	O
initiated	O
too	O
.	O

debridements	O
were	O
repeated	O
every	O
24	O
hours	O
but	O
due	O
to	O
the	O
extent	O
of	O
the	O
lesions	B-ety
,	O
on	O
the	O
10	O
th	O
day	O
,	O
the	O
patient	O
was	O
transported	O
to	O
operation	O
room	O
for	O
temporary	O
ileostomy	O
till	O
the	O
end	O
of	O
the	O
therapy	O
.	O

percutaneous	O
tracheotomy	O
was	O
also	O
performed	O
.	O

hyperbaric	O
oxygen	O
therapy	O
was	O
not	O
available	O
at	O
the	O
setting	O
.	O

one	O
day	O
after	O
the	O
second	O
surgery	O
,	O
patient's	O
condition	O
complicated	O
with	O
MRSA	O
ventilation	B-ety
associated	I-ety
pneumonia	I-ety
.	O

along	O
with	O
that	O
,	O
a	O
localized	B-ety
oedema	I-ety
appeared	O
in	O
her	O
left	O
upper	O
limb	O
.	O

A	O
palpable	B-ety
mass	I-ety
along	O
the	O
anterior	O
margin	O
of	O
the	O
sternocleidomastoid	O
muscle	O
was	O
also	O
noticed	O
.	O

vascular	O
ultrasound	O
examination	O
revealed	O
occlusion	B-ety
of	I-ety
left	I-ety
internal	I-ety
jugular	I-ety
vein	I-ety
.	O

transcranial	O
doppler	O
examination	O
was	O
normal	O
.	O

dental	O
consultation	O
and	O
examination	O
of	O
soft	O
palate	O
and	O
peritonsilar	O
tissues	O
showed	O
no	O
abnormalities	O
.	O

linezolide	O
600	O
mg	O
q12h	O
i.v	O
.	O
was	O
added	O
to	O
antibiotic	O
regimen	O
.	O

since	O
debridements	O
were	O
going	O
on	O
,	O
simultaneous	O
anticoagulation	O
therapy	O
was	O
started	O
with	O
only	O
bemiparine	O
2500	O
b.i.d	O
.	O
s.c	O
.	O

gradually	O
,	O
the	O
patient	O
became	O
afebrile	O
and	O
her	O
clinical	O
condition	O
improved	O
.	O

she	O
was	O
discharged	O
from	O
ICU	O
13	O
days	O
later	O
.	O

A	O
follow-up	O
CTA	O
confirmed	O
the	O
disappearance	O
of	O
the	O
left	B-ety
jugular	I-ety
vein	I-ety
thrombosis	I-ety
.	O

about	O
a	O
month	O
after	O
her	O
ICU	O
discharge	O
,	O
an	O
operation	O
was	O
performed	O
for	O
ileostomy	O
closure	O
and	O
reconstruction	O
of	O
the	O
right	O
gluteal	O
region	O
.	O

on	O
a	O
follow-up	O
examination	O
6	O
months	O
later	O
,	O
the	O
young	O
woman	O
had	O
returned	O
to	O
her	O
normal	O
everyday	O
life	O
.	O

A	O
31	O
-	O
year-old	O
woman	O
with	O
no	O
pathological	O
history	O
was	O
admitted	O
to	O
our	O
hospital	O
for	O
chest	B-ety
pain	I-ety
,	O
bone	B-ety
and	I-ety
joint	I-ety
pain	I-ety
,	O
hair	B-ety
loss	I-ety
and	O
asthenia	B-ety
for	O
the	O
last	O
3	O
months	O
.	O

on	O
physical	O
examination	O
,	O
we	O
found	O
fever	B-ety
at	O
38	O
°	O
C	O
,	O
polypnea	B-ety
at	O
32	O
cycles	O
/	O
min	O
,	O
arterial	O
hypertension	B-ety
at	O
160	O
/	O
90	O
mmhg	O
,	O
malar	O
rash	O
,	O
synovitis	B-ety
of	I-ety
wrists	I-ety
,	I-ety
elbows	I-ety
and	I-ety
ankles	I-ety
,	O
and	O
edema	B-ety
on	O
both	O
legs	O
.	O

diagnostic	O
assessment	O
:	O
laboratory	O
tests	O
disclosed	O
the	O
following	O
values	O
:	O
increase	O
level	O
of	O
erythrocyte	O
sedimentation	O
rate	O
120	O
mm	O
/	O
1	O
st	O
hour	O
,	O
C	O
reactive	O
protein	O
was	O
20	O
mg	O
/	O
l	O
.	O

the	O
blood	O
count	O
showed	O
hemoglobin	O
at	O
9g	O
/	O
dl	O
,	O
MCV	O
at	O
85	O
µ	O
3	O
,	O
lymphopenia	O
at	O
400	O
/	O
mm	O
3	O
,	O
while	O
platelets	O
were	O
normal	O
450	O
000	O
/	O
mm	O
3	O
.	O

direct	O
coombs	O
test	O
was	O
negative	O
.	O

serum	O
albumin	O
was	O
25g	O
/	O
l	O
;	O
proteins	O
level	O
was	O
low	O
at	O
50g	O
/	O
l	O
and	O
proteinuria	O
at	O
3.2g	O
/	O
day	O
.	O

creatinine	O
was	O
normal	O
.	O

anti-nuclear	O
antibody	O
ANA	O
were	O
positive	O
1	O
/	O
320	O
with	O
homogeneous	O
pattern	O
,	O
anti-dsdna	O
level	O
was	O
160U	O
/	O
ml	O
.	O

anti-cardiolipin	O
igg	O
antibodies	O
were	O
positive	O
25UGPL	O
.	O

rheumatoid	O
factor	O
was	O
negative	O
.	O

C3	O
and	O
C4	O
complement	O
fractions	O
were	O
low	O
(	O
0.2	O
g	O
/	O
l	O
and	O
0.05	O
g	O
/	O
l	O
)	O
.	O

chest	O
x-ray	O
,	O
electrocardiogram	O
and	O
echocardiography	O
were	O
normal	O
.	O

chest	O
computed	O
tomography	O
(	O
CT	O
)	O
scan	O
showed	O
proximal	O
pulmonary	B-ety
embolism	I-ety
.	O

renal	O
ultrasound	O
was	O
normal	O
.	O

renal	O
biopsy	O
reveals	O
immunocomplex	O
nephritis	B-ety
,	O
lupus	B-ety
nephritis	I-ety
,	O
segmental	O
mesangial	B-ety
proliferation	I-ety
,	O
mild	O
activity	O
lupus	O
nephritis	O
class	O
III	O
(	O
A	O
/	O
C	O
)	O
.	O

before	O
starting	O
corticosteroids	O
,	O
we	O
analyzed	O
electrolytes	O
.	O

serum	O
calcium	O
was	O
elevated	O
132	O
mg	O
/	O
l	O
with	O
hyper-calciuria	B-ety
479	O
mg	O
/	O
24	O
h	O
.	O
25	O
OHD	O
was	O
normal	O
.	O

alcaline	O
phosphatase	O
was	O
420	O
UI	O
/	O
l	O
.	O
the	O
patient	O
did	O
not	O
have	O
any	O
symptoms	O
of	O
hypercalcemia	B-ety
.	O

serum	O
protein	O
electrophoresis	O
showed	O
polyclonal	B-ety
hypergammaglobulinaemia	I-ety
.	O

serum	O
and	O
urine	O
immunofixation	O
as	O
well	O
as	O
bence-jones	O
proteinuria	O
were	O
negative	O
.	O

intact	O
parathyroid	O
hormone	O
(	O
ipth	O
)	O
was	O
high	O
628	O
pg	O
/	O
ml	O
.	O

CT	O
scan	O
and	O
ultrasound	O
of	O
parathyroid	O
imaging	O
revealed	O
a	O
lower	O
left	O
parathyroid	O
nodule	B-ety
measuring	O
2cm	O
x	O
1	O
cm	O
.	O

femoral	O
and	O
lumbar	O
bone	O
mineral	O
density	O
(	O
BMD	O
)	O
showed	O
osteoporosis	B-ety
(	O
t-score	O
:	O
-	O
2.6	O
)	O
.	O

in	O
addition	O
,	O
we	O
found	O
multiple	O
pelvic	O
osteolytic	B-ety
lesions	I-ety
at	O
CT	O
scan	O
.	O

other	O
causes	O
of	O
hypercalcemia	B-ety
and	O
bone	O
lysis	B-ety
were	O
excluded	O
.	O

the	O
diagnosis	O
in	O
this	O
case	O
was	O
SLE	B-ety
with	I-ety
lupus	I-ety
nephritis	I-ety
class	I-ety
III	I-ety
and	O
anti-phospholipid	B-ety
syndrome	I-ety
,	O
complicated	O
by	O
pulmonary	B-ety
embolism	I-ety
associated	O
to	O
primary	O
hyperparathyroidism	B-ety
causing	O
severe	O
hypercalcemia	B-ety
,	O
osteoporosis	B-ety
.	O

therapeutic	O
intervention	O
:	O
the	O
patient	O
was	O
given	O
a	O
pulse	O
of	O
methyl-prednisolone	O
15	O
mg	O
/	O
kg	O
/	O
day	O
for	O
3	O
days	O
followed	O
by	O
oral	O
prednisone	O
1	O
mg	O
/	O
kg	O
/	O
day	O
,	O
associated	O
with	O
intravenous	O
cyclophosphamide	O
750	O
mg	O
/	O
m	O
2	O
/	O
month	O
for	O
6	O
months	O
.	O

mycophenolate	O
mofetil	O
2	O
g	O
/	O
day	O
was	O
prescribed	O
as	O
a	O
maintenance	O
therapy	O
of	O
lupus	B-ety
nephritis	I-ety
with	O
hydroxychloroquine	O
at	O
a	O
dose	O
of	O
400	O
mg	O
/	O
day	O
.	O

treatment	O
of	O
pulmonary	B-ety
embolism	I-ety
was	O
initiated	O
with	O
subcutaneous	O
low	O
molecular	O
weight	O
heparin	O
(	O
enoxaparin	O
0.1	O
ml	O
/	O
10	O
kg	O
/	O
12h	O
)	O
followed	O
by	O
antivitamin	O
K	O
.	O

for	O
hypercalcemia	B-ety
,	O
patient	O
has	O
received	O
intravenous	O
fluid	O
with	O
furosemide	O
.	O

she	O
also	O
required	O
alendronate	O
70	O
mg	O
/	O
week	O
with	O
vitamin	O
D	O
400u	O
/	O
day	O
for	O
osteoporosis	B-ety
.	O

the	O
left	O
parathyroid	O
gland	O
was	O
surgically	O
removed	O
.	O

histopathological	O
examination	O
revealed	O
parathyroid	B-ety
adenoma	I-ety
.	O

her	O
immediate	O
postoperative	O
parathyroid	O
hormone	O
level	O
was	O
64	O
pg	O
/	O
ml	O
with	O
a	O
calcium	O
level	O
of	O
98	O
mg	O
/	O
l	O
.	O

follow-up	O
and	O
outcomes	O
:	O
forty-eight	O
hours	O
after	O
the	O
surgery	O
she	O
developed	O
oral	B-ety
paresthesia	I-ety
.	O

she	O
had	O
hypocalcemia	B-ety
at	O
72	O
mg	O
/	O
l	O
.	O

she	O
required	O
oral	O
supplementation	O
for	O
few	O
months	O
.	O

additional	O
investigations	O
for	O
multiple	B-ety
endocrine	I-ety
neoplasia	I-ety
were	O
negative	O
.	O

the	O
patient	O
remained	O
asymptomatic	O
.	O

her	O
SLE	B-ety
was	O
calm	O
without	O
any	O
relapse	O
.	O

control	O
of	O
proteinuria	B-ety
was	O
negative	O
.	O

corticosteroids	O
was	O
dropped	O
.	O

the	O
follow-up	O
was	O
4	O
years	O
.	O

this	O
case	O
report	O
describes	O
the	O
condition	O
of	O
a	O
30	O
-	O
year-old	O
man	O
involved	O
in	O
a	O
motor	O
vehicle	O
collision	O
.	O

clinical	O
examination	O
,	O
x-rays	O
,	O
and	O
computed	O
tomography	O
scan	O
revealed	O
a	O
posterior	B-ety
hip	I-ety
dislocation	I-ety
with	O
an	O
ipsilateral	O
femoral	B-ety
head	I-ety
and	I-ety
mid-shaft	I-ety
fractures	I-ety
.	O

the	O
patient	O
was	O
treated	O
by	O
closed	O
reduction	O
of	O
hip	B-ety
dislocation	I-ety
using	O
a	O
temporarily	O
applied	O
external	O
fixator	O
followed	O
by	O
intramedullary	O
nailing	O
of	O
the	O
femoral	O
shaft	O
.	O

achieving	O
a	O
closed	O
reduction	O
is	O
a	O
challenge	O
with	O
ipsilateral	O
fractures	O
but	O
it	O
should	O
be	O
favored	O
over	O
open	O
reduction	O
due	O
to	O
a	O
lower	O
risk	O
of	O
complications	O
.	O

the	O
type	O
of	O
femoral	O
head	O
fracture	O
,	O
in	O
this	O
case	O
,	O
may	O
have	O
aided	O
in	O
an	O
easier	O
reduction	O
.	O

in	O
may	O
2014	O
a	O
49	O
year	O
gentleman	O
was	O
admitted	O
for	O
widespread	O
mucocutaneous	O
blistering	O
diagnosed	O
as	O
PV	B-ety
by	O
histology	O
and	O
immunofluorescence	O
.	O

after	O
6	O
weeks	O
of	O
treatment	O
with	O
systemic	O
steroids	O
and	O
azathioprine	O
the	O
patient	O
developed	O
pulmonary	B-ety
emboli	I-ety
and	O
started	O
oral	O
anticoagulation	O
with	O
warfarin	O
.	O

in	O
late	O
september	O
,	O
the	O
patient	O
re-presented	O
with	O
a	O
severe	O
flare	O
of	O
PV	B-ety
and	O
a	O
recurrent	O
deep	B-ety
vein	I-ety
thrombosis	I-ety
despite	O
oral	O
anticoagulation	O
within	O
therapeutic	O
range	O
.	O

warfarin	O
was	O
changed	O
to	O
subcutaneous	O
low	O
molecular	O
heparin	O
in	O
therapeutic	O
dose	O
while	O
treatment	O
for	O
pemphigus	B-ety
was	O
escalated	O
:	O
first	O
azathioprine	O
was	O
switched	O
to	O
mycophenolate	O
mofetil	O
and	O
the	O
steroids	O
dose	O
increased	O
;	O
then	O
due	O
to	O
poor	O
response	O
,	O
intravenous	O
immunoglobulins	O
were	O
given	O
for	O
three	O
courses	O
and	O
finally	O
he	O
received	O
four	O
infusions	O
of	O
rituximab	O
that	O
induced	O
sustained	O
remission	O
.	O

in	O
april	O
2015	O
the	O
dose	O
of	O
mycophenolate	O
was	O
decreased	O
but	O
anticoagulation	O
was	O
continued	O
until	O
the	O
beginning	O
of	O
july	O
2015	O
to	O
ensure	O
that	O
decreasing	O
immune	O
suppression	O
did	O
not	O
allow	O
the	O
emergence	O
of	O
another	O
flare	O
with	O
attendant	O
thrombotic	O
risk	O
.	O

A	O
77	O
-	O
year-old	O
tunisian	O
woman	O
was	O
hospitalized	O
because	O
of	O
massive	O
painful	O
ascites	B-ety
.	O

her	O
family	O
history	O
did	O
not	O
include	O
any	O
autoimmune	B-ety
disease	I-ety
.	O

she	O
denied	O
a	O
history	B-ety
of	I-ety
hepatitis	I-ety
,	I-ety
jaundice	I-ety
or	I-ety
alcohol	I-ety
use	I-ety
.	O

she	O
had	O
a	O
history	O
of	O
diabetes	B-ety
,	O
hypertension	B-ety
treated	O
by	O
glinide	O
and	O
calcium	O
blocker	O
.	O

she	O
was	O
explored	O
4	O
years	O
prior	O
to	O
admission	O
for	O
exudative	B-ety
pleuritis	I-ety
of	O
the	O
right	O
lung	O
without	O
any	O
established	O
diagnosis	O
after	O
multiple	O
explorations	O
including	O
thoracoscopy	O
with	O
biopsies	O
.	O

on	O
admission	O
,	O
blood	O
pressure	O
was	O
150	O
/	O
70	O
mmhg	O
,	O
her	O
rate	O
was	O
80	O
/	O
mn	O
and	O
body	O
temperature	O
was	O
37	O
°	O
C	O
.	O

the	O
physical	O
examination	O
showed	O
only	O
abdominal	B-ety
distension	I-ety
related	O
to	O
the	O
important	O
ascites	B-ety
without	O
collateral	O
venous	O
circulation	O
.	O

she	O
had	O
no	O
skin	B-ety
lesions	I-ety
,	O
lymphadenopathy	B-ety
,	O
or	O
hepatosplenomegaly	B-ety
and	O
lower	O
extremities	O
showed	O
no	O
edema	O
.	O

laboratory	O
investigations	O
showed	O
:	O
leucopenia	B-ety
with	O
white	O
blood	O
cell	O
count	O
=	O
3100	O
/	O
mm3	O
,	O
lymphopenia	B-ety
=	O
840	O
/	O
mm3	O
,	O
hemoglobin	O
=	O
10.5g	O
/	O
dl	O
;	O
low	O
serum	O
albumin	O
level	O
=	O
29g	O
/	O
L	O
,	O
47	O
;	O
-	O
globulin	O
=	O
19g	O
/	O
L	O
.	O
blood	O
glucose	O
levels	O
=	O
180	O
mg	O
/	O
dl	O
and	O
hemoglobin	O
a1c	O
=	O
8.6	O
%	O
.	O

urine	O
analysis	O
showed	O
trace	O
protein	O
(	O
0.03g	O
/	O
24h	O
)	O
.	O

platelet	O
count	O
,	O
activated	O
partial	O
thromboplastin	O
time	O
,	O
liver	O
function	O
tests	O
,	O
blood	O
urea	O
nitrogen	O
,	O
serum	O
creatinine	O
,	O
erythrocyte	O
sediment	O
rate	O
and	O
total	O
cholesterol	O
were	O
within	O
normal	O
limits	O
.	O

tests	O
for	O
hbsag	O
and	O
HCV	O
were	O
negative	O
.	O

abdominal	O
ultrasonography	O
showed	O
ascitic	O
fluid	O
without	O
any	O
sign	O
of	O
bowel	O
loop	O
thickening	O
or	O
enteritis	B-ety
.	O

neither	O
lymphadenopathy	B-ety
nor	O
liver	B-ety
abnormality	I-ety
was	O
present	O
.	O

A	O
chest	O
x-ray	O
film	O
disclosed	O
bilateral	B-ety
pleural	I-ety
effusion	I-ety
.	O

ascitic	O
obtained	O
by	O
aspiration	O
contained	O
170	O
cells	O
mm3	O
(	O
67%	O
lymphocytes	O
)	O
,	O
46g	O
/	O
L	O
protein	O
,	O
but	O
no	O
malignant	O
cells	O
.	O

cultures	O
for	O
bacteria	O
and	O
mycobacteria	O
gave	O
no	O
growth	O
.	O

tuberculosis	O
investigation	O
including	O
initial	O
tuberculin	O
skin	O
test	O
and	O
the	O
research	O
of	O
koch	O
bacilli	O
in	O
sputum	O
and	O
urine	O
were	O
negative	O
.	O

echocardiogram	O
and	O
electrocardiogram	O
were	O
normal	O
.	O

computed	O
tomographic	O
scan	O
showed	O
massive	O
ascites	B-ety
,	O
no	O
dysmorphic	O
liver	O
,	O
and	O
a	O
mild	O
bilateral	B-ety
pleural	I-ety
effusion	I-ety
.	O

pelvic	O
examination	O
was	O
normal	O
.	O

oesogastroduodenoscopy	O
showed	O
hiatal	B-ety
hernia	I-ety
without	O
oesophageal	O
varices	O
.	O

an	O
exploratory	O
laparoscopy	O
was	O
performed	O
,	O
revealing	O
a	O
large	O
amount	O
of	O
ascite	B-ety
,	O
a	O
normal	O
liver	O
appearance	O
,	O
and	O
no	O
granulations	O
suggesting	O
tuberculosis	B-ety
or	O
peritoneal	O
carcinosis	B-ety
.	O

histological	O
examination	O
of	O
the	O
peritoneum	O
showed	O
non	O
specific	O
chronic	B-ety
inflammation	I-ety
.	O

systemic	B-ety
lupus	I-ety
erythematosus	I-ety
was	O
suspected	O
based	O
on	O
pleuritis	B-ety
,	O
lymphopenia	B-ety
and	O
leucopenia	B-ety
.	O

an	O
additional	O
serologic	O
survey	O
revealed	O
markedly	O
elevated	O
anti-nuclear	O
antibody	O
(	O
ANA	O
)	O
titer	O
of	O
1	O
/	O
1600	O
and	O
a	O
significantly	O
elevated	O
titer	O
of	O
antibody	O
to	O
double-stranded	O
DNA	O
(	O
83	O
IU	O
/	O
ml	O
;	O
normal	O
<	O
30	O
IU	O
/	O
ml	O
)	O
.	O

she	O
had	O
also	O
positive	O
serum	O
antibody	O
against	O
the	O
smith	O
antigen	O
and	O
low	O
serum	O
level	O
of	O
C3	O
complement	O
component	O
:	O
67	O
mg	O
/	O
dl	O
(	O
serum	O
normal	O
range	O
:	O
84	O
–	O
151	O
)	O
.	O

relying	O
on	O
these	O
findings	O
,	O
the	O
patient	O
was	O
diagnosed	O
with	O
SLE	B-ety
since	O
4	O
of	O
the	O
11	O
diagnostic	O
criteria	O
of	O
the	O
american	O
college	O
of	O
rheumatology	O
were	O
met	O
.	O

the	O
SLEDAI	O
score	O
according	O
to	O
systemic	O
lupus	O
erythematosus	O
disease	O
activity	O
index	O
was	O
estimated	O
to	O
be	O
7	O
on	O
admission	O
.	O

hydroxychloroquine	O
200	O
mg	O
daily	O
in	O
combination	O
with	O
diuretics	O
was	O
initiated	O
.	O

one	O
month	O
later	O
,	O
there	O
was	O
no	O
detectable	O
ascitic	O
fluid	O
and	O
no	O
pleural	B-ety
effusions	I-ety
.	O

five	O
months	O
later	O
she	O
remained	O
free	O
from	O
symptoms	O
while	O
continuing	O
to	O
take	O
hydroxychloroquine	O

A	O
24	O
-	O
year-old	O
african-american	O
man	O
presented	O
to	O
our	O
emergency	O
department	O
with	O
a	O
one-week	O
history	O
of	O
fever	B-ety
,	O
dyspnea	B-ety
,	O
cough	B-ety
,	O
and	O
abdominal	B-ety
pain	I-ety
.	O

A	O
computed	O
tomography	O
scan	O
of	O
his	O
chest	O
and	O
abdomen	O
revealed	O
bilateral	B-ety
lower	I-ety
lobe	I-ety
pneumonia	I-ety
and	O
two	O
retained	O
jackson-pratt	O
drains	O
in	O
the	O
right	O
upper	O
quadrant	O
.	O

he	O
was	O
taken	O
to	O
the	O
operating	O
room	O
for	O
drain	O
removal	O
,	O
a	O
right	O
hemicolectomy	O
,	O
debridement	O
of	O
a	O
duodenal	O
injury	O
,	O
a	O
roux-en-y	O
duodenojejunostomy	O
,	O
and	O
an	O
end	O
ileostomy	O
.	O

he	O
subsequently	O
became	O
increasing	O
hypoxemic	B-ety
in	O
the	O
intensive	O
care	O
unit	O
and	O
a	O
bronchoperitoneal	O
fistula	B-ety
was	O
diagnosed	O
.	O

he	O
required	O
high-frequency	O
oscillatory	O
ventilation	O
followed	O
by	O
lung	O
isolation	O
,	O
and	O
was	O
successfully	O
resuscitated	O
using	O
these	O
techniques	O
.	O

A	O
33	O
-	O
year-old	O
woman	O
came	O
to	O
department	O
of	O
fertility	O
,	O
endocrinology	O
and	O
reproduction	O
at	O
saiful	O
anwar	O
public	O
hospital	O
and	O
consulted	O
that	O
she	O
has	O
not	B-ety
menstruated	I-ety
since	O
5	O
years	O
ago	O
(	O
28	O
years	O
old	O
)	O
.	O

her	O
initial	O
menarche	O
was	O
at	O
the	O
age	O
of	O
14	O
years	O
and	O
it	O
is	O
in	O
accordance	O
with	O
the	O
normal	O
growth	O
of	O
a	O
child	O
at	O
her	O
age	O
.	O

the	O
patient	O
had	O
a	O
regular	O
menstrual	O
period	O
of	O
5	O
-	O
7	O
days	O
,	O
she	O
replaced	O
the	O
pads	O
for	O
2	O
-	O
3	O
times	O
/	O
day	O
,	O
and	O
had	O
no	O
menstrual	B-ety
pain	I-ety
.	O

the	O
patient	O
has	O
a	O
history	O
of	O
injective	O
contraceptive	O
that	O
was	O
done	O
every	O
once	O
a	O
month	O
in	O
2010	O
,	O
and	O
after	O
the	O
injection	O
,	O
she	O
menstruated	O
for	O
two	O
months	O
and	O
then	O
it	O
stopped	O
.	O

based	O
on	O
clinical	O
examination	O
and	O
a	O
physical	O
examination	O
,	O
the	O
patient	O
was	O
diagnosed	O
with	O
secondary	B-ety
amenorrhea	I-ety
.	O

investigations	O
that	O
were	O
used	O
are	O
ultrasonography	O
,	O
thorax	O
x-ray	O
and	O
CT	O
scan	O
head	O
.	O

ultrasonography	O
and	O
thorax	O
x-ray	O
showed	O
that	O
patient	O
is	O
suspected	O
to	O
have	O
right	B-ety
pleural	I-ety
effusion	I-ety
.	O

ct-scan	O
examination	O
showed	O
that	O
bilateral	O
ethmoidal	B-ety
sinusitis	I-ety
and	O
pituitary	O
gland	O
was	O
within	O
normal	O
limits	O
.	O

the	O
treatment	O
plan	O
in	O
this	O
patient	O
is	O
P	O
test	O
therapy	O
with	O
prothyra	O
1x10	O
mg	O
for	O
7	O
days	O
,	O
with	O
control	O
on	O
2	O
weeks	O
after	O
the	O
use	O
.	O

P	O
test	O
showed	O
a	O
negative	O
result	O
,	O
because	O
after	O
14	O
days	O
of	O
progesterone	O
consumption	O
the	O
prothyra	O
is	O
not	O
bleeding	O
.	O

the	O
treatment	O
is	O
followed	O
by	O
a	O
E	O
+	O
P	O
test	O
(	O
estrogen	O
+	O
progesterone	O
)	O
with	O
estrogen	O
1x0.625	O
mg	O
for	O
21	O
days	O
and	O
an	O
addition	O
of	O
progesterone	O
1x10	O
mg	O
on	O
12th	O
-	O
21st	O
days	O
,	O
while	O
the	O
control	O
was	O
performed	O
one	O
week	O
after	O
the	O
drug	O
runs	O
out	O
.	O

based	O
on	O
the	O
E	O
+	O
P	O
test	O
,	O
the	O
obtained	O
results	O
were	O
FSH	O
:	O
8.71	O
MIU	O
/	O
ml	O
,	O
LH	O
:	O
3.1	O
IU	O
/	O
L	O
,	O
prolactin	O
:	O
319.4	O
ng	O
/	O
ml	O
.	O

the	O
E	O
+	O
P	O
test	O
showed	O
a	O
negative	O
result	O
,	O
so	O
it	O
was	O
necessary	O
to	O
do	O
hysteroscopy	O
and	O
curettage	O
for	O
the	O
uterus	O
evaluation	O
.	O

hysteroscopy	O
results	O
showed	O
that	O
there	O
were	O
grade	O
4	O
adhesions	B-ety
in	I-ety
the	I-ety
uterine	I-ety
cavum	I-ety
,	O
with	O
a	O
pale	O
colored	O
connective	O
tissue	O
in	O
the	O
uterine	O
cavum	O
,	O
which	O
refers	O
to	O
the	O
diagnosis	O
of	O
secondary	B-ety
amenorrhea	I-ety
suspect	O
tuberculosis	B-ety
endometritis	I-ety
,	O
while	O
the	O
result	O
of	O
tissue	O
curettage	O
was	O
examined	O
on	O
the	O
anatomical	O
pathology	O
department	O
.	O

results	O
of	O
anatomical	O
pathology	O
hysteroscopy	O
showed	O
endometrial	O
tissue	O
with	O
stromal	O
looks	O
granulomas	O
with	O
lymphocytes	O
,	O
histiocytes	O
,	O
epithelioid	O
and	O
langhans	O
multinucleated	O
giant	O
cells	O
and	O
no	O
malignancy	O
was	O
found	O
in	O
this	O
preparation	O
,	O
which	O
showed	O
that	O
patient's	O
diagnosis	O
is	O
secondary	B-ety
amenorrhea	I-ety
suspected	O
tuberculosis	B-ety
endometritis	I-ety
.	O

based	O
on	O
the	O
anatomical	O
pathology	O
hysteroscopy	O
result	O
,	O
treatment	O
was	O
done	O
by	O
using	O
anti-tuberculosis	O
drug	O
category	O
I	O
(	O
FDC	O
1X3	O
tab	O
)	O
for	O
6	O
months	O
.	O

anatomical	O
pathology	O
result	O
through	O
macroscopic	O
observation	O
showed	O
visible	O
network	O
of	O
approximately	O
0.3	O
cm	O
and	O
0.4	O
cm	O
in	O
diameter	O
with	O
a	O
grayish-white	O
color	O
,	O
while	O
the	O
microscopic	O
observations	O
showed	O
fibromuscular	O
tissue	O
at	O
high	O
cylindrical	O
epithelium	O
with	O
polyps	O
shaped	O
vacuolar	O
,	O
and	O
inflammatory	O
granulomatic	O
and	O
aplastic	O
cells	O
were	O
not	O
found	O
.	O

mr	O
F.B	O
a	O
70	O
-	O
year-old	O
male	O
patient	O
presented	O
in	O
our	O
institution	O
because	O
of	O
the	O
occurrence	O
of	O
a	O
right	O
epistaxis	O
.	O

first	O
of	O
all	O
,	O
the	O
patient	O
is	O
not	O
smoking	O
and	O
reported	O
an	O
aneurysm	B-ety
of	I-ety
the	I-ety
abdominal	I-ety
aorta	I-ety
surgically	O
treated	O
by	O
prosthesis	O
under	O
plavix	O
.	O

the	O
beginning	O
of	O
the	O
symptomatology	O
goes	O
back	O
to	O
2	O
months	O
before	O
with	O
right	B-ety
nasal	I-ety
obstruction	I-ety
of	O
progressive	O
onset	O
,	O
associated	O
with	O
right	B-ety
epistaxis	I-ety
and	O
bloody	B-ety
rhinorrhea	I-ety
with	O
right	O
chronic	O
eye	B-ety
watering	I-ety
.	O

nasal	O
endoscopy	O
examination	O
revealed	O
a	O
pinnkish	O
burgeoning	O
mass	O
bleeding	O
on	O
contact	O
and	O
filling	O
the	O
right	O
nostril	O
vestibule	O
.	O

the	O
patient	O
didn't	O
presents	O
neurological	B-ety
signs	I-ety
nor	O
cervical	O
lymph	O
nods	O
.	O

otherwise	O
,	O
ophthalmologic	O
examination	O
found	O
normal	O
visual	O
acuity	O
and	O
ocular	O
mobility	O
on	O
both	O
sides	O
.	O

sinonasal	O
computed	O
tomography	O
(	O
CT	O
)	O
found	O
a	O
right	O
nasal	O
process	O
enhanced	O
after	O
injection	O
of	O
contrast	O
product	O
with	O
relatively	O
little	O
washing	O
at	O
the	O
late	O
time	O
.	O

otherwise	O
,	O
there	O
is	O
no	O
extension	O
involvement	O
at	O
the	O
level	O
of	O
the	O
cavum	O
and	O
the	O
pterygo	O
palate	O
fossa	O
.	O

this	O
finding	O
found	O
also	O
a	O
crenate	O
appearance	O
of	O
the	O
posterior	O
nasal	O
mucosa	O
especially	O
of	O
the	O
middle	O
turbinates	O
and	O
contralateral	O
inferior	O
turbinate	O
with	O
a	O
left	B-ety
deviation	I-ety
of	I-ety
the	I-ety
nasal	I-ety
septum	I-ety
with	O
nasal	O
spur	O
.	O

nasosinusal	O
MRI	O
shows	O
a	O
progressive	O
increase	O
in	O
size	O
of	O
the	O
tissue	B-ety
mass	I-ety
compared	O
to	O
the	O
previously	O
CT	O
occupying	O
the	O
right	O
nasal	O
fossa	O
on	O
almost	O
all	O
of	O
its	O
height	O
,	O
measuring	O
4	O
×	O
2.8	O
×	O
3.5cm	O
without	O
extension	O
within	O
the	O
cavum	O
with	O
probable	O
invasion	O
of	O
the	O
lower	O
part	O
of	O
the	O
nasolacrimal	O
duct	O
and	O
mass	O
effect	O
on	O
both	O
the	O
sinusonasal	O
bone	O
septum	O
and	O
the	O
intersinusonasal	O
septum	O
.	O

this	O
finding	O
shows	O
ethmoidal	B-ety
sinus	I-ety
fluid	I-ety
retention	I-ety
.	O

the	O
appearance	O
,	O
even	O
if	O
it	O
remains	O
unspecific	O
,	O
is	O
compatible	O
with	O
inverted	B-ety
papilloma	I-ety
.	O

the	O
patient	O
underwent	O
complete	O
endoscopic	O
removal	O
of	O
the	O
tumor	B-ety
with	O
ethmoidectomy	O
and	O
right	O
maxillary	O
antrostomy	O
.	O

the	O
extemporaneous	O
examination	O
is	O
in	O
favor	O
of	O
a	O
malignant	B-ety
tumor	I-ety
lesion	I-ety
.	O

histopathologic	O
analysis	O
shows	O
a	O
tumor	B-ety
proliferation	I-ety
made	O
of	O
polymorphic	O
cells	O
with	O
major	O
anisocytosis	O
,	O
most	O
often	O
located	O
in	O
lobules	O
.	O

there	O
is	O
sometimes	O
a	O
somewhat	O
palisadic	O
seat	O
on	O
the	O
periphery	O
of	O
the	O
tumor	B-ety
mass	I-ety
.	O

the	O
mitotic	O
index	O
is	O
10	O
mitoses	O
per	O
10	O
high	O
power	O
fields	O
.	O

the	O
immunohistochemical	O
study	O
of	O
the	O
tumor	B-ety
found	O
that	O
the	O
cytokeratin	O
KL1	O
and	O
CK7	O
and	O
the	O
neuroendocrine	O
marker	O
chromogranin	O
A	O
,	O
synaptophysin	O
and	O
CD56	O
are	O
positive	O
.	O

proliferation	O
index	O
ki67	O
is	O
of	O
the	O
order	O
of	O
80%	O
.	O

otherwise	O
there	O
is	O
an	O
absence	O
of	O
expression	O
of	O
PS100	O
,	O
melana	O
,	O
HMB45	O
,	O
desmin	O
,	O
p40	O
,	O
CD45	O
and	O
EBV	O
.	O

the	O
clear	O
positivity	O
of	O
cytokeratins	O
formally	O
excludes	O
the	O
diagnosis	O
of	O
olfactory	B-ety
neuroblastoma	I-ety
and	O
leads	O
to	O
neuroendocrine	B-ety
carcinoma	I-ety
.	O

given	O
the	O
atypia	O
,	O
the	O
mitotic	O
index	O
,	O
and	O
the	O
ki67	O
proliferation	O
index	O
,	O
it	O
is	O
a	O
high-grade	O
large-cell	B-ety
neuroendocrine	I-ety
carcinoma	I-ety
.	O

extension	O
assessment	O
,	O
comprising	O
a	O
PET	O
SCAN	O
,	O
was	O
negative	O
.	O

postoperative	O
treatment	O
consisted	O
in	O
adjuvant	O
polychemotherapy	O
,	O
with	O
six	O
cycles	O
(	O
cisplatin	O
and	O
etoposide	O
)	O
,	O
followed	O
by	O
loco	O
regional	O
external	O
radiotherapy	O
.	O

after	O
6	O
month	O
follow-up	O
,	O
the	O
patient	O
was	O
in	B-ety
complete	I-ety
clinical	I-ety
and	I-ety
radiological	I-ety
remission	I-ety
.	O

A	O
46	O
-	O
year-old	O
man	O
with	O
hypertension	B-ety
and	O
dyslipidemia	B-ety
diagnosed	O
4	O
-	O
months	O
before	O
,	O
as	O
well	O
as	O
new-onset	B-ety
diabetes	I-ety
mellitus	I-ety
unveiled	O
1	O
-	O
month	O
earlier	O
,	O
was	O
referred	O
to	O
emergency	O
department	O
for	O
hypokalemia	B-ety
.	O

hormonal	O
study	O
and	O
dynamic	O
biochemical	O
tests	O
performed	O
indicated	O
ECS	O
.	O

imaging	O
and	O
cytological	O
findings	O
pointed	O
toward	O
a	O
likely	O
primary	B-ety
right	I-ety
parotid	I-ety
malignancy	I-ety
with	O
liver	B-ety
metastases	I-ety
.	O

somatostatin	O
receptor	O
scintigraphy	O
has	O
shown	O
an	O
increased	O
uptake	O
in	O
the	O
parotid	O
gland	O
and	O
mild	O
expression	O
in	O
liver	B-ety
metastasis	I-ety
.	O

the	O
patient	O
underwent	O
right	O
parotidectomy	O
,	O
and	O
histopathologic	O
examination	O
confirmed	O
ACC	B-ety
.	O

meanwhile	O
,	O
hypercortisolism	B-ety
was	O
managed	O
with	O
metyrapone	O
,	O
ketoconazole	O
,	O
and	O
lanreotide	O
.	O

despite	O
chemotherapy	O
onset	O
,	O
a	O
rapid	O
disease	B-ety
progression	I-ety
and	O
clinical	O
course	O
deterioration	O
was	O
observed	O
.	O

forty	O
year	O
old	O
male	O
presented	O
with	O
a	O
huge	O
mass	O
in	O
this	O
left	O
arm	O
.	O

the	O
same	O
patient	O
apparently	O
was	O
admitted	O
three	O
years	O
back	O
for	O
excision	O
of	O
the	O
arm	B-ety
swelling	I-ety
which	O
was	O
relatively	O
small	O
that	O
time	O
.	O

however	O
the	O
patient	O
did	O
not	O
undergo	O
surgery	O
and	O
was	O
takin	O
treatment	O
from	O
local	O
bone	O
setters	O
during	O
the	O
last	O
three	O
years	O
and	O
tumor	B-ety
grew	O
to	O
a	O
larger	O
size	O
during	O
this	O
period	O
.	O

the	O
current	O
dimensions	O
of	O
tumor	B-ety
was	O
32x28	O
cms	O
with	O
circumference	O
of	O
87	O
cms	O
.	O

x-ray	O
showed	O
complete	O
destruction	B-ety
of	I-ety
the	I-ety
upper	I-ety
humerus	I-ety
with	O
central	O
calcification	B-ety
.	O

biopsy	O
releveled	O
a	O
chondrosarcoma	B-ety
.	O

skeletal	O
survey	O
and	O
bone	O
scan	O
did	O
not	O
reveal	O
any	O
other	O
lesion	B-ety
in	O
the	O
body	O
.	O

A	O
forequarter	O
amputation	O
was	O
done	O
and	O
a	O
16	O
kg	O
tumor	B-ety
mass	I-ety
was	O
excised	O
.	O

at	O
three	O
years	O
follow	O
up	O
,	O
the	O
patient	O
has	O
no	O
complains	O
with	O
no	O
recurrence	O
of	O
the	O
tumor	B-ety
.	O

A	O
20	O
-	O
year-old	O
right-handed	O
female	O
factory	O
worker	O
with	O
no	O
medical	O
history	O
is	O
consulting	O
in	O
the	O
emergency	O
ward	O
with	O
an	O
open	O
trauma	B-ety
of	O
the	O
left	O
hand	O
resulting	O
from	O
an	O
occupational	O
accident	O
.	O

her	O
hand	O
was	O
crushed	O
under	O
a	O
heavy	O
object	O
.	O

physical	O
examination	O
found	O
an	O
important	O
swelling	B-ety
and	O
obvious	O
distortion	O
at	O
the	O
dorsum	O
of	O
the	O
hand	O
associated	O
with	O
wounds	O
of	O
the	O
ulnar	O
and	O
radial	O
edges	O
of	O
the	O
left	O
hand	O
.	O

the	O
neurovascular	O
examination	O
was	O
normal	O
;	O
in	O
particular	O
no	O
sensitive	O
deficit	O
in	O
the	O
median	O
nerve	O
area	O
was	O
noted	O
.	O

plain	O
radiographs	O
with	O
front	O
and	O
lateral	O
views	O
showed	O
a	O
dislocation	B-ety
of	I-ety
the	I-ety
three	I-ety
lesser	I-ety
fingers	I-ety
associated	O
with	O
fractures	B-ety
of	I-ety
the	I-ety
hamatum	I-ety
and	I-ety
the	I-ety
second	I-ety
metacarpal	I-ety
.	O

the	O
three	O
lesser	O
metacarpals	O
and	O
the	O
distal	O
fragment	O
of	O
the	O
hamatum	O
were	O
medially	O
displaced	O
.	O

the	O
patient	O
was	O
immediately	O
brought	O
to	O
the	O
operating	O
theatre	O
.	O

the	O
treatment	O
consisted	O
of	O
a	O
reduction	O
and	O
stabilisation	O
using	O
a	O
multiple	O
carpo-metacarpal	O
and	O
cross	O
inter-metacarpal	O
pinning	O
.	O

the	O
wound	O
was	O
cleaned	O
up	O
trimmed	O
and	O
sutured	O
.	O

the	O
had	O
and	O
the	O
wrist	O
were	O
immobilized	O
with	O
a	O
splint	O
for	O
six	O
weeks	O
.	O

the	O
patient	O
had	O
an	O
intense	O
and	O
regular	O
rehabilitation	O
program	O
.	O

at	O
one	O
year	O
follow-up	O
,	O
the	O
outcome	O
is	O
good	O
:	O
the	O
patient	O
is	O
painless	O
with	O
good	O
bone	O
consolidation	O
in	O
right	O
position	O
,	O
strictly	O
normal	O
range	O
of	O
motion	O
(	O
metacarpophalangeal	O
90	O
°	O
,	O
proximal	O
interphalagienne	O
100	O
°	O
and	O
distal	O
interphalageal	O
90	O
°	O
)	O
and	O
a	O
80%	O
grip	O
strength	O
compared	O
to	O
the	O
right	O
side	O
.	O

A	O
16	O
-	O
year-old	O
indian	O
boy	O
presented	O
to	O
our	O
hospital	O
with	O
a	O
history	O
of	O
a	O
lump	B-ety
in	O
the	O
lower	O
back	O
region	O
since	O
birth	O
.	O

initially	O
,	O
it	O
was	O
small	O
,	O
but	O
its	O
size	O
increased	O
gradually	O
over	O
time	O
to	O
a	O
size	O
of	O
15	O
cm	O
×	O
15	O
cm	O
at	O
presentation	O
.	O

there	O
were	O
no	O
other	O
associated	O
abnormalities	O
.	O

investigations	O
revealed	O
the	O
lump	B-ety
to	O
be	O
a	O
benign	B-ety
cystic	I-ety
teratoma	I-ety
.	O

the	O
patient	O
underwent	O
surgery	O
,	O
and	O
the	O
whole	O
tumor	B-ety
,	O
from	O
its	O
base	O
to	O
the	O
vertebrae	O
,	O
was	O
excised	O
.	O

bisection	O
of	O
the	O
tumor	B-ety
revealed	O
that	O
it	O
contained	O
hair	O
and	O
pultaceous	O
material	O
consistent	O
with	O
a	O
teratoma	B-ety
,	O
which	O
was	O
later	O
confirmed	O
by	O
histopathologic	O
examination	O
.	O

A	O
70yrs	O
old	O
female	O
was	O
admitted	O
in	O
our	O
institution	O
diagnosed	O
with	O
severe	O
bilateral	B-ety
osteoarthritis	I-ety
.	O

the	O
x-rays	O
showed	O
bone	O
on	O
bone	O
tricompartment	O
OA	B-ety
knee	I-ety
with	I-ety
varus	I-ety
malalignment	I-ety
.	O

she	O
was	O
posted	O
for	O
single	O
stage	O
bilateral	O
total	O
knee	O
replacement	O
and	O
as	O
planned	O
the	O
left	O
knee	O
was	O
operated	O
first	O
.	O

after	O
exposure	O
,	O
proximal	O
tibial	O
,	O
distal	O
femoral	O
cuts	O
and	O
measurement	O
of	O
extension	O
gaps	O
the	O
synovium	O
from	O
the	O
anterior	O
femur	O
was	O
removed	O
and	O
sizing	O
was	O
done	O
.	O

the	O
AP	O
cut	O
was	O
then	O
proceeded	O
with	O
.	O

we	O
spotted	O
a	O
small	O
osteochondral	O
cyst	B-ety
in	O
the	O
anterior	O
femur	O
which	O
was	O
curretted	O
to	O
remove	O
the	O
cystic	O
material	O
,	O
which	O
is	O
when	O
we	O
realised	O
that	O
the	O
cyst	B-ety
was	O
large	O
and	O
communicating	O
with	O
the	O
medulary	O
canal	O
.	O

the	O
remaining	O
femoral	O
preparations	O
was	O
done	O
keeping	O
in	O
mind	O
the	O
risk	O
of	O
iatrogenic	O
fracture	B-ety
and	O
extension	O
stem	O
was	O
used	O
in	O
the	O
femur	O
.	O

the	O
defect	O
was	O
then	O
packed	O
cancellous	O
bone	O
graft	O
.	O

it	O
is	O
the	O
case	O
of	O
a	O
29	O
years	O
old	O
woman	O
,	O
G2P1001	O
,	O
married	O
,	O
at	O
9	O
weeks	O
of	O
pregnancy	O
.	O

she	O
consulted	O
at	O
our	O
emergency	O
service	O
for	O
the	O
exacerbation	O
of	O
a	O
left	O
pelvic	B-ety
pain	I-ety
that	O
has	O
been	O
evolving	O
for	O
two	O
weeks	O
prior	O
to	O
admission	O
.	O

A	O
transient	O
lull	O
was	O
observed	O
following	O
a	O
treatment	O
with	O
a	O
progesteron	O
(	O
hydroxyprogesterone	O
caproate	O
)	O
and	O
an	O
antispasmodic	O
(	O
tiemonium	O
methylsulfate	O
)	O
in	O
a	O
community	O
clinic	O
.	O

the	O
resurgence	O
of	O
that	O
lancinating	O
and	O
permanent	O
pain	B-ety
irradiating	O
to	O
the	O
loins	O
and	O
associated	O
with	O
slight	O
vaginal	B-ety
bleeding	I-ety
prompted	O
consultation	O
.	O

she	O
had	O
first	O
menses	O
at	O
14	O
and	O
her	O
menstrual	O
cycle	O
is	O
regular	O
with	O
a	O
length	O
of	O
30	O
days	O
.	O

she	O
has	O
never	O
practiced	O
contraception	O
.	O

she	O
has	O
been	O
adequately	O
treated	O
for	O
acute	B-ety
pelvic	I-ety
inflammatory	I-ety
disease	I-ety
five	O
years	O
earlier	O
.	O

her	O
only	O
child	O
is	O
a	O
girl	O
born	O
vaginally	O
seven	O
years	O
ago	O
.	O

her	O
blood	O
group	O
is	O
B	O
rhesus	O
positive	O
and	O
she	O
has	O
never	O
undergone	O
surgery	O
.	O

she	O
presented	O
with	O
sympathetic	O
signs	B-ety
of	I-ety
pregnancy	I-ety
and	O
the	O
urinary	O
pregnancy	O
test	O
was	O
positive	O
but	O
echography	O
was	O
not	O
yet	O
done	O
.	O

on	O
admission	O
,	O
besides	O
the	O
main	O
complain	O
,	O
the	O
patient	O
had	O
vaginal	B-ety
bleeding	I-ety
and	O
nausea	B-ety
but	O
neither	O
fever	B-ety
,	O
nor	O
vomiting	B-ety
.	O

on	O
physical	O
examination	O
her	O
general	O
condition	O
was	O
good	O
and	O
the	O
blood	O
pressure	O
was	O
110	O
/	O
70	O
millimeters	O
of	O
mercury	O
,	O
the	O
respiratory	O
rate	O
:	O
20	O
cycles	O
/	O
minute	O
;	O
the	O
pulse	O
rate	O
:	O
70	O
pulsations	O
/	O
minute	O
and	O
the	O
temperature	O
:	O
37.3	O
degree	O
celsius	O
.	O

the	O
conjunctivae	O
were	O
pink	O
and	O
the	O
tongue	O
was	O
clean	O
and	O
moist	O
.	O

there	O
were	O
no	O
cervical	O
adenopathies	O
.	O

the	O
breast	O
and	O
cardiopulmonary	O
examination	O
revealed	O
no	O
abnormalities	O
.	O

the	O
abdomen	O
was	O
flat	O
,	O
and	O
mobile	O
with	O
respiration	O
.	O

on	O
palpation	O
there	O
was	O
just	O
a	O
tenderness	B-ety
of	I-ety
the	I-ety
left	I-ety
iliac	I-ety
fossa	I-ety
and	O
the	O
bowel	O
sounds	O
were	O
normal	O
on	O
auscultation	O
.	O

inspection	O
under	O
speculum	O
revealed	O
normal	O
gravid	O
external	O
cervical	O
os	O
and	O
there	O
was	O
no	O
vaginal	O
discharge	O
.	O

on	O
digital	O
exploration	O
,	O
the	O
cervix	O
was	O
posterior	O
long	O
and	O
closed	O
,	O
the	O
uterus	O
was	O
globular	O
,	O
increased	O
in	O
size	O
and	O
compatible	O
with	O
an	O
eight	O
weeks	O
pregnancy	O
.	O

the	O
left	O
adnexae	O
presented	O
with	O
a	O
tender	O
,	O
smooth	O
and	O
mobile	O
mass	O
of	O
seven	O
centimeters	O
diameter	O
but	O
the	O
right	O
one	O
were	O
normal	O
.	O

the	O
posterior	O
cervico-vaginal	O
fornix	O
was	O
neither	O
tender	O
nor	O
bulging	O
.	O

we	O
suspected	O
a	O
non	O
ruptured	O
extra-uterine	B-ety
pregnancy	I-ety
with	O
the	O
following	O
differentials	O
:	O
heterotopic	B-ety
pregnancy	I-ety
,	O
torsion	B-ety
of	I-ety
ovarian	I-ety
cyst	I-ety
in	O
pregnancy	O
,	O
and	O
intra-cystic	O
ovarian	B-ety
bleeding	I-ety
in	O
pregnancy	O
.	O

paraclinical	O
investigations	O
revealed	O
:	O
beta	O
human	O
chorionic	O
gonadotropin	O
(	O
β	O
hcg	O
)	O
level	O
of	O
96	O
702	O
milli	O
international	O
units	O
per	O
milliliter	O
of	O
plasma	O
(	O
miu	O
/	O
ml	O
)	O
.	O

ultrasonography	O
revealed	O
a	O
heterogenous	O
left	B-ety
ovarian	I-ety
mass	I-ety
of	O
82	O
millimeters	O
in	O
diameter	O
,	O
an	O
empty	O
uterus	O
and	O
no	O
peritoneal	B-ety
effusion	I-ety
.	O

this	O
comforted	O
our	O
first	O
diagnosis	O
.	O

after	O
a	O
normal	O
pre-operative	O
work	O
up	O
,	O
an	O
emergency	O
laparotomy	O
was	O
done	O
under	O
general	O
anesthesia	O
.	O

the	O
findings	O
were	O
:	O
left	O
ovary	O
containing	O
a	O
gestational	O
sac	O
and	O
the	O
corpus	O
luteum	O
,	O
normal	O
right	O
adnexae	O
,	O
normal	O
left	O
tube	O
and	O
normal	O
uterus	O
.	O

there	O
was	O
no	O
hemoperitoneum	O
.	O

we	O
dissected	O
the	O
ovarian	O
capsule	O
and	O
carried	O
out	O
ablation	O
of	O
the	O
gestational	O
sac	O
,	O
then	O
we	O
did	O
hemostasis	O
.	O

the	O
specimen	O
was	O
analysed	O
by	O
the	O
pathologist	O
who	O
found	O
decidual	O
cells	O
and	O
trophoblastic	O
tissue	O
within	O
the	O
ovarian	O
capsule	O
and	O
thus	O
confirmed	O
the	O
ovarian	B-ety
pregnancy	I-ety
.	O

post	O
operative	O
course	O
was	O
uneventful	O
and	O
the	O
patient	O
was	O
discharged	O
six	O
days	O
after	O
surgery	O
.	O

the	O
?	O

hcg	O
level	O
decreased	O
and	O
disappeared	O
25	O
days	O
after	O
surgery	O
.	O

A	O
26	O
-	O
year-old	O
pregnant	O
patient	O
with	O
a	O
history	O
of	O
two	O
previous	O
cesarean	O
deliveries	O
was	O
referred	O
to	O
our	O
tertiary	O
clinic	O
.	O

the	O
patient	O
was	O
having	O
severe	O
right	B-ety
sided	I-ety
abdominal	I-ety
pain	I-ety
with	O
sudden	O
onset	O
.	O

she	O
was	O
in	O
the	O
18	O
th	O
week	O
of	O
her	O
pregnancy	O
based	O
on	O
last	O
menstrual	O
period	O
.	O

obstetric	O
ultrasound	O
measurements	O
revealed	O
a	O
live	O
pregnancy	O
compatible	O
with	O
18	O
weeks	O
gestation	O
without	O
any	O
abnormality	O
.	O

however	O
,	O
a	O
15x12cm	O
in	O
size	O
edematous	O
multicystic	O
adnexal	B-ety
mass	I-ety
occupying	O
the	O
mid	O
and	O
upper	O
right	O
abdomen	O
without	O
vascularity	O
was	O
identified	O
.	O

the	O
mass	O
was	O
suspected	O
to	O
originate	O
from	O
right	O
ovary	O
.	O

it	O
was	O
pushing	O
the	O
pregnant	O
uterus	O
into	O
the	O
left	O
and	O
anterior	O
direction	O
.	O

there	O
was	O
no	O
ultrasonographic	O
evidence	O
of	O
malignancy	B-ety
.	O

considering	O
the	O
severe	O
sudden	O
pain	B-ety
complaint	O
and	O
adnexal	B-ety
mass	I-ety
finding	O
,	O
explorative	O
laparotomy	O
was	O
planned	O
for	O
the	O
suspected	O
diagnosis	O
of	O
adnexal	B-ety
torsion	I-ety
.	O

A	O
mediolateral	O
(	O
near	O
vertical	O
)	O
skin	O
incision	O
was	O
made	O
originated	O
from	O
infra-umbilical	O
level	O
on	O
the	O
lateral	O
side	O
of	O
right	O
rectus	O
muscle	O
.	O

specifically	O
,	O
the	O
starting	O
point	O
for	O
this	O
slightly	O
oblique	O
incision	O
was	O
at	O
3cm	O
lateral	O
to	O
the	O
midline	O
and	O
near	O
to	O
lateral	O
one	O
third	O
of	O
the	O
rectus	O
muscle	O
.	O

the	O
skin	O
and	O
fascia	O
incisions	O
were	O
approximately	O
4cm	O
and	O
2.5cm	O
in	O
length	O
,	O
respectively	O
and	O
this	O
difference	O
was	O
due	O
to	O
the	O
thick	O
subcutaneous	O
fat	O
tissue	O
.	O

the	O
oblique	O
paramedian	O
incision	O
of	O
the	O
anterior	O
rectus	O
sheath	O
was	O
approximately	O
2cm	O
medial	O
to	O
the	O
lateral	O
border	O
of	O
the	O
rectus	O
muscle	O
and	O
it	O
was	O
extended	O
to	O
caudal-lateral	O
direction	O
,	O
down	O
to	O
1	O
/	O
2cm	O
to	O
the	O
lateral	O
border	O
of	O
rectus	O
muscle	O
.	O

the	O
lateral	O
edge	O
of	O
anterior	O
rectus	O
sheath	O
incision	O
was	O
dissected	O
off	O
from	O
the	O
rectus	O
muscle	O
laterally	O
up	O
to	O
semilunar	O
line	O
of	O
rectus	O
muscle	O
in	O
1cm	O
width	O
.	O

then	O
,	O
the	O
rectus	O
muscle	O
was	O
retracted	O
medially	O
to	O
expose	O
the	O
posterior	O
sheath	O
of	O
rectus	O
(	O
below	O
the	O
arcuate	O
line	O
,	O
only	O
the	O
transversalis	O
fascia	O
and	O
parietal	O
peritoneum	O
are	O
exposed	O
)	O
.	O

an	O
oblique	O
incision	O
was	O
made	O
on	O
the	O
posterior	O
sheath	O
of	O
rectus	O
and	O
peritoneum	O
behind	O
the	O
rectus	O
muscle	O
,	O
in	O
a	O
projection	O
of	O
the	O
anterior	O
sheath	O
incision	O
.	O

in	O
this	O
manner	O
,	O
the	O
abdominal	O
wall	O
incisions	O
were	O
located	O
at	O
anterior	O
and	O
posterior	O
sheaths	O
of	O
rectus	O
muscle	O
at	O
least	O
1	O
/	O
2cm	O
medial	O
to	O
the	O
semilunar	O
line	O
and	O
to	O
the	O
lateral	O
border	O
of	O
rectus	O
.	O

in	O
other	O
words	O
,	O
incision	O
was	O
not	O
made	O
from	O
fascial	O
layers	O
'	O
merging	O
point	O
or	O
by	O
muscle	O
splitting	O
dissection	O
.	O

therefore	O
,	O
traction	O
forces	O
from	O
enlarging	O
uterus	O
in	O
advancing	O
pregnant	O
abdomen	O
could	O
be	O
minimized	O
.	O

A	O
large	O
edematous	B-ety
,	O
necrotic	B-ety
and	O
dark	O
purple	O
torsion	B-ety
of	I-ety
a	I-ety
right	I-ety
adnexal	I-ety
mass	I-ety
was	O
observed	O
.	O

it	O
was	O
pulled	O
out	O
and	O
was	O
partially	O
dissected	O
from	O
its	O
surface	O
layer	O
following	O
a	O
2cm	O
incision	O
.	O

the	O
cystic	O
structure	O
was	O
aspirated	O
and	O
right	O
salpingo-ooferectomy	O
was	O
performed	O
.	O

the	O
operation	O
was	O
completed	O
by	O
avoiding	O
the	O
manipulation	O
of	O
the	O
pregnant	O
uterus	O
.	O

frozen	O
section	O
pathology	O
of	O
the	O
removed	O
specimen	O
was	O
reported	O
as	O
benign	O
(	O
necrotic	O
tissues	O
,	O
teratoma	O
)	O
and	O
final	O
pathology	O
was	O
mucinous	B-ety
cystadenoma	I-ety
.	O

follow	O
up	O
on	O
the	O
pregnant	O
patient	O
was	O
uneventful	O
a	O
month	O
later	O
.	O

we	O
report	O
the	O
case	O
of	O
a	O
15	O
-	O
year-old	O
caucasian	O
girl	O
who	O
was	O
diagnosed	O
with	O
silver-russell	B-ety
syndrome	I-ety
at	O
the	O
age	O
of	O
four	O
and	O
a	O
half	O
years	O
.	O

recombinant	O
growth	O
hormone	O
was	O
administered	O
for	O
18	O
months	O
without	O
an	O
appropriate	O
increase	O
in	O
growth	O
velocity	O
.	O

at	O
the	O
age	O
of	O
seven	O
years	O
,	O
her	O
serum	O
growth	O
hormone	O
levels	O
were	O
high	O
,	O
and	O
an	O
insulin-like	O
growth	O
factor	O
1	O
generation	O
test	O
did	O
not	O
increase	O
insulin-like	O
growth	O
factor	O
1	O
levels	O
(	O
baseline	O
insulin-like	O
growth	O
factor	O
1	O
levels	O
,	O
52	O
μg	O
/	O
L	O
;	O
reference	O
range	O
,	O
75	O
μg	O
/	O
L	O
to	O
365	O
μg	O
/	O
L	O
;	O
and	O
peak	O
,	O
76	O
μg	O
/	O
L	O
and	O
50	O
μg	O
/	O
L	O
after	O
12	O
and	O
84	O
hours	O
,	O
respectively	O
,	O
from	O
baseline	O
)	O
.	O

the	O
genetic	O
analysis	O
showed	O
that	O
the	O
patient	O
was	O
homozygous	O
for	O
the	O
R217X	O
mutation	O
in	O
the	O
growth	O
hormone	O
receptor	O
gene	O
,	O
which	O
is	O
characteristic	O
of	O
laron	B-ety
syndrome	I-ety
.	O

on	O
the	O
basis	O
of	O
these	O
results	O
,	O
the	O
diagnosis	O
of	O
primary	O
growth	B-ety
hormone	I-ety
insensitivity	I-ety
syndrome	I-ety
was	O
made	O
,	O
and	O
recombinant	O
insulin-like	O
growth	O
factor	O
1	O
therapy	O
was	O
initiated	O
.	O

the	O
patient's	O
treatment	O
was	O
well	O
tolerated	O
,	O
but	O
unexplained	O
central	O
hypothyroidism	O
occurred	O
at	O
the	O
age	O
of	O
12.9	O
years	O
.	O

at	O
the	O
age	O
of	O
15	O
years	O
,	O
when	O
the	O
patient's	O
sexual	O
development	O
was	O
almost	O
completed	O
and	O
her	O
menstrual	O
cycle	O
occurred	O
irregularly	O
,	O
her	O
height	O
was	O
129.8	O
cm	O
,	O
which	O
is	O
4.71	O
standard	O
deviations	O
below	O
the	O
median	O
for	O
normal	O
girls	O
her	O
age	O
.	O

male	O
infant	O
9.5	O
month	O
old	O
was	O
examined	O
in	O
the	O
emergency	O
department	O
of	O
our	O
hospital	O
because	O
of	O
an	O
empty	B-ety
scrotum	I-ety
and	O
the	O
ipsilateral	O
testis	O
lying	O
in	O
a	O
high	O
iliac	O
crest	O
position	O
.	O

with	O
the	O
increase	O
in	O
intrabdominal	O
pressure	O
[	O
crying	O
etc	O
.	O
]	O
there	O
was	O
an	O
ever-increasing	O
swelling	B-ety
with	O
spiral	O
course	O
from	O
the	O
groin	O
to	O
ipsilateral	O
iliac	O
crest	O
.	O

on	O
clinical	O
examination	O
,	O
a	O
reducible	O
mass	O
was	O
present	O
in	O
the	O
right	O
ileac	O
crest	O
.	O

the	O
swelling	B-ety
looked	O
like	O
a	O
spigelian	B-ety
hernia	I-ety
[	O
4	O
]	O
.	O

however	O
no	O
abdominal	B-ety
wall	I-ety
defect	I-ety
could	O
be	O
palpated	O
at	O
that	O
area	O
.	O

moreover	O
the	O
ipsilateral	O
scrotum	O
was	O
empty	O
and	O
the	O
testis	O
could	O
be	O
palpated	O
with	O
difficulty	O
lying	O
in	O
a	O
high	O
inguinal	O
position	O
.	O

ultrasonography	O
showed	O
a	O
loop	O
of	O
herniated	O
small	O
bowel	O
and	O
an	O
undescended	B-ety
testis	I-ety
on	I-ety
the	I-ety
right	I-ety
.	O

at	O
operation	O
,	O
under	O
general	O
anesthesia	O
,	O
an	O
extended	O
transverse	O
inguinal	O
incision	O
was	O
made	O
.	O

upon	O
entering	O
the	O
inguinal	O
canal	O
a	O
large	O
hernia	B-ety
sac	I-ety
was	O
identified	O
.	O

this	O
followed	O
a	O
course	O
through	O
the	O
superficial	O
inguinal	O
ring	O
,	O
extended	O
upwards	O
to	O
the	O
anterior	O
abdomninal	O
wall	O
below	O
the	O
subcutaneous	O
plane	O
and	O
was	O
fixed	O
in	O
the	O
area	O
of	O
the	O
right	O
iliac	O
crest	O
.	O

we	O
noticed	O
that	O
the	O
hernia	B-ety
orifice	O
was	O
in	O
a	O
higher	O
than	O
normal	O
position	O
5	O
cm	O
from	O
the	O
pubic	O
bone	O
.	O

this	O
bulk	O
was	O
easily	O
reduced	O
back	O
to	O
the	O
abdomen	O
along	O
with	O
an	O
ipsilateral	O
mobile	O
intravaginal	O
testis	O
.	O

after	O
careful	O
isolation	O
of	O
the	O
sac	O
at	O
a	O
length	O
of	O
3	O
cm	O
the	O
ipsilateral	O
testis	O
was	O
isolated	O
.	O

the	O
vas	O
and	O
the	O
vessels	O
were	O
intravaginal	O
,	O
the	O
gubernaculum	O
was	O
fixed	O
in	O
an	O
ectopic	O
position	O
and	O
the	O
dorsal	O
inguinal	O
wall	O
was	O
lax	O
.	O

we	O
removed	O
the	O
large	O
sac	O
after	O
separating	O
the	O
vas	O
and	O
vessels	O
and	O
the	O
testis	O
.	O

moreover	O
we	O
strengthened	O
the	O
dorsal	O
inguinal	O
wall	O
,	O
fixated	O
the	O
testis	O
in	O
a	O
subdartos	O
pouch	O
and	O
closed	O
the	O
wound	O
.	O

patient	O
stayed	O
for	O
a	O
day	O
in	O
the	O
hospital	O
.	O

no	O
postoperative	O
complications	O
happened	O
.	O

three	O
years	O
later	O
the	O
boy	O
was	O
operated	O
for	O
left	B-ety
hydrocele	I-ety
.	O

the	O
boy	O
remains	O
in	O
perfect	O
health	O
now	O
five	O
years	O
after	O
the	O
initial	O
operation	O
.	O

A	O
32	O
-	O
year-old	O
female	O
patient	O
with	O
kniest	B-ety
syndrome	I-ety
presented	O
at	O
our	O
department	O
with	O
a	O
painful	O
pseudarthrosis	B-ety
after	O
femoral	O
valgisation	O
osteotomy	O
8	O
years	O
ago	O
.	O

A	O
wagner	O
cone	O
stem	O
and	O
acetabular	O
roof	O
cup	O
with	O
a	O
cemented	O
ecofit	O
cup	O
2M	O
(	O
dual-articulation	O
acetabular	O
cup	O
system	O
)	O
were	O
implanted	O
due	O
to	O
a	O
dysplastic	B-ety
femur	I-ety
with	O
a	O
small	O
medullary	O
space	O
.	O

the	O
ecofit	O
cup	O
itself	O
is	O
associated	O
with	O
a	O
reduced	O
risk	O
of	O
dislocation	O
.	O

the	O
patient	O
was	O
satisfied	O
with	O
the	O
range	O
of	O
motion	O
after	O
hip	O
endoprosthesis	O
and	O
reported	O
a	O
significant	O
increase	O
in	O
quality	O
of	O
life	O
.	O

the	O
patient	O
is	O
still	O
comfortable	O
with	O
the	O
hip	O
prosthesis	O
at	O
the	O
most	O
recent	O
follow-up	O
4	O
years	O
after	O
implantation	O
.	O

follow-up	O
radiographs	O
over	O
4	O
years	O
have	O
not	O
revealed	O
any	O
signs	O
of	O
loosening	O
or	O
migration	O
,	O
and	O
no	O
trendelenburg	B-ety
sign	I-ety
was	O
reported	O
for	O
the	O
affected	O
side	O
.	O