The kidneys play a central role in maintaining homeostasis by filtering metabolic waste, excess ions, and fluid from the bloodstream via glomerular filtration, reabsorption, and secretion. Impaired renal function results in the accumulation of uremic toxins, dysregulation of electrolyte balance (e.g., potassium, phosphate), and fluid overload, which can lead to hypertension, metabolic acidosis, and progressive glomerulosclerosis. Chronic kidney disease (CKD) progression is influenced by underlying pathophysiological mechanisms including glomerular injury, tubular atrophy, and vascular remodeling, with clinical outcomes dependent on stage, comorbidities, and biomarker profiles such as estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR).

The patient is a 49-year-old Asian woman.

She presented with severe abdominal distension and dyspnea.

She had dull nature abdominal discomfort and pain.

She had dyspnea for 3 weeks before her visit.

She visited another hospital 2 days prior to her visit.

She was transferred to the emergency room due to a huge ovarian cystic mass.

The CT scan showed a large amount of left pleural effusion.

On initial vital sign assessment, she had tachycardia.

Her white blood cells were 21.00 × 103/μL.

Her PT international normalized ratio was prolonged.

Her activated partial thromboplastin time was not reported.

The coagulation tests could possibly imply disseminated intravascular coagulation.

Physical examination showed abdominal distension.

Physical examination showed severe tenderness in the whole abdomen.

Chest tube insertion at the left lung was performed.

Approximately 850 mL of pleural fluid was drained.

Approximately 2 L of ascites was drained.

A dynamic abdomen-pelvis CT scan showed a 30-cm-sized multiseptated cystic mass.

The CT scan showed peritoneal thickening.

The CT scan showed large amount of ascites.

The findings suggested ovarian malignancy.

The findings suggested peritoneal carcinomatosis.

The patient's CA125 level was 674.3 U/mL.

The premenopausal ROMA index was 86.67%.

The postmenopausal ROMA index was 92.83%.

CA19-9, CEA, and AFP were within normal range.

Rupture of a malignant ovarian tumor was suspected.

The initial operation identified a ruptured 30-cm-sized right ovarian multiseptated cystic mass.

The mass showed diffuse adhesion to the retroperitoneum.

The mass showed diffuse adhesion to the abdominal wall.

The mass showed diffuse adhesion to the uterus.

Frozen section biopsy revealed poorly differentiated carcinoma.

Debulking surgery including hysterectomy could not be performed.

Bilateral salpingo-oophorectomy was performed.

The pathologic diagnosis was high-grade stromal sarcoma.

The tumor showed features of brisk mitosis.

The tumor had an adenofibromatous component.

The tumor had endometriosis with mucinous metaplasia.

The tumor consisted of monotonous uniform cells with endometrial stromal differentiation.

Highly atypical neoplastic cells were noted.

Metastasis to the omentum was identified.

Tumor cells were positive for Cyclin D1.

Tumor cells were focally positive for desmin.

Tumor cells were focally positive for smooth muscle actin.

Tumor cells were negative for beta-catenin.

Tumor cells were negative for inhibin A.

The endometrial biopsy result was nonspecific.

The patient underwent three courses of Adriamycin chemotherapy.

A follow-up CT scan showed new 11-mm-sized probable seeding nodules in the right omentum.

A follow-up CT scan showed new 11-mm-sized probable seeding nodules in the left paracolic gutter.

A 1.5-cm-sized partly solid nodule was identified in the right upper lung field.

The lung lesion was considered both primary and metastatic.

A secondary debulking operation was planned.

The secondary debulking operation included total hysterectomy.

The secondary debulking operation included metastasectomy.

The secondary debulking operation included omentectomy.

The secondary debulking operation included peritonectomy.

The secondary debulking operation included appendectomy.

HIPEC with paclitaxel 175 mg/m2 was performed.

The final pathologic report confirmed no specific findings in the uterine cervix, myometrium, and endometrium.

The peritoneum, omentum, and appendix were confirmed as metastatic high-grade endometrial stromal sarcoma.

A right upper lung lobectomy was performed.

The lung biopsy was revealed as adenocarcinoma.

The patient has double primary malignancy.

The patient is currently alive 28 months after diagnosis.

The patient is under a new chemotherapy regimen: paclitaxel 175 mg/m2 and ifosfamide 1.6 g/m2.

The patient is a 49-year-old Asian woman.

She presented with disseminated intravascular coagulation.

The cause of disseminated intravascular coagulation was ruptured primary high-grade ovarian endometrial stromal sarcoma.

The sarcoma had multiple intraperitoneal metastases.

The patient underwent adjuvant chemotherapy with three courses of Adriamycin.

The secondary debulking operation included omentectomy.

The secondary debulking operation included hyperthermic intraperitoneal chemotherapy.

The hyperthermic intraperitoneal chemotherapy used paclitaxel 175 mg/m2.

The patient has been alive for 28 months.

The patient is under a new chemotherapy regimen.

The patient is a 49-year-old Asian woman.

She had dull nature abdominal discomfort and pain.

She had dyspnea for 3 weeks before her visit.

She visited another hospital 2 days prior to her visit.

On initial vital sign assessment, she had tachycardia.

Her white blood cells were 21.00 × 103/μL.

Her PT international normalized ratio was prolonged.

Physical examination showed abdominal distension.

Chest tube insertion at the left lung was performed.

Approximately 850 mL of pleural fluid was drained.

Approximately 2 L of ascites was drained.

The CT scan showed peritoneal thickening.

The CT scan showed large amount of ascites.

The findings suggested ovarian malignancy.

The findings suggested peritoneal carcinomatosis.

The patient's CA125 level was 674.3 U/mL.

The premenopausal ROMA index was 86.67%.

The postmenopausal ROMA index was 92.83%.

CA19-9, CEA, and AFP were within normal range.

Rupture of a malignant ovarian tumor was suspected.

The mass showed diffuse adhesion to the abdominal wall.

The mass showed diffuse adhesion to the uterus.

Bilateral salpingo-oophorectomy was performed.

The tumor showed features of brisk mitosis.

The tumor had an adenofibromatous component.

The tumor had endometriosis with mucinous metaplasia.

Highly atypical neoplastic cells were noted.

Metastasis to the omentum was identified.

Tumor cells were positive for Cyclin D1.

Tumor cells were focally positive for desmin.

Tumor cells were negative for beta-catenin.

Tumor cells were negative for inhibin A.

The endometrial biopsy result was nonspecific.

A secondary debulking operation was planned.

The secondary debulking operation included omentectomy.

HIPEC with paclitaxel 175 mg/m2 was performed.

A right upper lung lobectomy was performed.

The lung biopsy was revealed as adenocarcinoma.

The patient has double primary malignancy.


Your body needs to keep your blood clean and your organs working well. If your kidneys aren’t doing their job, it’s like having a leaky faucet — waste builds up, and you might feel tired or sick. You should talk to a doctor if you notice these signs so they can check your kidneys and help you feel better.

Kidney function is essential for filtering waste and excess fluids from the blood. When kidney function declines, toxins accumulate, leading to symptoms like fatigue, swelling, and high blood pressure. Early detection through regular screening is key to managing the condition and preventing complications. Lifestyle changes and medical monitoring can help maintain kidney health.

The patient was referred for percutaneous LAAO.

Past medical history was significant for mitral regurgitation.

Past medical history was significant for tricuspid regurgitation.

Past medical history was significant for persistent atrial fibrillation.

Persistent atrial fibrillation was complicated by recurrent significant gastrointestinal haemorrhage on anticoagulation.

The gastrointestinal haemorrhage was secondary to diverticulosis.

Five months prior to referral, she underwent surgical mitral and tricuspid valve repair.

Five months prior to referral, she underwent LAA ligation with 35 mm AtriClip.

The LAA ligation was due to elevated stroke risk (CHA2DS2-VASc score 5).

The patient had intolerance to oral anticoagulation.

Initial pre-procedural clinical examination revealed a haemodynamically stable, well-appearing female.

Initial pre-procedural clinical examination revealed a regular heart rate.

Initial pre-procedural clinical examination revealed an irregular rhythm.

Pre-operative laboratory assessment revealed normal kidney function (serum creatinine 0.81 mg/dL).

Pre-operative laboratory assessment revealed mild anaemia (haemoglobin 10.8 g/dL).

Intra-operative transoesophageal echocardiogram demonstrated closure of the LAA.

40-day post-operative TEE demonstrated a significant persistent communication between the left atrium and LAA.

40-day post-operative cardiac CT imaging demonstrated a significant persistent communication between the left atrium and LAA.

A 27 mm LAAO device (WATCHMAN™) was selected.

The LAAO device was deployed with all the P.A.S.S. criteria satisfied.

She continued on apixaban 5 mg twice daily post-operatively.

She continued on aspirin 81 mg daily post-operatively.

Follow-up TEE at 6 weeks demonstrated a trivial PDL measuring 1.9 mm along posterior aspect.

The decision was made to continue aspirin 81 mg daily.

The decision was made to continue clopidogrel 75 mg daily.

The decision was made to discontinue apixaban.

The patient has not experienced any further episodes of major bleeding.

We are tentatively planning to stop clopidogrel at 6 months post-operatively.

We are tentatively planning to continue aspirin 81 mg daily indefinitely thereafter.

The patient underwent LAAO device deployment within a surgically occluded LAA with PDL.

A 27 mm LAAO device (WATCHMANTM) was deployed.

All the P.A.S.S. criteria were satisfied.

The patient was continued on apixaban and aspirin post-operatively.

A post-operative transoesophageal echocardiogram was performed at 6 weeks.

The 6-week transoesophageal echocardiogram demonstrated trivial PDL measuring 1.49 mm.

The patient was continued on aspirin and clopidogrel.

A 27 mm LAAO device (WATCHMAN™) was selected.

The decision was made to discontinue apixaban.

**System Role:**

You are an expert medical editor and Health Literacy specialist. Your task is to transform complex medical text into three distinct versions based on the reader's health literacy level. You must maintain the source language of the input while adjusting the linguistic complexity. Use the provided Gold Summary as the factual anchor to ensure the simplified versions remain accurate and focused on the most important information.

**User Prompt:**

Please process the following medical Source Text and its corresponding Gold Summary to generate three versions tailored to different health literacy levels.
### Instructions for Each Level:

1. Level: Low Health Literacy (High Readability)

Target: Individuals needing the simplest terms for immediate action.

Linguistic Goal: Use "living room" language. Replace all medical jargon with functional descriptions (e.g., "renal" becomes "kidney").

Information Density: Focus strictly on the "need-to-know" info found in the Gold Summary.

Strategy: High paraphrasing using analogies. One idea per sentence.

Faithfulness: Must align perfectly with the Gold Summary.

2. Level: Intermediate Health Literacy (Medium Readability)

Target: The general public (news-reading level).

Linguistic Goal: Standard vocabulary. Common medical terms are okay, but technical "doctor-speak" must be simplified.

Information Density: Balanced. Use the Gold Summary as the lead, supplemented by necessary context from the Source Text.

Strategy: Moderate paraphrasing. Remove minor technical details to avoid information overload.

Faithfulness: Maintains the main narrative of the Gold Summary.

3. Level: Proficient Health Literacy (Low Readability)

Target: Researchers, clinicians, or highly informed patients.

Linguistic Goal: Technical and academic language. Prioritize clinical nuance and medical accuracy.

Information Density: High. Use the Full Source Text to include data, physiological mechanisms, and statistics.

Strategy: Minimal paraphrasing. Retain all original technical terminology.

Faithfulness: Adhere to the Source Text; you may add related subclaims that provide deeper scientific context.

I will provide the following information:

- Input Language: <<<SOURCE_LANGUAGE>>>
- Gold Summary (the anchor reference summary): <<<GOLD_SUMMARY>>>
- Source Text (detailed content): <<<FULL_TEXT>>>

**Output Format (JSON only):**
    {
    "low_health_literacy": "...",
    "intermediate_health_literacy": "...",
    "proficient_health_literacy": "..."
    }


The kidneys play a central role in maintaining homeostasis by filtering metabolic waste, excess ions, and fluid from the bloodstream via glomerular filtration, reabsorption, and secretion. Impaired renal function results in the accumulation of uremic toxins, dysregulation of electrolyte balance (e.g., potassium, phosphate), and fluid overload, which can lead to hypertension, metabolic acidosis, and progressive glomerulosclerosis. Chronic kidney disease (CKD) progression is influenced by underlying pathophysiological mechanisms including glomerular injury, tubular atrophy, and vascular remodeling, with clinical manifestations often emerging in the later stages of disease. Early intervention through biomarker monitoring, blood pressure control, and pharmacological management (e.g., RAS inhibitors) is critical to slow disease progression and preserve renal function.

The patient has a history of atrial fibrillation.

The patient was previously on apixaban and was switched to aspirin only.

The patient has type II diabetes mellitus.

The patient has asthma, well controlled on home inhalers.

The patient tested positive for coronavirus disease 2019 (COVID-19) on April 7th, 2021.

The patient is fully vaccinated with Moderna.

The patient presented to the emergency department with progressive worsening of bilateral lower extremity edema and dyspnea over one month.

The patient had a chronic two-pillow orthopnea.

The patient performed all activities of daily living independently at baseline.

This work has been reported in accordance with SCARE.

At presentation, the patient denied chest pain.

At presentation, the patient denied fever.

At presentation, the patient denied nausea.

At presentation, the patient denied vomiting.

At presentation, the patient denied diarrhea.

At presentation, the patient denied dysuria.

At presentation, the patient denied travel.

At presentation, the patient denied trauma.

At presentation, the patient denied drug use.

At presentation, the patient denied cough.

Vital signs were all within normal limits on admission.

Physical exam was notable for bibasilar crackles in the lungs.

Physical exam was notable for bilateral lower extremity 2+ pitting edema.

Physical exam was notable for jugular venous distention up to 9 cm.

Labs were notable for a pro B-type natriuretic peptide of 8458 pg/mL.

The pro B-type natriuretic peptide reference range is 1–450 pg/mL.

The pro B-type natriuretic peptide was a significant increase from 3301 pg/mL during a previous admission.

A chest radiograph obtained during admission showed bilateral ground glass opacities from prior COVID-19.

A chest radiograph obtained during admission showed pulmonary congestion.

A chest radiograph obtained during admission showed interposition of the right hepatic flexure of the colon between subdiaphragmatic space and the right dome of the liver (Chilaiditi's sign).

The comparison was made from a prior chest radiograph that showed normal anatomy of the right subdiaphragmatic space.

Electrocardiogram demonstrated atrial fibrillation with low voltage.

Electrocardiogram showed no acute ischemic features.

Echocardiogram showed an ejection fraction of 40%.

The ejection fraction was reduced from 70% only a year ago.

Echocardiogram showed normal right ventricular (RV) size.

Echocardiogram showed reduced RV contractility.

Echocardiogram showed a dilated right atrium.

The patient did not have any prior COVID-19 complications.

The patient did not have development of pulmonary embolism.

The patient did not require supplemental oxygen.

A negative D-dimer and CT chest without contrast showed no evidence of embolism.

Acute pulmonary embolism was effectively ruled out.

The patient was admitted for congestive heart failure exacerbation.

The patient was started on furosemide 40 mg IV twice a day.

The patient had a net negative urine output of 6.8 L over 48 hours since admission.

Home medications were resumed, including Losartan 25 mg daily.

Home medications were resumed, including carvedilol 3.125 mg twice daily.

Home medications were resumed, including atorvastatin 40 mg.

Home medications were resumed, including aspirin 81mg.

Home medications were resumed, including albuterol inhaler as needed every 6 hours.

Home medications were resumed, including montelukast 10 mg daily.

The patient successfully achieved euvolemic status.

The patient had resolution of bilateral leg edema.

The patient had improvement of jugular venous distention.

Cardiology was consulted for a new reduction in ejection fraction to rule out acute coronary syndrome.

An electrocardiogram showed no ischemic features.

Troponin was negative on three separate assessments.

It was concluded that the patient did not have acute coronary syndrome.

The patient received coronary angiography.

Coronary angiography found non-obstructive coronary artery disease.

The patient continued to have persistent dyspnea.

The patient had some mild pleuritic chest pain on the right subcostal region.

The patient did not need supplemental oxygen.

The aforementioned medications were continued for a total of 5 days.

Community or hospital acquired pneumonia was ruled out.

There was an absence of inflammatory response.

There were no imaging findings concerning pneumonia.

A computed tomography scan of the chest without contrast was repeated.

The CT scan showed colonic interposition between the diaphragm and right lobe of the liver.

Surgery was consulted for potential Chilaiditi syndrome.

The patient refused to undergo any surgery.

The patient preferred to be discharged from the hospital.

The patient was discharged with guidelines for long-term medical treatment for heart failure.

The patient was discharged with Lasix 40mg by mouth twice daily.

The patient was discharged with carvedilol 3.125 mg twice daily.

The patient was discharged with Losartan 25mg daily.

The patient was discharged with aspirin 81mg.

The patient was discharged with albuterol inhaler as needed.

The patient was discharged with montelukast 10mg daily.

The patient has a past medical history of asthma.

The patient has a past medical history of heart failure with preserved ejection fraction.

The patient was admitted for acute heart failure exacerbation with reduced ejection fraction.

A new incidental finding of Chilaiditi's sign was noted on chest radiograph.

The patient received guideline-directed medical treatment for heart failure exacerbation.

Mild dyspnea with pleuritic chest pain persisted.

Dyspnea with pleurisy was likely attributed to a structural anatomical defect.

Chilaiditi's sign can be picked up on imaging.

The patient has a history of atrial fibrillation.

The patient has type II diabetes mellitus.

The patient has asthma, well controlled on home inhalers.

The patient is fully vaccinated with Moderna.

The patient had a chronic two-pillow orthopnea.

This work has been reported in accordance with SCARE.

At presentation, the patient denied chest pain.

At presentation, the patient denied fever.

At presentation, the patient denied nausea.

At presentation, the patient denied vomiting.

At presentation, the patient denied diarrhea.

At presentation, the patient denied dysuria.

At presentation, the patient denied travel.

At presentation, the patient denied trauma.

At presentation, the patient denied drug use.

At presentation, the patient denied cough.

Vital signs were all within normal limits on admission.

Physical exam was notable for bibasilar crackles in the lungs.

Electrocardiogram showed no acute ischemic features.

Echocardiogram showed an ejection fraction of 40%.

The ejection fraction was reduced from 70% only a year ago.

Echocardiogram showed normal right ventricular (RV) size.

Echocardiogram showed reduced RV contractility.

Echocardiogram showed a dilated right atrium.

The patient did not have any prior COVID-19 complications.

The patient did not have development of pulmonary embolism.

The patient did not require supplemental oxygen.

Acute pulmonary embolism was effectively ruled out.

The patient was started on furosemide 40 mg IV twice a day.

Home medications were resumed, including Losartan 25 mg daily.

Home medications were resumed, including atorvastatin 40 mg.

Home medications were resumed, including aspirin 81mg.

The patient successfully achieved euvolemic status.

The patient had resolution of bilateral leg edema.

The patient had improvement of jugular venous distention.

An electrocardiogram showed no ischemic features.

Troponin was negative on three separate assessments.

The patient received coronary angiography.

The patient continued to have persistent dyspnea.

The patient did not need supplemental oxygen.

Community or hospital acquired pneumonia was ruled out.

There was an absence of inflammatory response.

There were no imaging findings concerning pneumonia.

Surgery was consulted for potential Chilaiditi syndrome.

The patient refused to undergo any surgery.

The patient preferred to be discharged from the hospital.

The patient was discharged with Lasix 40mg by mouth twice daily.

The patient was discharged with carvedilol 3.125 mg twice daily.

The patient was discharged with Losartan 25mg daily.

The patient was discharged with aspirin 81mg.

The patient was discharged with albuterol inhaler as needed.

The patient was discharged with montelukast 10mg daily.


The patient has rapidly progressing dyspnea.

The patient was diagnosed with COPD in 2010.

Over the last 5 years, the patient experienced a gradual progression of dyspnea.

The dyspnea limited the patient's performance of everyday activities.

In 2019, the patient underwent Bentall’s heart surgery with resection of the left atrial appendage.

The patient did not claim any diseases of affluence.

The patient works as a managing director.

The patient denies any risk factors for lung disease from his occupation.

The patient’s father contracted tuberculosis after the Second World War.

The patient’s father died of lung cancer.

The patient’s brother has diabetes mellitus.

The patient’s lower limbs were without swelling.

Arterial blood gas examination showed an oxygen partial pressure pO2 = 7.67 kPa.

Arterial blood gas examination showed a carbon dioxide partial pressure pCO2 = 4.56 kPa.

Arterial blood gas examination showed a pH = 7.46.

Arterial blood gas examination showed blood saturation SpO2 = 90%.

Computed tomography results demonstrated centrilobular emphysema bilaterally.

The centrilobular emphysema reflects a severe obstructive ventilation disorder.

The patient underwent spirometry and body plethysmography examinations.

Forced expiratory volume in 1 s was 1.07 L.

Inspiratory muscle performance was examined with the PrO2 device.

Maximal inspiratory pressure (MIP) was 57 cmH2O.

Sustained maximal inspiratory pressure (SMIP) was 404 PTU.

The modified Medical Research Council Breathlessness score was 3.

The six-minute walk test (6-MWT) was used to assess exercise tolerance.

The distance walked during the 6-MWT was 270 m.

Oxygen saturation decreased from 95% at baseline to 75% during the 6-MWT.

The BODE index was used as a predictor of prognosis.

The Charlson Comorbidity Index calculated the 10-year mortality risk to be 53%.

The patient was a 71-year-old man with severe COPD, Global Initiative for Obstructive Lung Diseases stage 3.

The patient underwent an 8-wk remotely monitored inspiratory muscle training with a device based on the test of incremental respiratory endurance method.

Spirometry was performed as part of the initial and final examination.

Body plethysmography was performed as part of the initial and final examination.

The test of incremental respiratory endurance examination was performed as part of the initial and final examination.

The 6-min walking test was performed as part of the initial and final examination.

Body mass index was measured as part of the initial and final examination.

Airflow obstruction was assessed as part of the initial and final examination.

Dyspnea was assessed as part of the initial and final examination.

Exercise capacity index was measured as part of the initial and final examination.

Subjective perception of dyspnea was assessed as part of the initial and final examination.

The physiotherapist monitored the patient remotely through a web application.

The web application allowed the physiotherapist to evaluate all training parameters in real-time.

The web application allowed the physiotherapist to respond to any problems.

After 8 wk of home training, there was a significant increase in maximal inspiratory pressure.

After 8 wk of home training, there was a significant increase in a novel parameter sustained maximal inspiratory pressure.

After 8 wk of home training, there was a significant increase in forced expiratory volume in 1 s.

After 8 wk of home training, there was a significant increase in total lung capacity.

After 8 wk of home training, there was a significant increase in forced vital capacity.

After 8 wk of home training, there was a significant increase in peak expiratory flow.

After 8 wk of home training, there was a significant increase in inspiratory capacity.

There was an improvement in the perception of dyspnea according to the COPD Assessment Test.

There was an improvement in the perception of dyspnea according to the modified Medical Research Council Breathlessness Scale.

There was an increase in exercise tolerance according to the 6-min walking test.

There was a decrease in the exercise capacity index as a predictor of prognosis.

The patient has rapidly progressing dyspnea.

The patient was diagnosed with COPD in 2010.

The dyspnea limited the patient's performance of everyday activities.

The patient did not claim any diseases of affluence.

The patient works as a managing director.

The patient’s father contracted tuberculosis after the Second World War.

The patient’s father died of lung cancer.

The patient’s brother has diabetes mellitus.

The patient’s lower limbs were without swelling.

Arterial blood gas examination showed a pH = 7.46.

Arterial blood gas examination showed blood saturation SpO2 = 90%.

The patient underwent spirometry and body plethysmography examinations.

Forced expiratory volume in 1 s was 1.07 L.

Inspiratory muscle performance was examined with the PrO2 device.

Maximal inspiratory pressure (MIP) was 57 cmH2O.

Sustained maximal inspiratory pressure (SMIP) was 404 PTU.

The modified Medical Research Council Breathlessness score was 3.

The six-minute walk test (6-MWT) was used to assess exercise tolerance.

The distance walked during the 6-MWT was 270 m.

The BODE index was used as a predictor of prognosis.

Spirometry was performed as part of the initial and final examination.

Dyspnea was assessed as part of the initial and final examination.


She presented to the emergency department in September 2019.

She had a history of exertional shortness of breath since 1 month before admission.

She had 2 attacks of syncope during the 1 month before admission.

She reported 8-kg weight loss within the last 2 months.

On physical examination, her heart rate was 112 beats/min.

Heart examination revealed a pansystolic murmur at the lower left sternal edge.

The murmur was concordant with tricuspid regurgitation.

Electrocardiography showed sinus tachycardia.

Electrocardiography showed right bundle branch block.

Electrocardiography showed frequent ventricular ectopic rhythm.

Holter ECG monitoring showed sinus tachycardia reaching 136–140 bpm.

Transthoracic and transesophageal echocardiography revealed a large mass in the right atrium.

The mass originated below the fossa ovalis.

The right side of the heart was dilated.

Erythrocyte sedimentation rate was 53 mm/h.

Brain-type natriuretic peptide was 822 pg/mL.

An initial diagnosis of cardiac myxoma was made.

Surgical resection of the mass was planned.

The patient underwent cardiac surgery after 4 days of admission.

Intraoperatively, 400 mL of pericardial effusion was found.

The mass was attached to the interatrial septum below the fossa ovalis by a thin stalk.

The patient came out of cardiopulmonary bypass without the need for direct-current shock.

The patient was intubated for 12 h postoperatively.

The patient was kept in the intensive care unit for 24 h.

The mass was sent for histopathologic examination.

Macroscopic examination showed myxoid areas with other areas of hemorrhage and necrosis.

Microscopic examination showed stellate myxoma cells with abundant eosinophilic cytoplasm.

The intrapericardial drain was removed on the third postoperative day.

The patient was discharged without any complications.

She was seen in the clinic at 1-month, 2-month, 5-month, and 1-year intervals postoperatively.

She was doing well without any complaint.

Her liver transaminases returned to normal levels.

Repeated TTE 5 months and nearly 1 year postoperatively was free of any cardiac masses.

The right atrium and right ventricle were still dilated.

She was found to have a right atrioventricular myxoma.

The myxoma was associated with tricuspid regurgitation.

The myxoma was associated with right-sided heart failure.

The myxoma was associated with pulmonary hypertension.

The syncopal attacks resolved completely after tumor resection.

The shortness of breath resolved completely after tumor resection.

Tricuspid regurgitation (grade 1) remained as a sequela of delayed presentation.

Mild pulmonary hypertension (right ventricular systolic pressure 35 mmHg) remained as a sequela of delayed presentation.

These may be due to recurrent embolization of tumor fragments to segments of the pulmonary artery.

Electrocardiography showed sinus tachycardia.

The mass originated below the fossa ovalis.

The right side of the heart was dilated.

Erythrocyte sedimentation rate was 53 mm/h.

Brain-type natriuretic peptide was 822 pg/mL.

Surgical resection of the mass was planned.

She was doing well without any complaint.


The patient is a 77-year-old African American woman.

The patient has a medical history of hypertension.

The patient's systolic blood pressure was 200 mmHg.

A renal ultrasound showed a 12 × 9 × 7.5 cm mass medial to the left kidney.

A follow-up CT scan showed an enhancing 9 × 6 cm mass anterior and medial to the left kidney.

The dexamethasone suppression test was normal.

The androstenedione level was 182 ng/dl.

An androgen-producing adrenal tumor was suspected.

The differential diagnosis included pheochromocytoma, lymphoma, and mesenteric gastrointestinal stromal tumor.

The patient underwent robotic-assisted left adrenalectomy.

The intraoperative finding of 'focal invasion' into the renal parenchyma raised the possibility of adrenal cortical carcinoma.

An additional left upper pole partial nephrectomy was performed.

The specimen received was an 11 × 7.2 × 6.8 cm adrenal mass with attached portion of kidney.

The mass was golden yellow, well circumscribed, and grossly adherent to the kidney.

Histologic evaluation revealed an adrenal cortical adenoma without any features of malignancy.

The adjacent adrenal parenchyma shared an incomplete capsule with the kidney.

The adjacent adrenal parenchyma was in direct contact with the renal cortex.

The diagnosis was fusion between the adrenal gland and the kidney.

The postoperative course was uneventful.

The patient is a 77-year-old African American female.

The patient presented with a systolic blood pressure of 200 mmHg.

Computed tomography showed an enhancing 9 × 6 cm mass anterior and medial to the left kidney.

The patient underwent a left adrenalectomy with partial nephrectomy.

Gross and histologic examinations revealed an adrenal cortical adenoma.

Gross and histologic examinations revealed renal-adrenal fusion.


The patient is a 61-year-old obese male.

The patient underwent laparoscopic partial nephrectomy.

The tumor was found incidentally during a work-up for hypertension.

The tumor was located in the left kidney.

Microscopic examination of the tumor revealed chromophobe renal cell carcinoma.

After one year of surveillance, a tumor was found in the left seminal vesicle.

MRI showed a well-circumscribed heterogeneous solid tumor in the left seminal vesicle.

The tumor measured 32 mm across its largest dimension.

The tumor had well-defined cleavage planes with the rectum and bladder walls.

The patient underwent laparoscopic surgical excision of the left seminal vesicle.

Grossly, the seminal vesicle measured 6 x 3 x 2 cm.

The cut surface showed a solid, well-circumscribed, brownish and smooth nodule.

The nodule measured 30 mm across its largest dimension.

The surgical margins were free from tumor.

Microscopic examination disclosed well-defined nests of cuboidal cells.

The nests were separated by vascular fibrous septa.

There was no evidence of vascular invasion.

Gland-like structures were identified focally.

The tumor cells had a large central nucleus.

The tumor cells had small to medium-sized nucleoli.

The tumor cells had granular eosinophilic cytoplasm.

The diagnostic possibilities included metastasis of the previous chromophobe renal cell carcinoma.

The diagnostic possibilities included adenocarcinoma of the seminal vesicle.

The diagnostic possibilities included paraganglioma.

Immunohistochemical characterization was used for the differential diagnosis.

The tumor cells were immunoreactive for chromogranin.

The tumor cells were immunoreactive for synaptophysin.

S100 protein-positive cells were identified at the periphery of the tumor nests.

The tumor cells did not express keratins (AE1/AE3, CK7 and CK8/18).

The absence of keratin immunoreactivity ruled out the hypothesis of primary or metastatic carcinoma.

The diagnosis was supported as seminal vesicle paraganglioma.

The Ki-67 labeling index was less than 2%.

VHL and SDHB mutations were investigated using genomic DNA.

No genetic alterations were found in the VHL gene.

No genetic alterations were found in the SDHB gene.

Thorough imaging analysis showed no tumor elsewhere.

The diagnosis was reinforced as primary seminal vesicle paraganglioma.

The patient is still alive after 14 months of follow-up.

The patient's blood pressure is under control.

This report describes, for the first time to the best of our knowledge, a primary paraganglioma of the seminal vesicle occurring in a 61-year-old male.

The patient presented persistent arterial hypertension.

The patient had a previous diagnosis of chromophobe renal cell carcinoma.

It was hypothesized that the seminal vesicle tumor could be a metastasis from the chromophobe renal cell carcinoma.

Immunohistochemical characterization revealed expression of synaptophysin and chromogranin in tumor cell nests.

Immunohistochemical characterization revealed peripheral S100 protein expression in sustentacular cells.

Succinate dehydrogenase A and B-related (SDHA and SDHB) expression was present in both tumors.

The patient is a 61-year-old obese male.

The tumor was located in the left kidney.

The surgical margins were free from tumor.

The nests were separated by vascular fibrous septa.

There was no evidence of vascular invasion.

Gland-like structures were identified focally.

The tumor cells had a large central nucleus.

The tumor cells had small to medium-sized nucleoli.

The Ki-67 labeling index was less than 2%.

No genetic alterations were found in the VHL gene.

No genetic alterations were found in the SDHB gene.

The patient's blood pressure is under control.


The patient has a diagnosis of acute lymphoid leukemia of T precursors.

The patient was finishing the cycle of induction chemotherapy with the PETHEMA 2013 protocol.

The PETHEMA 2013 protocol includes L asparaginase, Vincristine, and Daunorrubicin.

The PETHEMA 2013 protocol includes continuous prednisone for more than a month.

The patient developed 12 days of epigastric abdominal pain.

The physical examination showed exquisite pain to palpation in the epigastric region.

The physical examination showed peristalsis present.

The physical examination showed no data of obstruction.

The laboratory examinations showed moderate neutropenia.

The laboratory examinations showed increased c reactive protein.

Acute pancreatitis was initially suspected.

Acute pancreatitis was ruled out as pancreatic enzymes were normal.

Acute pancreatitis was ruled out as abdominal computed tomography was normal.

Steroid acid-peptic disease was then suspected.

Medical treatment with proton pump inhibitors was continued.

Medical treatment with prokinetic was continued.

Medical treatment with oral tolerance was continued.

The next day, the patient presented with increasing abdominal pain at night.

The next day, the patient had emetic episodes on multiple occasions.

The next day, the patient had haematemesis.

The next day, the patient had severe hypokalaemia.

The next day, the patient had hyperglycaemia.

The next day, the patient had severe neutropenia.

The next day, the patient had signs of shock.

The patient was transferred to the paediatric intensive care unit.

Emergency esophagogastroduodenoscopy was performed.

An acute erosive haemorrhagic pangastritis was reported.

The EGD was consistent with necrotizing gastritis.

Necrotizing gastritis was confirmed by biopsy.

Management was initiated with potassium replacement.

Management was initiated with fluid replacement.

Management was initiated with omeprazole in continuous infusion.

Management was initiated with ondansetron.

Laboratory tests were negative with no bacterial isolation.

Blood cultures were negative with no bacterial isolation.

The patient progressed to catecholamine refractory shock.

Multiple vasoactive support with norepinephrine, epinephrine, and vasopressin was initiated.

Parenteral nutrition was indicated on the second day.

The EGD on the sixth day showed persistence of necrotizing gastritis.

Intestinal rest, proton pump inhibitors, and sucralfate were maintained.

A control EGD was performed 30 days after intestinal rest.

The control EGD showed significant improvement of extensive necrosis of the body, fundus, and gastric antrum.

The control EGD showed persistence of necrosis area that compromised 20% of the greater curvature of the gastric body.

The start of enteral nutrition was evaluated.

The enteral nutrition was a polymeric diet.

The start of enteral nutrition progressed to bland diet without irritants or lactose.

The enteral nutrition was initiated orally.

The patient had adequate intrahospital tolerance for 72 hours.

Double dose of proton pump inhibitors was prescribed.

On control at 2 months of discharge, the patient was hemodynamically stable.

The control EGD showed complete improvement of the necrotizing gastritis.

The control EGD showed remaining areas of fibrosis at the level of the corpus antrum region.

Chemotherapy treatment was postponed for a month and a half.

The same high-risk PETHEMA protocol was initiated.

In the intensification stage, the doses were reduced to 50% of the cytostatic.

In the next stage, the protocol was continued with the usual dose.

The patient has no complications associated with the underlying pathology.

The patient has been in remission for two years.

The patient has a diagnosis of acute lymphoid T-cell leukemia.

The patient completed a cycle of induction chemotherapy with the PETHEMA 2013 protocol.

The patient had epigastric abdominal pain for 12 days.

Acute pancreatitis was initially suspected.

Acute pancreatitis was ruled out by normal pancreatic enzymes.

Acute pancreatitis was ruled out by abdominal computed tomography.

Treatment with proton pump inhibitors was initiated.

Treatment with procinetics was initiated.

An esophagogastroduodenoscopy was performed.

The esophagogastroduodenoscopy was compatible with necrotizing gastritis.

Necrotizing gastritis was confirmed by histopathology.

Pharmacological management was provided.

Progressive improvement was evidenced in imaging controls.

Enteral nutrition was initiated after fasting.

The chemotherapy plan was completed after improvement.

There were no complications after 2 years.

The physical examination showed peristalsis present.

The physical examination showed no data of obstruction.

The laboratory examinations showed moderate neutropenia.

Acute pancreatitis was initially suspected.

Steroid acid-peptic disease was then suspected.

Medical treatment with prokinetic was continued.

Medical treatment with oral tolerance was continued.

The next day, the patient had haematemesis.

The next day, the patient had severe hypokalaemia.

The next day, the patient had hyperglycaemia.

The next day, the patient had severe neutropenia.

The next day, the patient had signs of shock.

Emergency esophagogastroduodenoscopy was performed.

An acute erosive haemorrhagic pangastritis was reported.

The EGD was consistent with necrotizing gastritis.

Necrotizing gastritis was confirmed by biopsy.

Management was initiated with potassium replacement.

Management was initiated with fluid replacement.

Management was initiated with ondansetron.

Blood cultures were negative with no bacterial isolation.

The patient progressed to catecholamine refractory shock.

Parenteral nutrition was indicated on the second day.

A control EGD was performed 30 days after intestinal rest.

The start of enteral nutrition was evaluated.

The enteral nutrition was a polymeric diet.

The enteral nutrition was initiated orally.

Double dose of proton pump inhibitors was prescribed.

The same high-risk PETHEMA protocol was initiated.

The patient has been in remission for two years.


The kidneys play a central role in maintaining homeostasis by filtering metabolic waste, excess ions, and fluid from the bloodstream via glomerular filtration, reabsorption, and secretion. Impaired renal function results in the accumulation of uremic toxins, dysregulation of electrolyte balance (e.g., potassium, phosphate), and fluid overload, which can lead to hypertension, metabolic acidosis, and progressive glomerulosclerosis. Chronic kidney disease (CKD) progression is influenced by factors including glomerular filtration rate (GFR), proteinuria, and comorbidities such as diabetes and hypertension. Early intervention with pharmacological agents, dietary modifications, and blood pressure control is critical to slow disease progression and reduce cardiovascular risk.

The patient complains of a history of sore throat.

The patient complains of neck and facial swelling.

The patient has a normal consciousness level.

On examination, there is tonsilar swelling.

On examination, there is tonsilar tenderness.

On examination, there is bilateral cervical lymphadenopathy.

The patient has no previous history of chronic disease.

The patient has no previous history of chronic drug usage.

The patient has no previous history of allergy.

A laboratory examination showed leukocytosis.

A laboratory examination showed high C-reactive protein serum.

An ultrasound examination demonstrates left jugular vein thrombosis.

Contrast-enhanced neck Computed tomography reveals fluid and air density collections.

Contrast-enhanced neck Computed tomography reveals soft tissue phlegmon formation in the anterior cervical region.

Contrast-enhanced neck Computed tomography reveals soft tissue phlegmon formation in both soft tissue of the anterior mandibular ramus.

Contrast-enhanced neck Computed tomography reveals soft tissue phlegmon formation in the peritonsillar area.

Contrast-enhanced neck Computed tomography reveals soft tissue phlegmon formation in the left parapharyngeal area.

Contrast-enhanced neck Computed tomography reveals soft tissue phlegmon formation in the left carotid space.

Contrast-enhanced neck Computed tomography reveals left jugular vein thrombosis.

Preliminary differential diagnoses reveal Ludwig's angina.

Preliminary differential diagnoses reveal Lemierre's syndrome.

The patient underwent surgical drainage in the ENT department.

The patient was treated with Penicillin g 1.2 unit 1 × 1 im for one dose.

The patient was treated with metrodenzol 3 × 1 iv.

The patient was treated with unacefen 1g 2 × 1.

The patient was treated with Clexane 4000 IU 1 × 1.

The blood culture was positive for Fusobacterium necrophorum.

The patient develops headaches after 10 days.

The patient develops fever after 10 days.

A contrast-enhanced MRI showed an intracranial epidural abscess on the left side of the brain.

The patient was added to the treatment with intravenous clindamycin 600mg 1 × 3.

The patient was added to the treatment with intravenous vancomycin 1g 3 × 1.

After 45 days, the patient improved clinically.

The patient was discharged for a home treatment regimen with clavulanate 1000 mg 1 × 2.

The patient was discharged for a home treatment regimen with metro 500mg 1 × 3.

The patient was discharged for a home treatment regimen with warfarin 5 mg 1 × 1.

There were no other symptoms after a one-month follow-up.

There were no other symptoms after a one-month follow-up with neck ultrasonography.

This work has been reported in line with the SCARE 2020.

The patient came to the emergency department.

The patient complained of a history of a sore throat.

The patient complained of neck swelling.

The patient had a normal consciousness level.

A laboratory examination showed leukocytosis.

Radiological diagnosis revealed an anterior neck abscess.

Radiological diagnosis revealed left jugular vein thrombosis.

Radiological diagnosis revealed left epidural abscess.

The patient underwent surgical drainage.

The patient was treated with antibiotics.

The patient was treated with anticoagulant drugs.

After 45 days, the patient improved clinically.

The patient complains of a history of sore throat.

The patient complains of neck and facial swelling.

The patient has a normal consciousness level.

On examination, there is tonsilar swelling.

On examination, there is tonsilar tenderness.

The patient has no previous history of allergy.

A laboratory examination showed leukocytosis.

The patient was treated with metrodenzol 3 × 1 iv.

The patient was treated with unacefen 1g 2 × 1.

The patient develops headaches after 10 days.

The patient develops fever after 10 days.

After 45 days, the patient improved clinically.


A 4-year-old boy was admitted because of persistent lower limb pain and claudication in the left lower limb over the past 9 mo.

The patient had mild persistent lower limb pain and claudication without any inducement.

The child had no fever, urinary frequency or urgency, numbness, fatigue, or lameness.

He was admitted to our joint hand surgery department.

The child had no history of family illness, and his medical history was unremarkable.

Pressing pain and local swelling were present in the left shank.

The results of sensation and strengthening test, and tendon reflex test were normal in both lower limbs.

No pathological signs were observed upon physical examination.

Preoperative imaging examinations showed erosion-like changes with bone expansion of the left middle and lower fibular segment.

No invasion of circumferential soft tissue or pathological fracture of the lesion site was observed.

Initial pathological examination revealed fibular fibrous dysplasia.

Postoperative photography showed that an allograft bone was implanted into the fibular medullary cavity.

Recurrent fibular fibrous dysplasia was observed at the age of 6 years.

A 4-year-old boy was admitted for persistent pain in the left lower limb and abnormal gait over the previous 9 mo.

He had no history of present or past illness.

Preoperative imaging data showed erosion-like changes with bone expansion of the left middle and lower fibular segment.

Tumor tissue in the fibular bone marrow cavity was removed by curettage.

Rapid intraoperative pathological examination suggested fibular fibrous dysplasia.

An allograft was implanted into the fibular medullary cavity.

He was readmitted with clinical symptoms including persistent pain, abnormal gait, and local swelling at the age of 6 years.

He was diagnosed with recurrent fibular fibrous dysplasia based on the second medical examination.

He underwent fibular bone tumor radical resection and longus fibular allograft transplantation combined with fibular bone locking plate and screws.

Good host bone to allogenic bone graft fusion was observed by the physician on postoperative regular follow-up.


The kidneys play a central role in maintaining homeostasis by filtering metabolic waste, excess ions, and fluid from the bloodstream via glomerular filtration, reabsorption, and secretion. Impaired renal function results in the accumulation of uremic toxins, dysregulation of electrolyte balance (e.g., potassium, phosphate), and fluid overload, which can lead to hypertension, metabolic acidosis, and progressive glomerulosclerosis. Chronic kidney disease (CKD) progression is influenced by factors including glomerular filtration rate (GFR), proteinuria, and comorbidities such as diabetes and hypertension. Early intervention with pharmacological agents, dietary modifications, and blood pressure control is critical to slow disease progression and preserve renal function.

She has a long history of low back pain.

She had undergone an L5-S1 discectomy 11 years ago.

She had undergone an L4-L5 decompressive laminectomy 2 years ago.

She presented with an acute cauda equina syndrome.

The acute cauda equina syndrome was characterized by paraparesis.

The acute cauda equina syndrome was characterized by acute urinary incontinence.

On examination, she had mild tenderness over the lower back region.

Laboratory tests revealed a white blood cell count of 12,600/mm3.

Laboratory tests revealed a high C-reactive protein level.

Plain X-rays showed laminectomy defects from L4 to L5.

The MRI showed an oblong posterior epidural lesion compressing the thecal sac from L4 to S1.

The lesion was hypointense on T1-weighted images.

The lesion was hyperintense on T2-weighted images.

The lesion demonstrated ring enhancement with gadolinium injection.

She underwent a decompressive laminectomy.

At surgery, there was an encapsulated posterior epidural abscess that required drainage.

A granulomatous lesion was noted at the antero-inferior part of the abscess wall at the level of S1.

The granulomatous lesion was completely removed.

The granulomatous lesion was unsuspected surgical cottonoid.

Culture of the capsule revealed Klebsiella oxytoca.

The infection required 2 months of ciprofloxacin.

The patient's paraparesis only partially recovered.

The histopathological examination confirmed a textiloma.

There was chronic inflammation and fibrosis surrounding the retained cottonoid.

After the first postoperative year, there was no evidence of infection recurrence.

The patient had two prior spinal operations at the L4-S1 levels.

The prior spinal operations were 11 and 2 years previously.

The patient presented over a few weeks with the acute onset of a cauda equina syndrome.

The cauda equina syndrome included paraparesis and acute urinary incontinence.

The patient had a mildly elevated white blood cell count of 12,600/mm3.

The patient had an abnormally increased C-reactive protein level.

Magnetic resonance imaging showed a dorsal epidural abscess extending from the L4 to S1 levels.

At surgery, an encapsulated posterior epidural abscess was drained.

Surgical findings included a granulomatous lesion consistent with a retained surgical cottonoid.

The granulomatous lesion was removed from the antero-inferior portion of the abscess wall at S1.

Culture of the thick fibrotic abscess wall grew Klebsiella oxytoca.

After 2 months of ciprofloxacin, the patient's infection cleared.

The motor deficit only partially resolved.


He was initially managed at a nearby community hospital.

He was diagnosed to have multiple rib fractures on both sides.

The primary management was performed with bilateral intercostal chest drains.

Positive pressure ventilation was used for lung contusion.

The patient had no neurological deficit at initial presentation.

He was referred to our center after four weeks.

On examination, there was tenderness over the tenth thoracic vertebrae.

There was no motor or sensory deficit at any level.

Superficial and deep tendon reflexes were normal.

Radiographs showed a fracture dislocation with spondyloptosis of the ninth thoracic vertebra (T9) over the tenth thoracic vertebra (T10).

The vertebral body of the eighth thoracic vertebra was fractured.

The pedicles of both T9 and T10 vertebrae were fractured bilaterally.

The posterior elements were separated from their respective vertebral bodies.

There was complete spondyloptosis of T9 over T10 vertebral body.

Both T9 and T10 vertebral bodies could be seen in a single transverse section of computerized tomography.

The patient was scheduled for surgery after improvement in general and lung condition.

The spine was approached through a standard posterior midline incision.

The posterior elements of the eighth and ninth thoracic vertebrae were lying almost in place.

The fractures in the lamina of the eighth and ninth thoracic vertebrae were undisplaced.

Pedicle screws were inserted in the fifth, sixth, and seventh thoracic vertebrae proximally.

Pedicle screws were inserted in the tenth, eleventh, and twelfth thoracic vertebrae distally.

An in-situ posterior instrumentation with laminectomy of T8 and T9 vertebrae was performed.

Posterolateral fusion from the fifth to twelfth thoracic vertebrae was performed.

No attempt was made to reduce spondyloptosis of T9 over the T10 vertebrae.

The patient tolerated the operation well.

There was no postoperative neurological deterioration.

He was mobilized with the help of a customized dorsolumbar rigid orthosis on the fifth postoperative day.

He was followed up at monthly intervals.

Radiographs showed satisfactory in situ fusion between T9 and T10 vertebral bodies.

Computerized tomography showed satisfactory in situ fusion between T9 and T10 vertebral bodies.

The patient returned to his previous occupation.

We reported a four-week spondyloptosis of the ninth thoracic vertebra over the tenth thoracic vertebra.

The patient had no neurological deficit.

The patient had associated chest injuries.

The spine injury was managed surgically with in-situ posterior instrumentation and fusion.

The patient tolerated the operation well.

Postoperatively there was no neurological deterioration.

Postoperatively there was no surgical complication.

The patient tolerated the operation well.

He was followed up at monthly intervals.


She has a history of coronary artery disease.

She has a history of atrial fibrillation.

She has a history of basal cell carcinoma removed via Mohs procedure on the nose.

She has a history of diabetic retinopathy.

She has a history of macular degeneration.

She presented with a recent increase in the number of falls.

The falls were due to a recent, sudden deterioration of vision bilaterally.

She was initially seen by the ophthalmologist 2 months ago for loss of vision in her right eye.

The loss of vision in her right eye was thought to be related to previously diagnosed diabetic retinopathy.

She underwent focal laser photocoagulation for diabetic retinopathy in her right eye.

There was no significant improvement in vision after focal laser photocoagulation.

A fleshy, salmon colored conjunctival tumor was identified in her left eye.

She was referred to the ocular oncology service.

Histopathologic examination revealed sheets of large neoplastic lymphoid cells with moderate nuclear pleomorphism, vesicular chromatin, and large nucleoli.

The large neoplastic lymphoid cells were found underlying the normal conjunctival epithelium.

Small lymphocytes were observed admixed with the atypical large lymphoid cells.

Immunohistochemical studies showed the large lymphoid cells stained positive (diffuse, strong) for CD20.

Immunohistochemical studies showed the large lymphoid cells stained positive for MUM-1.

Immunohistochemical studies showed the large lymphoid cells stained less intensely positive for Pax-5.

Immunohistochemical studies showed the large lymphoid cells stained weakly positive for Bcl-6.

Immunohistochemical studies showed the large lymphoid cells were negative for CD10.

The small background lymphocytes were CD3-positive.

Histopathological findings were consistent with diffuse large B-cell lymphoma.

The immunophenotypic profile was consistent with nongerminal center origin.

The proliferation index estimated by Ki-67 labeling was 80%.

The large lymphoid cells were positive for c-myc rearrangement.

The patient's laboratory workup, including complete blood count with differential, comprehensive metabolic panel, and coagulation profile, was within normal limits.

Serum lactate dehydrogenase (LDH) level was 506 U/L.

The normal range for serum lactate dehydrogenase (LDH) is 313-618 U/L.

The patient's hepatitis screen was negative.

Orbital computed tomography (CT) scans failed to reveal any discrete masses.

Magnetic resonance imaging (MRI) scans revealed mild asymmetric thickening and enhancement of the sclera in the anterior left globe.

Positron emission tomography-CT (PET-CT) failed to reveal any other systemic central nervous system (CNS) involvement.

An MRI of the brain failed to reveal any other systemic central nervous system (CNS) involvement.

Cerebrospinal fluid (CSF) analysis did not reveal any malignant cells.

The patient was presumed to have CNS involvement.

She was treated with high dose systemic methotrexate in addition to rituximab.

She received three cycles of methotrexate at 1.5 g/m2.

The methotrexate dose was reduced by 50% due to age and low creatinine clearance.

She received rituximab at a dose of 375 mg/m2.

The first cycle was complicated by severe diarrhea related to Clostridium difficile infection.

The first cycle was complicated by dehydration.

The third cycle was complicated by acute renal insufficiency.

The third cycle was complicated by fluid overload.

The third cycle was complicated by insufficient methotrexate clearance.

The third cycle was complicated by prolonged hospital stay.

Further chemotherapy had to be stopped in view of the side effects.

Ophthalmic follow-up revealed improved vision in her right eye.

Interval MRI revealed interval improvement in nonspecific scleral thickening and enhancement along the anterior aspect of the left globe.

Based on the documented improvement, the patient was to be continued on the same chemotherapy regimen.

She was evaluated by radiation oncology.

She opted to decline further treatment at this time.

She has not followed up by physicians at this hospital after that.

The patient has a history of diabetic retinopathy.

The patient has a history of macular degeneration.

The patient presented with a sudden deterioration of vision.

The sudden deterioration of vision was initially attributed to diabetic retinopathy.

The patient was noted to have a salmon patch lesion in her conjunctiva.

The salmon patch lesion was diagnosed on biopsy to be a diffuse large B-cell lymphoma.

She has a history of coronary artery disease.

She has a history of atrial fibrillation.

She has a history of diabetic retinopathy.

She has a history of macular degeneration.

She presented with a recent increase in the number of falls.

She was referred to the ocular oncology service.

The small background lymphocytes were CD3-positive.

The proliferation index estimated by Ki-67 labeling was 80%.

The large lymphoid cells were positive for c-myc rearrangement.

Serum lactate dehydrogenase (LDH) level was 506 U/L.

The patient's hepatitis screen was negative.

The patient was presumed to have CNS involvement.

She received three cycles of methotrexate at 1.5 g/m2.

She received rituximab at a dose of 375 mg/m2.

The first cycle was complicated by dehydration.

The third cycle was complicated by acute renal insufficiency.

The third cycle was complicated by fluid overload.

The third cycle was complicated by prolonged hospital stay.

Further chemotherapy had to be stopped in view of the side effects.

Ophthalmic follow-up revealed improved vision in her right eye.

She was evaluated by radiation oncology.

She opted to decline further treatment at this time.

She has not followed up by physicians at this hospital after that.


Kidney function is essential for filtering waste and excess fluids from the blood. When kidneys don’t work properly, toxins accumulate, leading to symptoms like fatigue, swelling, and high blood pressure. Early detection through regular screening is key to managing kidney health and preventing complications.

The kidneys play a central role in maintaining homeostasis by filtering metabolic waste, excess ions, and fluid from the bloodstream via glomerular filtration and tubular reabsorption. Impaired renal function results in the accumulation of uremic toxins, dysregulation of electrolyte balance, and fluid overload, which can manifest clinically as fatigue, hypertension, and edema. Chronic kidney disease progression is influenced by underlying pathophysiological mechanisms including glomerulosclerosis, tubular atrophy, and vascular remodeling, and early intervention through biomarker monitoring and targeted therapies is critical to mitigate disease progression.

He presented with a generalized erythematous maculopapular rash on his trunk and extremities.

He had been diagnosed as having pulmonary tuberculosis two weeks earlier.

He had long-standing hypertension and diabetes mellitus.

His treatment included daily amlodipine 5mg, metformin 500mg, and glipizide 5mg.

Anti-tuberculosis therapy of isoniazid 300mg, rifampicin 450mg, and ethambutol 800mg daily was administered.

After two weeks of anti-tuberculosis medication, a generalized exanthematous rash appeared on his trunk and extremities.

All anti-tuberculosis drugs were stopped after his admission due to a clinical suspicion of drug-induced adverse cutaneous reactions.

The exanthematous rash resolved within three days of admission, leaving post-inflammatory hyperpigmentation.

One day later, multiple well-defined, non-blanchable, erythematous-to-purplish macules and papules, some of which showed an annular arrangement, were noticed.

Laboratory findings showed leukocytes 12.8×103 cells/mm3.

Hepatitis B surface antigen, anti-hepatitis C virus, and anti-HIV test results were all negative.

Anti-nuclear antibody and anti-neutrophil cytoplasmic antibody test results were also negative.

Urine analysis showed no evidence of proteinuria or hematuria.

The findings from an abdominal ultrasound were unremarkable.

A skin biopsy from a purpuric annular lesion on his leg showed peri-vascular and interstitial infiltration of neutrophils with extravasation of erythrocytes and fibrin deposition.

A direct immunofluorescence study was positive for IgA, IgM, and C3 along superficial dermal blood vessels.

These findings were diagnostic for annular leukocytoclastic vasculitis associated with anti-tuberculosis drugs and drug-induced cholestasis.

The patient was treated with an oral antihistamine and topical corticosteroids.

The skin eruption cleared within one week without hyperpigmentation.

Liver function test results returned to normal limits three weeks after the anti-tuberculosis drugs were withdrawn.

Streptomycin (750mg per day), ethambutol (800mg per day), and ofloxacin (400mg per day) were administered as second-line anti-tuberculosis therapy.

He was subsequently treated with ethambutol, ofloxacin, and streptomycin without recurrence of the skin rash.

We report a case of annular leukocytoclastic vasculitis induced by anti-tuberculosis medication.

A 62-year-old Thai man presented to our facility with a generalized exanthematous rash on his trunk and extremities that resolved shortly afterwards.

Subsequently, he developed multiple, erythematous-to-purplish, non-blanchable macules and papules with an annular arrangement on his extremities.

The skin rash occurred after two weeks of anti-tuberculosis medication.

The histopathology of the purpuric skin lesion was consistent with leukocytoclastic vasculitis.

The skin lesion improved after discontinuation of the anti-tuberculosis drugs and treatment with oral antihistamine and topical corticosteroid drugs.

Streptomycin, ethambutol and ofloxacin were administered as second-line anti-tuberculosis therapy during his hospitalization.


The patient is a 29-year-old Asian female.

She presented with recurrent episodes of severe headache, nausea, and vomiting.

She described the headache as 'pulling' downward.

She reported axial tension and rotatory manipulation of her neck one week prior to the onset of her symptoms.

She denied immediate symptoms after the chiropractic manipulation.

She experienced increasingly painful headaches over the 2 weeks following her chiropractic manipulation.

She had no known prior history of trauma.

She had no known prior history of dural structural pathology.

She had no known prior history of connective tissue disease.

Physical exam was normal with no neurological deficits.

Previous cervical MRI with and without contrast had been unremarkable.

Cervical MRI at presentation revealed a CSF-isodense ventral extradural fluid collection in the lower cervical spine and upper thoracic spine.

There was no mass effect on the thecal sac.

There was no abnormal venous engorgement.

The patient was managed conservatively with bed rest for 2 weeks.

She made a complete spontaneous recovery.

Follow-up cervical MRI at 6 months demonstrated decreased size of ventral extradural fluid collection.

We present a case of subacute cervical cerebrospinal fluid (CSF) leak resulting from chiropractic manipulation of the cervical spine.

The patient received manipulation one week prior to developing symptoms.

The patient developed symptoms of severe orthostatic headache, nausea, and vomiting.

Magnetic resonance imaging (MRI) revealed a new C5-C6 ventral CSF collection.

Symptomatic onset corresponded with the recent cervical chiropractic adjustment.

We present serial imaging correlating with her symptomatology.

We review the pertinent literature on complications of chiropractic manipulation.


The patient is a 24-year-old Caucasian man.

He had fever and upper quadrant abdominal pain over the previous 20 days.

Before admission, ciprofloxacin and metronidazole, followed by cefixime had been prescribed.

Six years prior, the patient had been diagnosed with PSC.

Six years prior, the patient had been diagnosed with UC.

Six years prior, the patient had been diagnosed with suspected retroperitoneal fibrosis.

Six years prior, the patient had been diagnosed with bile sludge.

Six years prior, the patient had been diagnosed with splenomegaly.

At that time, ursodiol 300mg BID was prescribed.

At that time, mesalamine 4g per day was prescribed.

At that time, exploratory laparotomy and a biopsy of the perihepatic, retroperitoneal tissue were performed.

Over this six-year period, the patient presented with recurrent episodes of cholangitis.

The serum level of aminotransferases remained substantially normal.

There was a progressive worsening of cholestatic test results.

There was a progressive liver enlargement along with fibrosis.

Gamma glutamyl transpeptidase (GGT) increased from 141UI/L to 344UI/L.

Alkaline phosphatase (ALP) increased from 847UI/L to 2534UI/L.

Hepatic tissue stiffness, measured by FibroScan®, progressed from 12.6 to 17.3kPa.

The patient was never treated with immunosuppressive therapy.

The patient was never treated with corticosteroids.

One month before admission, an upper endoscopy was performed.

The upper endoscopy excluded esophageal varices.

One week before admission, a magnetic resonance of his abdomen and bile ducts was performed.

The magnetic resonance revealed further enlargement of the liver.

The magnetic resonance revealed further enlargement of the spleen.

The magnetic resonance revealed further enlargement of the tissue surrounding his hepatic hilum.

The tissue surrounding his hepatic hilum caused a compression of his second duodenal tract.

The tissue surrounding his hepatic hilum caused a wrapping of the splenic and hepatic arteries.

Beading and narrowing of the intra-hepatic and common bile ducts were reported.

A narrowing of the pancreatic duct was also reported.

At admission, the patient had a fever of 38.8°C.

Physical examination revealed tenderness of his epigastrium.

Physical examination revealed tenderness of his right upper hypochondrium.

Microbiological blood and urine investigations were negative for bacteria.

An abdominal sonography revealed an enlarged liver.

An abdominal sonography revealed thickened choledocus.

An abdominal sonography revealed dilatation of the intra-hepatic biliary tree.

An abdominal sonography revealed splenomegaly.

An abdominal sonography revealed lymphadenopathy of the hepatic hilus.

A colonoscopy showed erythema of the colonic mucosa from the rectum to the cecum.

Random biopsy showed focal atrophy of the colonic mucosa with edema.

Random biopsy showed chronic inflammatory infiltrates.

Specific investigations for CMV were not carried out.

Imipenem 500mg IV four times daily was administered.

Three days later, imipenem was substituted with tigecycline 50mg IV BID.

Further blood and urine cultures for bacteria were negative.

The erythrocyte sedimentation rate (ESR) remained high.

The C-reactive protein level (C-RP) remained high.

The white blood cell (WBC) count decreased.

The upper abdominal pain subsided slightly.

Investigations for Toxoplasma gondii were negative.

Investigations for measles were negative.

Investigations for parotitis were negative.

Investigations for hepatitis C virus (HCV) were negative.

Results for varicella zoster virus indicated previous infection.

Results for human herpes virus indicated previous infection.

Results for Epstein Barr indicated previous infection.

Results for rubella indicated previous infection.

Results for parvo virus B19 indicated previous infection.

CD4?+?T lymphocytes were 1055mm3 (20.3%).

Mycobacterium tuberculosis interferon gamma release assay showed negative results.

Twelve days after admission, teicoplanin 400mg die was prescribed.

Twelve days after admission, gentamicin 80mg TID was prescribed.

Twelve days after admission, metronidazole 500mg TID was prescribed.

Two days later, DNA Cytomegalovirus was detected in the blood with ≤253 copies/mL.

Three days later, this value increased to 6189 copies/mL.

Three days later, 1431 copies/mL were evidenced from a urine sample.

CMV serology indicated acute CMV infection.

The patient’s abdominal pain extended to the right lower abdominal quadrant.

The patient’s abdominal pain radiated to the right groin.

The patient’s abdominal pain radiated to the right testicle.

Ultrasound suggested acute appendicitis.

Histology showed inflammatory infiltrates, including lymphocytes and neutrophils.

Histochemistry was positive for CMV early antigens.

Real time reaction of the appendix tissue was positive.

Shell vial culture of the appendix tissue was positive.

Microbiological investigations for bacteria showed Peptococcus spp.

Microbiological investigations for fungi showed Candida albicans.

Teicoplanin, gentamicin and metronidazole were administered for a total of 12 days.

Intravenous ganciclovir 5mg/kg twice was administered for 15 days.

After discharge, oral valganciclovir 900mg BID was prescribed for 10 days.

After this, the CMV nucleic acid in the blood and urine was negative.

After this, ESR remained abnormally high.

After this, cholestatic liver test results remained abnormally high.

The authors report on a case of acute primary Cytomegalovirus infection complicated with acute appendicitis due to Cytomegalovirus in an apparently immunocompetent 24-year-old Caucasian man.

The patient also suffered from primary sclerosing cholangitis and ulcerative colitis.

Diagnosis was based on clinical manifestations.

Diagnosis was based on serology results.

Diagnosis was based on microbiological findings.

Diagnosis was based on histological findings.

Treatment consisted of anti-Cytomegalovirus therapy.

The patient is a 24-year-old Caucasian man.

Six years prior, the patient had been diagnosed with PSC.

Six years prior, the patient had been diagnosed with UC.

Six years prior, the patient had been diagnosed with bile sludge.

Six years prior, the patient had been diagnosed with splenomegaly.

At that time, ursodiol 300mg BID was prescribed.

At that time, mesalamine 4g per day was prescribed.

There was a progressive worsening of cholestatic test results.

There was a progressive liver enlargement along with fibrosis.

Alkaline phosphatase (ALP) increased from 847UI/L to 2534UI/L.

The patient was never treated with immunosuppressive therapy.

The patient was never treated with corticosteroids.

One month before admission, an upper endoscopy was performed.

The upper endoscopy excluded esophageal varices.

The magnetic resonance revealed further enlargement of the liver.

The magnetic resonance revealed further enlargement of the spleen.

A narrowing of the pancreatic duct was also reported.

At admission, the patient had a fever of 38.8°C.

Physical examination revealed tenderness of his epigastrium.

An abdominal sonography revealed an enlarged liver.

An abdominal sonography revealed thickened choledocus.

An abdominal sonography revealed splenomegaly.

Random biopsy showed chronic inflammatory infiltrates.

Specific investigations for CMV were not carried out.

Imipenem 500mg IV four times daily was administered.

Further blood and urine cultures for bacteria were negative.

The erythrocyte sedimentation rate (ESR) remained high.

The C-reactive protein level (C-RP) remained high.

The white blood cell (WBC) count decreased.

The upper abdominal pain subsided slightly.

Investigations for Toxoplasma gondii were negative.

Investigations for measles were negative.

Investigations for parotitis were negative.

Investigations for hepatitis C virus (HCV) were negative.

Results for varicella zoster virus indicated previous infection.

Results for human herpes virus indicated previous infection.

Results for Epstein Barr indicated previous infection.

Results for rubella indicated previous infection.

Results for parvo virus B19 indicated previous infection.

CD4?+?T lymphocytes were 1055mm3 (20.3%).

Twelve days after admission, teicoplanin 400mg die was prescribed.

Twelve days after admission, gentamicin 80mg TID was prescribed.

Three days later, this value increased to 6189 copies/mL.

CMV serology indicated acute CMV infection.

The patient’s abdominal pain radiated to the right groin.

The patient’s abdominal pain radiated to the right testicle.

Ultrasound suggested acute appendicitis.

Histochemistry was positive for CMV early antigens.

Real time reaction of the appendix tissue was positive.

Shell vial culture of the appendix tissue was positive.

Microbiological investigations for fungi showed Candida albicans.

Intravenous ganciclovir 5mg/kg twice was administered for 15 days.

After this, ESR remained abnormally high.


The patient was diagnosed with high-risk CD20+ common-type B-cell precursor acute lymphoblastic leukemia.

The patient received two cycles of HyperCVAD.

The patient consulted the National Cancer Institute for a relapse and five-day polyarthralgia.

The patient was initiated into the protocol established in 2003 by the Adult Acute Lymphoblastic Leukemia Research Group (GRAALL-2003).

The patient developed febrile neutropenia.

The patient had cellulitis of the left hand without abscess.

The patient had methicillin-sensitive Staphylococcus aureus bacteremia.

Cefapime and oxacillin were administered.

On day 21 of hospitalization, the patient presented lesions on the back of the left hand.

The lesions on the back of the left hand were of the type erythematoedematosa plaque.

The lesions on the back of the left hand had mild and fine desquamation on the surface.

The lesions on the back of the left hand had central blood crust.

The patient had lesions in the right scapular and infra-scapular region.

The lesions in the right scapular and infra-scapular region were 3 mm non-follicular papules.

The lesions in the right scapular and infra-scapular region were grouped.

The lesions in the right scapular and infra-scapular region were some erythematous and others erythemoparous.

The lesions were assessed by the Dermatology Service.

A skin biopsy was taken for histopathological study.

The results were inconclusive for the diagnosis of mycosis.

No culture was done for fungi of the biopsy.

An invasive fungal infection was suspected.

The chest and sinus computed tomography (CT) scans were negative for invasive aspergillosis.

The serum galactomannan detection was negative for invasive aspergillosis.

Despite antimicrobial and antifungal treatment, the patient did not show significant improvement.

The patient persisted with a fever of up to 40 °C.

The patient had 1 cm nodules, soft, depressible, painless and in the previous sites of venipuncture.

The blood count showed a profound neutropenia (20 white blood cells per µl).

The control CT scan of the paranasal sinuses showed incipient chronic inflammatory changes in the right maxillary sinus.

The abdomen scan documented hepatosplenomegaly.

The three blood cultures and the urine culture from day 28 of hospitalization showed yeast-like structures.

The yeast-like structures were not identified in the automated panel Yeast ID (BD Phoenix™ 100).

Arthroconidia were observed by microscopy.

Colonies compatible with Geotrichum spp. were documented.

The diagnosis was confirmed by matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry.

Treatment with amphotericin B deoxycholate was given at a daily dose of 1 mg/kg for 14 days.

400 mg/day of voriconazole was given for four weeks.

The patient recovered from neutropenia on day 24 of the combined antifungal treatment.

The patient was discharged on day 101 of hospitalisation due to clinical improvement.

The patient has relapsed acute lymphoblastic leukemia.

The patient had five-day-old polyarthralgia.

The patient had cellulitis without abscesses.

The patient had methicillin-resistant Staphylococcus aureus bacteremia.

The patient received therapy with oxacillin and cefepime.

An invasive fungal infection was suspected.

Arthroconidia were identified in the blood cultures.

Matrix-assisted laser desorption ionization-mass spectrometry confirmed the presence of Geotrichum spp.

Antifungal treatment was adjusted to 14 days of deoxycholate amphotericin B.

Antifungal treatment was adjusted to four weeks of voriconazole.

The patient was discharged after a prolonged stay.

The patient received two cycles of HyperCVAD.

The patient developed febrile neutropenia.

Cefapime and oxacillin were administered.

A skin biopsy was taken for histopathological study.

No culture was done for fungi of the biopsy.

An invasive fungal infection was suspected.

The patient persisted with a fever of up to 40 °C.

The abdomen scan documented hepatosplenomegaly.

Arthroconidia were observed by microscopy.

400 mg/day of voriconazole was given for four weeks.


He presented with hematuria and urinary obstruction symptoms.

He came to the hospital four times each with presence of gross hematuria.

The patient suffered from frequency and nocturia at least for six months.

Physical examination revealed enlargement of prostate.

There was no palpable nodule on the digital rectal examination.

The first transurethral resection of the prostate (TURP) and biopsy was done.

Pathologic results showed the evidence of BPH.

After 28 days, the patient was admitted again due to gross hematuria.

Pelvic CT-scan revealed a big clot in bladder without any lymphadenopathy.

There was significant heterogeneity in prostate.

In second TURP, clot evacuation and biopsy were performed on more than 15 different areas of prostate.

During the next 2 weeks, the patient underwent 3 other trans-urethral coagulation and clot evacuations due to hematuria.

Partial thromboplastin time (PTT) was normal.

Sections from prostate show foci of hemorrhage.

The first transfusion was 2 units of PC during the second surgery.

The second transfusion was 2 units of PC and 2 FFP, two days later.

The consecutive third and fourth transfusions were done two days later.

During the third and fourth transfusions, the patient received 3 units of FFP.

During the third and fourth transfusions, the patient received 3 units of whole blood.

Immunohistochemistry studies demonstrate CD20-positive in 90% of lymphoid cells.

Immunohistochemistry studies demonstrate CD20-positive in the lymphoepithelial lesions.

CK markers are negative in neoplastic cells.

PSA markers are negative in neoplastic cells.

Bone marrow biopsy did not show other involvement.

Abdominal and pelvic CT-scan did not show other involvement.

In the last follow up, around eight months after discharging, the patient was alive.

In the last follow up, around eight months after discharging, the patient was asymptomatic.

There is no evidence of other organ involvement.

We report here another case of primary prostatic MALT lymphoma.

The diagnosis was primarily considered as BPH.

Immunohistochemistry studies demonstrate the diagnosis.

Immunohistochemistry studies demonstrate MALT lymphoma.

Six months after starting the treatment the patient was alive and well.


The patient had a history of testicular seminoma that was removed twice.

The patient had been experiencing disorientation and difficulty in thinking for 1 month before the visit.

Contrast-enhanced magnetic resonance imaging showed a markedly contrast-enhanced mass in the dorsal midbrain.

Systemic examination showed no obvious abnormalities.

Blood samples showed a high serum soluble interleukin-2 receptor level of 624 U/ml.

Human chorionic gonadotropin was within normal limits.

Neoplastic diseases such as PCNSL, tectal glioma, or intracranial metastasis of seminoma were considered in the differential diagnosis.

Endoscopic tumor biopsy was performed with endoscopic third ventriculostomy.

The burr hole was located 11 cm from the nasion and 2 cm to the right of the midline.

A Neuroport mini was inserted into the anterior horn.

The aqueduct was stenotic due to the tumor.

A biopsy of the swollen area was performed.

The lesion was pale pink, soft, and had minimal bleeding after the biopsy.

A third ventriculostomy was performed using an expanding balloon catheter.

Intraoperative cerebrospinal fluid cytology showed a small number of atypical cells with bifurcated nuclear irregularities.

The final histopathological diagnosis of the tumor was diffuse large B-cell lymphoma.

The patient underwent three courses of high-dose methotrexate.

The patient underwent whole-brain irradiation.

The patient’s KPS was 100 when he was discharged home.

The patient was referred to our hospital with a 1-month history of disorientation.

Magnetic resonance imaging showed hydrocephalus.

Magnetic resonance imaging showed an enhancing lesion in the tectum.

Preoperative blood tests showed a high serum soluble interleukin-2 receptor level of 624 U/ml.

Through a single burr hole, endoscopic third ventriculostomy and biopsy of the lesion were simultaneously performed with a flexible endoscope.

The histological examination confirmed diffuse large B-cell lymphoma.


The patient is a 51-year-old Caucasian woman.

She presented with spinal, pelvic, and sternal inflammatory pain lasting for many years.

The symptoms had a strong negative impact on her quality of life.

She did not present palmoplantar pustulosis.

She had been diagnosed with synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome at the age of 40 years.

She had received sulfasalazine and nonsteroidal anti-inflammatory drugs (NSAIDs) for many years with incomplete pain relief.

She also had a history of cervical and lumbar arthrodesis.

Total spine and pelvis magnetic resonance imaging (MRI) showed a short tau inversion recovery (STIR) hypersignal on several thoracic vertebrae (T6, T7, T8, and T9).

Total spine and pelvis MRI showed a short tau inversion recovery (STIR) hypersignal on the sternal part of the right clavicle.

Bone marrow oedema was also found on the right iliac bone.

Bone scintigraphy showed anterior chest wall involvement.

Right sternoclavicular hyperostosis was found on computed tomography.

The C-reactive protein (CRP) was found to be 89.2 mg/L.

The reference range for CRP is 0–5 mg/L.

Several blood tests performed earlier had already shown elevation of inflammation parameters.

The diagnosis of active SAPHO syndrome was confirmed.

Conventional synthetic disease-modifying antirheumatic drug (csDMARD) as methotrexate was not considered.

Methotrexate is more effective on peripheral arthritis.

Methotrexate has not shown comparable activity in axial disease in patients with axial spondyloarthritis.

Anti-tumour necrosis factor (TNF) drugs could not be prescribed because the criteria for reimbursement of these drugs in Belgium were not met.

The criteria for reimbursement were not met in the absence of sacroiliitis.

Tofacitinib 5 mg twice daily was initiated.

The patient reported rapid and significant reduction of pain within weeks of starting the treatment.

Blood tests performed one month after the onset of treatment showed a clear regression of inflammatory parameters.

The CRP was 25.5 mg/L one month after the onset of treatment.

The CRP was 14 mg/L after 4 months of treatment.

The CRP was 9.9 mg/L after 10 months of treatment.

Total spine and pelvis MRI performed after 3 months of treatment showed regression of the STIR hypersignal on the body of the thoracic vertebrae.

The hypersignal of the right iliac bone disappeared after 3 months of treatment.

The rheumatic evolution was favourable from a clinical, biological, and radiological point of view since the introduction of a JAK-inhibitor.

The treatment had to be discontinued due to pulmonary embolism occurring after 8 months on tofacitinib.

Spinal, pelvic, and chest (sternal and costal) pain reappeared after discontinuation of tofacitinib.

Elevation of inflammatory parameters occurred after discontinuation of tofacitinib.

Written informed consent was obtained from the patient for the publication of this report and its accompanying images.

The patient was a 51-year-old Caucasian woman.

She had SAPHO syndrome with mainly axial involvement.

She had been treated with sulfasalazine and anti-inflammatory drugs for many years.

The treatment with sulfasalazine and anti-inflammatory drugs was without any success.

A few weeks after starting treatment with tofacitinib, both clinical and biological parameters dramatically improved.

Imaging showed considerable regression of the vertebral and pelvic lesions.

Tofacitinib had to be discontinued due to the occurrence of pulmonary embolism.

Recurrence of bone pain and biologic inflammation was rapidly observed.

The patient is a 51-year-old Caucasian woman.

She did not present palmoplantar pustulosis.

The reference range for CRP is 0–5 mg/L.

Tofacitinib 5 mg twice daily was initiated.

The CRP was 14 mg/L after 4 months of treatment.

The CRP was 9.9 mg/L after 10 months of treatment.


The patient had a 4-month history of right brachial/shoulder pain and numbness.

The patient had hyposensitivity in the C5 distribution.

The MRI scan showed degenerative cervical spondylosis from the C3–C4 to C5–C6 levels.

The MRI scan showed a C5–C6 right anterolateral disc herniation with foraminal stenosis.

The MRI scan showed syringomyelia extending from the C5–C6 to the T1 level.

The patient underwent C5–C6 anterior cervical discectomy and fusion (ACDF) with placement of a polyetheretherketone cage.

The patient’s symptoms markedly improved following the ACDF.

Three months later, the MRI scan confirmed adequate decompression of the spinal cord.

Three months later, the MRI scan confirmed the total resolution of the syrinx.

The patient underwent placement of an eight-electrode subdural spinal cord stimulator from the C3 to C4 through the C5–C6 levels.

The patient significantly improved after the subdural spinal cord stimulator placement.

Syringomyelia is usually attributed to Chiari malformations, spinal arachnoiditis, intramedullary tumors, and trauma.

Syringomyelia is seldom associated with cervical disc disease or spondylosis.

In two cases, ACDF resulted in complete radiological and clinical resolution of the syrinx.

Younger patient age, a longer history of disease, and lower functional scores were associated with syringomyelia.

Postoperative outcomes and progression-free survival for patients with syringomyelia did not differ significantly versus those without syringomyelia.

The authors presented a rare case of syringomyelia attributed to cervical disc disease/stenosis.

The syringomyelia in this case fully resolved following a C5–C6 ACDF.

The complete radiological resolution indicates that cervical disc disease/spondylosis might alter cerebrospinal fluid flow.

The cerebrospinal fluid flow was adequately restored to normal with surgery.

The patient had a 4-month history of right brachial pain.

The cervical MR imaging scan showed a C5-C6 right anterolateral disc herniation.

The cervical MR imaging scan showed syringomyelia extending from C5-C6 to T1.

The patient underwent C5-C6 anterior cervical discectomy and fusion.

The patient's symptoms resolved following the C5-C6 anterior cervical discectomy and fusion.

The 3-month postoperative MR documented total resolution of the syrinx.

The patient required a subdural spinal cord stimulator due to residual neuropathic pain.

The subdural spinal cord stimulator was placed without any complications.


She had been undergoing oral treatment for diabetes with canagliflozin 100 mg/day, metformin 1,000 mg/day, and saxagliptin 5 mg/day.

She noticed general malaise a month before her emergency department visit.

Two weeks before her emergency department visit, her oral intake decreased because of reduced appetite.

She continued oral medications at their initial dose.

The day prior to her emergency department visit, her malaise worsened.

She developed nausea and abdominal pain.

A local doctor discovered notable metabolic acidosis (pH, 6.860; CO2, 8 mmHg; HCO3, −1.0 mEq/L; base excess measurement, below sensitivity).

She was urgently transferred to Kurume University Hospital Advanced Emergency Medical Service Center.

On admission, her body temperature was 35.0 °C.

On admission, her respiratory rate was 28/min.

On admission, her blood pressure was 111/75 mmHg.

The findings on consultation included notable dryness inside the oral cavity.

The findings on consultation included a cold sensation on distal regions of the limbs.

Chest auscultation revealed no significant findings.

There was mild tenderness in the lower abdominal region.

Blood gases demonstrated notable metabolic acidosis (pH, 6.89; CO2, 11.4 mmHg; HCO3, 1.9 mEq/L; base excess, −31.3 mmol/L).

Lactic acid was mildly elevated at 3.3 mmol/L.

Blood sugar was mildly elevated at 259 mg/dL.

Hyperkalemia was observed accompanying the acidosis.

No significant kidney function impairment was observed.

A diagnosis of lactic acidosis secondary to metformin was considered.

The patient had not recently been exposed to a contrast agent.

Point-of-care urine testing showed strongly positive urinary ketones.

Point-of-care urine testing showed strongly positive urinary glucose.

Plasma 3-hydroxybutyric acid was markedly high (>10,000 μmol/L).

An injection of 0.45% sodium chloride was given as an intravenous drip at 800 mL/h.

Blood sugar dropped to 180 mg/dL after using two units of short-acting insulin.

An intravenous drip of glucose was started.

Around 6 units/day of insulin were used as appropriate.

Sodium bicarbonate was given as an intravenous drip.

Continuous renal replacement therapy (CRRT) was started from day 2 after hospital admission.

The acidosis improved because of CRRT over 3 days.

Hyperketonemia reduced notably after a few days.

Osmotic diuresis set in with urinary glucose as the cause.

Fluid replacement was carried out using Ringer’s solution.

Urinary sugar turned negative on day 16 after admission.

She was discharged on day 18 after admission.

She was being treated for type 2 diabetes.

She was taking canagliflozin, metformin, and saxagliptin orally.

She presented to the ED for evaluation of reduced oral intake, malaise, nausea, and abdominal pain.

The 3-hydroxybutyric acid was > 10,000 μmol/L.

The uncontrolled acidosis improved following 3 days of continuous renal replacement therapy.

Elevated urinary glucose continued for more than 10 days.

Ringer's lactated fluid supplementation was continued for management of polyurea and glucosuria.

Urinary glucose turned negative on day 16.

There was improvement in the patient's overall state.

She developed nausea and abdominal pain.

On admission, her body temperature was 35.0 °C.

On admission, her respiratory rate was 28/min.

Lactic acid was mildly elevated at 3.3 mmol/L.

Blood sugar was mildly elevated at 259 mg/dL.

An intravenous drip of glucose was started.

Hyperketonemia reduced notably after a few days.

She was discharged on day 18 after admission.


The patient is a 33-year-old nulligravid woman.

The patient had newly diagnosed AA (WHO grade III, IDH1 negative).

The patient had undergone a craniotomy with complete resection of her right parietal lobe tumor one month prior.

The patient was scheduled to start chemotherapy and radiation in the next month.

The patient’s neuro-oncologist recommended fertility preservation prior to chemo-radiation.

The fertility preservation did not delay the anticipated start of her chemo-radiation treatment.

The patient had no significant medical or gynecological history.

On physical exam, the patient was a healthy-appearing woman.

Transvaginal ultrasound demonstrated a normal-appearing uterus and ovaries bilaterally.

A dominant follicle was noted on the patient’s right ovary.

It was decided to administer HCG 10,000 IU at the time of her presentation to trigger ovulation.

The patient had a high antral follicle count (6 on right, 7 on left).

The patient received low dose gonadotropins: 1 ampule of Human Menopausal Gonadotropin (Menopur®), 75–187.5 IU of FSH (Gonal F®) for 10 days.

The patient received cetrorelix acetate (Ganirelex®) for the last 6 days.

Final oocyte maturation was triggered with Lupron Luprolide Acetate (Lupron®) 40u.

Twelve oocytes were retrieved transvaginally under ultrasound guidance.

Eight embryos developed and were vitrified in liquid nitrogen.

The patient returned to the Center one year later after being cleared by her neuro-oncologist.

The patient had 6 weeks of radiation therapy with Temozolomide (Temodar®).

The patient had 6 months of maintenance dose chemotherapy.

The patient’s last dose of chemotherapy was one month prior to returning to the office.

The patient had maintained regular cycles post chemotherapy.

The patient underwent a frozen-thaw natural cycle embryo transfer of a single day-3 embryo.

The patient used vaginal progesterone (Crinone®) for luteal phase support.

A viable singleton pregnancy was seen on ultrasound 1 month later.

The patient delivered a healthy female baby weighing 7lbs 5 oz. at term.

The patient returned two years later desirous of another pregnancy.

The patient was tumor free and cleared by her oncologist to conceive again.

This time the patient was treated with Estrace® 6 mg a day.

The patient underwent a frozen-thaw cycle with a single day-5 blastocyst transferred.

The patient conceived with a viable singleton pregnancy.

The patient delivered a healthy male at term weighing 6lbs.

Throughout the patient’s treatment regimen for fertility preservation and frozen embryo transfers, no adverse or unanticipated events were encountered.

The patient is a 33-year-old nulligravid woman.

The patient has newly diagnosed anaplastic astrocytoma.

The anaplastic astrocytoma is WHO grade III.

The anaplastic astrocytoma is IDH1-negative.

The patient sought fertility preservation.

The patient underwent in vitro fertilization for fertility preservation.

The in vitro fertilization resulted in 8 vitrified embryos.

The patient underwent two rounds of frozen embryo transfers.

Each frozen embryo transfer resulted in a successful singleton pregnancy.

The patient is a 33-year-old nulligravid woman.

The patient had 6 months of maintenance dose chemotherapy.

The patient conceived with a viable singleton pregnancy.