Patient concerns:
A 41-year-old man who presented with acute onset of right-hand clumsiness and aphasia even under high international normalized ratio (INR: 7.64) from warfarin use. He was previously treated with warfarin for the LV thrombus and non-valvular AF. Brain magnetic resonance imaging (MRI) showed multiple acute infarction in the cortex of the bilateral frontal lobes, left parietal lobe, and bilateral central semiovale, which highly suggested embolic stroke.

Diagnosis:
The repeated transthoracic echocardiogram still revealed LV thrombus (1.27 × 0.90 cm), which failed to respond to warfarin therapy.

Interventions:
Due to acute infarctions occurred under supratherapeutic range of INR, we switched warfarin to edoxaban (dose: 60 mg/day) after INR decreased to less than 2.

Outcomes:
The thrombus disappeared after receiving edoxaban for 23 days, and no more recurrent stroke was noted for more than 6 months.


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 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 etiologies such as diabetes, hypertension, and glomerular injury, with biomarkers like estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) serving as key indicators of disease severity and progression. Management strategies include pharmacological interventions, blood pressure control, dietary modifications, and monitoring of renal function over time to prevent end-stage renal disease (ESRD).

We report a clinical case of a combat patient who was injured after the multiple launcher rocket system "Grad" shelling, diagnosed with hydrodynamic liver rupture followed by medical management with application of damage control (DC) tactic in conditions of hybrid war. The patient underwent relaparatomy, liver resection, endoscopic papillosphincterotomy, endoscopic retrograde cholecystopancreatography, stenting of the common bile duct, and VAC-therapy. Applied treatment modalities were effective; the patient was discharged on the 49th day after injury.

**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": "..."
    }


A 59-year-old male with suspected lung cancer in the left lower lobe was scheduled to undergo surgery. Chest computed tomography revealed a displaced B1 + 2 and hyperlobulation between S1 + 2 and S3, while the interlobar fissure between S1 + 2 and S6 was completely fused. Three-dimensional computed tomography (3D-CT) revealed an anomalous V1 + 2 joining the left inferior pulmonary vein and a branch of the V1 + 2 running between S1 + 2 and S6. We performed left lower lobectomy via video-assisted thoracic surgery, while taking care with the abovementioned anatomical structures. The strategy employed in this operation was to preserve V1 + 2 and confirm the locations of B1 + 2 and B6 when dividing the fissure.


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.

A 14-year-old boy attended a local hospital for ankylosing spondylitis. Chest radiography showed an enhanced circular-density shadow near the left mediastinum. The patient had no chest symptoms and the physical examination was normal. Because of the mediastinal occupation, the patient visited our department of chest surgery for further treatment. During surgery, a left pericardial defect was observed. The bronchogenic cyst was removed by thoracoscopic surgery, but the pericardial defect remained untreated, and a satisfactory outcome was achieved after the operation. The patient was diagnosed with a mediastinal tumor. The pathological diagnosis of the tumor was a bronchogenic cyst.


We report and analyse a case of a 34-year-old female who presented with ataxia. Magnetic Resonance Imaging (MRI) of the brain revealed demyelinating lesions in the white matter. Genetic testing identified the c.4044C > G and c.1186-2A > G variants in the POLR3A gene. The patient was diagnosed with hypomyelinating leukodystrophy type 7 and received neurotrophic and symptomatic supportive therapy. However, after 1 month of follow-up, there was no improvement in her symptoms.


A 70-year-old Japanese man with essential hypertension, dyslipidemia, chronic kidney disease and emphysema was hospitalized with the novel coronavirus disease. He had hypoxemia that was disproportionate to the severity of pneumonia indicated by computed tomography (CT), along with coagulation abnormalities. We speculated that there was a high possibility that he had developed ventilation and blood flow imbalance due to pulmonary intravascular coagulopathy (PIC) or hypoxic pulmonary vasoconstriction (HPV). In this case, early, short-term combination therapy with remdesivir, nafamostat mesylate and low-dose dexamethasone (Dex) was successful.


We present the case of an adult male patient with cerebral malaria by Plasmodium vivax, who starts with general discomfort and fever, then presents convulsions more than twice a day with loss of consciousness and motor functional limitation. He is given a thick drop where Plasmodium vivax trophozoites and depression of the three blood series are observed. He is given treatment with artesunate and clindamycin for five days, a blood transfusion and continues with primaquine for seven days. The patient shows clinical improvement with neurological sequelae in the left lower extremity.


A 46-year-old male with end-stage renal disease of unknown cause received a cadaveric renal transplant one year ago. Although three antihypertensive medications were administrated, his blood pressure gradually increased to 190/120 mmHg 3 weeks posttransplantation. Also the level of creatinine increased to 194 μmol/L.Color Doppler ultrasonography indicated a decreased resistance index (RI) in intrarenal arteries and increased blood flow of the transplant renal artery, therefore, a vascular complication of TRAS was suspected. Arteriography was performed and demonstrated TRAS caused by stretch of an artery branch, and the TRAS occurred in the distal site of the anastomosis instead of the anastomosis. Percutaneous transluminal bare stent implantation treatment was successfully performed. Satisfactory clinical efficacy with improvement in transplant renal function and renovascular hypertension was achieved after the interventional treatment.


We present a case where a combined lumbar epidural and spinal anesthesia was performed using the loss of resistance to air technique (LOR), on a 78-year-old Greek (Caucasian) male undergoing a total hip replacement. Despite being hemodynamically stable throughout the operation, two hours following epidural analgesia the patient manifested a sudden drop in blood pressure and heart rate that required the administration of adrenaline to counter. Pneumomediastinum, pneumorrachis and paravertebral soft tissue emphysema were demonstrated in a Computed Tomography scan. We believe that injected air from the epidural space and surrounding tissues slowly moved towards the mediastinum, stimulating the para-aortic ganglia causing parasympathetic stimulation and therefore hypotension and bradycardia.


A 70-years-old woman, who had been diagnosed with SLE at 69 years, was admitted for further examination of liver dysfunction. PBC was confirmed based on elevated serum levels of transaminase, high levels of antimitochondrial antibodies and following a liver biopsy. The oral administration of ursodeoxycholic acid stabilized the liver dysfunction.


A 48-year-old caucasian male with an extensive psychiatric history ingested a high dose of venlafaxine causing a serum venlafaxine concentration of 12.6 mg/L 24 hours after ingestion. Seven hours post-ingestion, he experienced tonic-clonic seizures, and 8 hours later, takotsubo cardiomyopathy was recognized followed by cardiac arrest. The patient was resuscitated with prolonged cardiopulmonary resuscitation including ongoing automatic external compressions during helicopter transportation to a tertiary hospital for extracorporeal membrane oxygenation treatment. Despite a cardiopulmonary resuscitation duration of 2 hours, 36 hours of extracorporeal membrane oxygenation, and a total of 30 days of intensive care, the patient made a full recovery.


A Chinese family with ATS was recruited for the current study. Clinical characteristics (including findings from renal biopsy) of ATS patients were collected from medical records, and potential causative genes were explored by whole-exome sequencing. A heterozygous substitution in intron 22 of COL4A3 (NM_000091 c.2657-1G>A) was found in the patients, which was further confirmed by quantitative polymerase chain reaction.


Here case report, a 24-year-old patient from an endemic region of Somalia presented with fever, headache, abdominal pain, nausea, vomiting, and weight loss for two months. Initially, the patient received symptomatic treatment and a blood transfusion but showed no improvement. Physical examination revealed fever, pallor, and hepatosplenomegaly. Laboratory tests showed pancytopenia and positive rapid diagnostic test for plasmodium parasite antigen. Despite three days of anti-malarial treatment, the symptoms persisted, and hepatosplenomegaly worsened. Further investigations, including infectious disease tests, were conducted, ruling out HIV, viral hepatitis, Brucella, and Leishmania antibodies. Peripheral blood smear showed pancytopenia and bone marrow aspiration revealed no evidence of infection or malignancy. A tru-cut biopsy of the spleen was performed, confirming the diagnosis of visceral leishmaniasis. The patient received a combination therapy of sodium stibogluconate and paromomycin, leading to significant improvement. After completing treatment, the patient was discharged with normal spleen biopsy results.


A 59-year-old female with a history of recurrent UCS presented with the new onset of the left lower extremity pain, numbness, and episodic urinary incontinence. When the MR revealed an enhancing intradural extramedullary mass posterior to the L1 vertebral body, she underwent a focal decompressive laminectomy. Although she improved neurologically postoperatively, she succumbed to the leptomeningeal spread of her disease within 2 postoperative months.


A 56-year-old woman was referred to the emergency department due to a severe headache in the frontal area for 2 days before admission. The patient experienced nausea and vomiting in the morning and had no history of seizures or decreased consciousness. Examination of neurological symptoms was completely normal and showed no symptoms of meningeal irritation. In terms of past history, the patient had undergone tympanomastoidectomy surgery and resection of the cholesteatoma 1 week previously. The Mount Fuji sign was found on the brain computed tomography (CT) scan of the patient. Treatments such as CBR (complete bed rest), 30-degree head elevation, anti-fever, analgesics and oxygen therapy, along with anti-compulsive drug (phenytoin), were prescribed. At the end of 5 days, the patient's pneumocephalus was resolved completely.


A 64-year-old male was admitted to the hospital with a headache, fever and later imbalance, blurred vision, and general slowness. Neurological examination revealed nuchal rigidity and general clumsiness. Meningitis was suspected, and the patient was treated with dexamethasone, ceftriaxone and acyclovir. A brain computer tomography (CT) scan was normal, and cerebrospinal fluid (CSF) Gram staining and bacterial cultures remained negative, so the antibacterial treatment was discontinued. Nine days after admission, the patient's condition deteriorated. The antibacterial treatment was restarted, and a brain magnetic resonance imaging revealed ventriculitis. A subsequent CT scan showed hydrocephalus, so a ventriculostomy was performed. In CSF Gram staining, chains of gram-positive cocci were observed. Bacterial cultures remained negative, but a bacterial PCR detected Streptococcus intermedius. An orthopantomography revealed advanced periodontal destruction in several teeth and periapical abscesses, which were subsequently operated on. The patient was discharged in good condition after one month.


A 10-year-old Kurdish boy was presented with generalized bone pain and fever of 1 month's duration which was associated with sweating, easy fatigability, nose bleeding, breathlessness and severe weight loss. On examination, we observed pallor, tachypnea, tachycardia, low blood pressure, fever, petechial hemorrhage, ecchymoses, tortuous dilated veins over the chest and upper part of abdomen, multiple small cervical lymph node enlargements, mildly enlarged spleen, palpable liver and gross abdominal distention. Blood analysis revealed pancytopenia and elevated lactate dehydrogenase and erythrocyte sedimentation rate. Imaging results showed mediastinal widening on a planar chest X-ray and diffuse focal infiltration of the axial bone marrow on magnetic resonance imaging of the lumbosacral vertebrae. Bone marrow aspiration and biopsy examination showed extensive bone marrow necrosis. Immunophenotyping analysis of the bone marrow biopsy confirmed T-cell acute lymphoblastic leukemia, as CD3 and terminal deoxynucleotidyl transferase markers were positive and CD10, CD20 and CD79a markers were negative.


This case report presents the case of a 77 year old female patient with degenerative hip disease in the presence of an ipsilateral arthrodesis of the knee. The patient was operated using the DAA. No complications were found and the patient had an excellent follow-up with a forgotten joint score of 93.75 at 1 year. The difficulty in this case consists in finding the correct stem anteversion with the altered knee anatomy. Using pre-operative templating on X-rays, intraoperative fluoroscopy and the posterior femoral neck the hip biomechanics could be restored.


We report a case of a 33-year-old man, presenting with a five-month history of bilateral lower extremity pain, as well as paresthesia, and mild weakness in one lateral lower extremity. A lumbar laminectomy of L3 to L5 and en bloc resection of the tumor was performed. Postoperative histopathology and immunohistochemical analysis of the tumor were consistent with that of a carcinoid tumor. There were no clinical or radiological signs of tumor recurrence or metastasis at the patient's two year postoperative follow-up.


A 70-year-old male patient was affected by encephalitis caused by scrub typhus that occurred 23 years ago. He had poor cognition and his clinical examination findings were as follows: Mini-Mental Status Examination score, 14; and handgrip strength (right/left, kg), 32.3/31.3. DTT revealed serious injuries of the left thalamocingulate tract and right mammillothalamic tract in the Papez circuit, and a partial injury of the anterior part of the fornix.


We report a case of a 23-year-old patient with Burkitt's lymphoma and graft-versus-host disease admitted with intracerebral hemorrhage and sequential development of 12 anterior circulation aneurysms from disseminated Scedosporium infection. Despite aggressive surgical and antimicrobial treatment, the patient died 6 months later from multiorgan failure. The notable feature of this case is the rapid angioinvasiveness of the infection with new aneurysm formation within days of clear angiographic imaging despite the apparent lack of skull base osteomyelitis.


Severe thermal corneoscleral injury occurred during phacoemulsification in the right eye of a 74-year-old male. His medical history was prostate hypertrophy. Visual acuity was hand motion and the intraocular pressure was 3 mm Hg OD. There was heavy corneal stromal opacity with intraocular fluid leakage. The patient underwent transplantation of a donor scleral graft to the burn site. Histologically, the injured sclera showed coagulation necrosis without inflammatory cell infiltration. An intraocular lens was eventually fixed in the ciliary sulcus 7 months later. His visual acuity remains at 2/20 OD.


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).

A 56-year-old female, with previous history of intestinal pneumonitis, mild pulmonary hypertension and gastroesophageal reflux secondary to systemic scleroderma, is considered for lung transplant. Initially, due to persistent gastroesophageal reflux, a transplant was not a viable. This was corrected with an open gastrectomy with roux-en-Y anastomosis. Follow-up one week later revealed normal anatomy, adequate esophageal-jejunal anastomosis, and adequate contrast medium transit via esophagogram. Additionally, there was no evidence of contrast medium reflux indicating a resolved gastroesophageal reflux disease. This led to the patient becoming a candidate for lung transplant.


A 71-year-old female who was being treated for type 2 diabetes with canagliflozin, metformin, and saxagliptin orally presented to the ED for evaluation of reduced oral intake, malaise, nausea, and abdominal pain. Although her blood glucose was not severely elevated (259 mg/dL), there was notable ketoacidosis (pH 6.89; CO2, 11.4 mmHg; HCO3, 1.9 mEq/L; base excess, - 31.3 mmol/L; 3-hydroxybutyric acid > 10,000 μmol/L) was observed. The uncontrolled acidosis improved following 3 days of continuous renal replacement therapy, but 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, and there was improvement in the patient's overall state; hence, she was discharged on day 18.


A 62-year-old male presented with a 4-month history of right brachial pain and hyposensitivity in the C5 distribution. The cervical magnetic resonance (MR) imaging scan revealed a C5-C6 right anterolateral disc herniation with syringomyelia extending from C5-C6 to T1. Following a C5-C6 anterior cervical discectomy and fusion (ACDF), the patient's symptoms resolved. The 3-month postoperative MR documented total resolution of the syrinx. Notably, due to residual neuropathic pain, the patient required a subdural spinal cord stimulator which was placed without any complications.


We report the case of a 51-year-old Caucasian woman who presented with SAPHO syndrome with mainly axial involvement. She had been treated with sulfasalazine and anti-inflammatory drugs for many years without any success. A few weeks after starting treatment with tofacitinib, both clinical and biological parameters dramatically improved. Imaging also showed considerable regression of the vertebral and pelvic lesions. However, tofacitinib had to be discontinued due to the occurrence of pulmonary embolism. Consequently, recurrence of bone pain and biologic inflammation was rapidly observed.


Herein we present a 63-year-old man with idiopathic spontaneous intraperitoneal hemorrhage (ISIH) caused by spontaneous rupture of non-aneurysmal inferior pancreaticoduodenalartery (IPDA).


A 63-year-old male presented with a prominent itching sensation and wholebody jaundice. He showed obstructive-pattern jaundice, an elevated IgG4 level, and infiltration of a large number of IgG4-positive cells in the ampulla of Vater. The imaging findings of intrahepatic duct (IHD) and common bile duct dilation, an elevated serum IgG4 level, and characteristic histological findings led to diagnosis of IgG4-SC that compatible with the 2019 ACR/EULAR classification criteria. We planned to treat the patient with high-dose glucocorticoid (GC), followed by cyclophosphamide pulse therapy. After treatment with high-dose GC and an immunosuppressant, imaging studies showed that IHD dilatation had completely resolved.


We present a case of a patient who suffered a cardiac arrest after a fall during a chronic obstructive pulmonary disease exacerbation, leading to pneumoretroperitoneum.


33-year-old nulligravid woman with newly diagnosed anaplastic astrocytoma (AA; WHO grade III, IDH1-negative) sought fertility preservation. Prior to chemotherapy and radiation for AA, the patient underwent in vitro fertilization (IVF) for fertility preservation, resulting in 8 vitrified embryos. Following chemo-radiation, the patient underwent two rounds of frozen embryo transfers (FET), each resulting in a successful singleton pregnancy.


A 34-year-old male patient presented with multiple large tuberous xanthomas related to FH. There were 15 masses in different body parts, including the dorsum of the hands, elbows, buttocks, feet, and Achille's tendon. The largest masses in the buttocks measured 8 × 8 × 5 cm. Surgical removal of 13 masses was carried out in combination with medical treatment. The skin incision was oval around the circumference of masses with the longitudinal axis parallel to the Langer's line. Skin defects were closed directly or dissected on both sides of the incision to reduce tension. Wound healing was normal. After 1.5 months, there was no recurrence of xanthomas.


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.

A 40-year-old woman was admitted to our hospital after presenting with liver dysfunction. She had been previously diagnosed with ET; aspirin and anagrelide had been prescribed. Subsequent examination at our hospital revealed cecal cancer. Distant metastasis was absent; laparoscopic ileocecal resection was performed. Anagrelide was discontinued only on the surgery day. She was discharged on the seventh postoperative day without thrombosis or hemorrhage. However, when capecitabine and oxaliplatin were administered as adjuvant chemotherapy with continued anagrelide administration, she experienced hepatic dysfunction and thrombocytopenia; thus, anagrelide was discontinued. Five days later, her platelet count recovered. Subsequently, anagrelide and aspirin administration was resumed, without any adjuvant chemotherapy. Her liver function normalized gradually in 4 months. One-year post operation, she is well without tumor recurrence or new metastasis.


We report here another case of primary prostatic MALT lymphoma which is presented by hematuria and diagnosed primarily as BPH. Immunohistochemistry studies demonstrate the diagnosis and MALT lymphoma. Six months after starting the treatment the patient was alive and well.


An isolated retinal astrocytic hamartoma was detected in the nasal retina of the left eye of a 4-day-old male infant. At the time of initial presentation, we detected a solitary yellowish-white flat mass with an approximate size of 1.5 disc diameters in the nasal retina. Fluorescein angiography (FA) revealed a diffuse hyperfluorescence with slight fluorescence leakage. Seven months later, the fundus examination showed no lesion in the left eye, FA revealed mild tortuous vessels without leakage.


We describe a case of a Ashkenazi Jew patient who presented in the typical way that carcinoma of the colon might present but turned out to have a very rare type of tumor in both its histology and its location.


A 27-year-old male with a relapsed acute lymphoblastic leukemia presented with five-day-old polyarthralgia. He also had febrile neutropenia, cellulitis without abscesses, and methicillin-resistant Staphylococcus aureus bacteremia for which he received therapy with oxacillin and cefepime. However, the febrile neutropenia persisted, and an invasive fungal infection was suspected. A new set of blood cultures was taken and antifungal treatment was initiated. Arthroconidia were identified in the blood cultures and a matrix-assisted laser desorption ionization-mass spectrometry confirmed the presence of Geotrichum spp. Antifungal treatment was adjusted to 14 days of deoxycholate amphotericin B and four weeks of voriconazole. After a prolonged stay, he was discharged.


We present a case of subacute cervical cerebrospinal fluid (CSF) leak resulting from chiropractic manipulation of the cervical spine. The patient is a 29-year-old female who received manipulation one week prior to developing 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 and review the pertinent literature on complications of chiropractic manipulation.


The patient was referred to our hospital with a 1-month history of disorientation and magnetic resonance imaging showed hydrocephalus with 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 underwent chemotherapy and radiotherapy.


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 also suffering from primary sclerosing cholangitis and ulcerative colitis. Diagnosis was based on clinical manifestations, serology results, as well as microbiological and histological findings. Treatment consisted of surgery and anti-Cytomegalovirus therapy.


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. No adverse reactions were observed.


The patient was a 55-year-old woman with a transglottic squamous cell carcinoma of the T3N0M0 stage and PCF development following total laryngectomy surgery with total thyroidectomy and bilateral elective cervical lymph node dissection level I-IV. In spite of conservative treatment, the fistula was not recovered after 3 weeks. It was decided to perform fibrin glue injection into the fistula tract via the endoscopic approach. One month after the fibrin glue injection, no evidence of contrast extravasation was observed on barium swallow test, and the fistula was completely closed.


a 1-month-old baby presented with severe AS and CoA. The decision was made to perform a hybrid surgical procedure. The patient underwent a lateral thoracotomy for repair of the CoA and carotid cutdown for aortic balloon valvuloplasty (AoVP).


We report the case of a 2 years and-5-month-old boy admitted in our clinic for fever, abdominal pain and diarrhea. The clinical exam at the time of admission revealed influenced gen-eral status, bilateral palpebral edema and conjunctivitis, mucocutaneous signs of dehydration, and abdominal tenderness at palpation. The laboratory tests performed pointed out lymphopenia, thrombocytopenia, anemia, elevated C-reactive protein - CRP, erythrocyte sedimentation rate and ferritin levels, hyponatremia, hypopotassemia, hypertriglyceridemia, elevated D-dimer, in-creased troponin and NT-proBNP. The real-time polymerase chain reaction (RT-PCR) test for SARS-CoV-2 infection was negative, but the serology was positive. Thus, established the diagnosis of PIMS-TS. We initiated intravenous immunoglobulin, empirical antibiotic, anticoagulation therapy and symptomatic drugs. Nevertheless, the clinical course and laboratory parameters worsened, and the 2nd echocardiography pointed out minimal pericardial effusion, slight dilation of the left cavities, dyskinesia of the inferior and septal basal segments of the left ventricle (LV), and LV systolic dysfunction. Therefore, we associated intravenous methylprednisolone, angiotensin converting enzyme inhibitors, spironolactone and hydrochlorothiazide, with outstanding favorable evolution.


An 84-year-old male was admitted with a history of difficulty rising from a chair and a fall. Laboratory results showed increased creatine kinase levels of more than 50 times the normal reference values. Electromyography (EMG) showed myopathic changes, and FDG-PET/CT scan showed increased FDG uptake in bilateral quadriceps. A biopsy was performed revealing lymphocytic predominant infiltrates and myonecrosis. Prednisone and intravenous immunoglobulin (IVIG) were administered with strength improvement. The patient was discharged for further follow-up.


A young man involved in a car accident and sustained blunt thoracic injuries, among others. As part of primary survey, FAST scan was performed. Subxiphoid view to look for evidence of pericardial effusion showed part of the cardiac image obscured by A-lines. Other cardiac windows showed only A-lines, as well. A suspicion of pneumopericardium was raised and CT scan confirmed the diagnosis.


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.

We describe a 30-year-old Caucasian woman who tested positive for COVID-19 after developing nasal congestion and cough. Ten days after testing positive, she developed a systemic rash on her extremities and torso. At the same time, she developed swelling of the tongue lasting 1 hour, with subsequent appearance of oral lesions that resembled geographic tongue. She also had an irritable sensation on her tongue and some mild loss of sense of taste. We opted for conservative therapy, including mouth rinses containing lidocaine to be used every 6 hours. The patient used the mouth rinse therapy for 1 month and experienced a 90% improvement in her oral lesions and tongue sensitivity. However, she had repeated flares every 3 weeks over a 6-month period, and the steroid mouthwash achieved incomplete resolution. After three sessions of photobiomodulation therapy, she had no further flares or tongue sensitivity and the lesions healed.


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 can slow disease progression and reduce the risk of end-stage renal disease.

The medical record of a 64-year-old female with Sjogren's syndrome was reviewed. The clinical and pathological data along with chest CT images were obtained. The literature related to the transformation was reviewed. There were no specific clinical manifestations of LIP and its transformation into malignant lymphoma in the patient. The chest CT mainly displayed multiple cystic foci, with multiple nodules and ground-glass shadows in both lungs.


We report a case of a 93-year-old Middle Eastern male presenting for longstanding treatment-refractory hiccups. Imaging with computed tomography of the chest and abdomen was unremarkable. An upper endoscopy was normal without any endoscopic finding to suggest eosinophilic esophagitis. Given his elevated peripheral eosinophil count, biopsies were taken from mid- and distal esophagus and revealed eosinophilic infiltration in the range of 15 eosinophils per high-power field, favoring a diagnosis of eosinophilic esophagitis. The hiccups resolved following the initiation of eosinophilic esophagitis treatment.


The patient was a 77-year-old hypertensive male who presented to the emergency following an episode of slip and fall at home. After prompt resuscitation, he was sent for radiological evaluation which revealed fractures of the left inter-trochanteric femur and left proximal humerus. Meanwhile, laboratory investigations showed grossly deranged renal parameters, along with elevated serum creatinine phosphokinase levels (more than 5 times the baseline). A diagnosis of acute kidney injury secondary to traumatic rhabdomyolysis was made. Medical management included adequate intravenous fluid administration combined with strict input-output monitoring. Subsequently, the patient underwent closed reduction and internal fixation of the inter-trochanteric femur fracture with a proximal femoral nail. However, fracture of the proximal humerus was managed non-operatively with sling immobilization as patient refused to give consent for a second surgery.


In this case, we present a preterm newborn who developed pneumomediastinum and pneumothorax. The pneumothorax persisted, despite placement of a thorax tube, requiring a thoracotomy to detect and treat the bronchial rupture.


A 21-year-old man was referred to our hospital for treatment after presenting to a nearby hospital with right inguinal pain. Abdominal magnetic resonance imaging showed an intra-abdominal mass measuring 34 × 15 × 8 cm with partial signal hyperintensity on T2-weighted imaging and hypointensity on T1-weighted imaging, extending from the left abdominal cavity to the pelvic region. Although no definitive diagnosis was obtained preoperatively, surgery was performed under suspicion of gastrointestinal stromal tumor or other significant disease. A mass was identified firmly adherent to the transverse colon, gastric wall, and diaphragm, and these organs were partially resected. The excised specimen measured 38 × 21 × 8 cm and weighed 6400 g. Macroscopically, the tumor showed a smooth surface and homogeneous interior. Pathological examination revealed atypical cells with spindle-shaped nuclei and collagen fiber hyperplasia in the stroma, and immunostaining was negative for c-kit, CD34, desmin, S-100, and positive for β-catenin, leading to a confirmed diagnosis of desmoid tumor. Fifteen months after surgery, a local recurrence with a diameter of 3.0 cm was identified, and the patient remains under careful follow-up.


Patient concerns:
A 68-year-old man was admitted to our hospital with dyspea and general fatigue. He was diagnosed with acute decompensated heart failure due to ischemic cardiomyopathy. In order to improve fluid retention and relieve his dyspnea, low-dose TLV (7.5 mg qd) was performed. After the 3-day treatment using TLV, we observed that he became delirious and his limbs shook uncontrollably. High serum sodium 173 mmol/L was noted compared to the results of the first examination (137 mmol/L). After intensive rescue, serum sodium was restored to normal (135 mol/L). Later, when the patient refused continuous renal replacement therapy (CRRT), we tried again to use a lower dose of TLV to improve diuretic resistance. Two days later, Serum sodium rose again (162 mmol/L).

Diagnoses:
During the course of therapy, we did not strictly require the patient to control the fluid intake. No other medication could cause elevation of serum sodium. Therefore, we suspected a high sensitivity to the side effect of TLV.

Intervention:
Stop the use of TLV and encourage the patient to drink plenty of water. Gastric tube was inserted orally to increase the intake of fresh water.

Outcomes:
His serum sodium decreased gradually and his psychiatric symptom recovered. During this period, Overall condition of the patient was stable. After being discharged from the hospital, the patient eventually died of cardiac arrest due to critically ill heart failure.


A patient from TRITON2 with BRCA-mutated mCRPC had a response to the PARP inhibitor rucaparib and remained on treatment for 32 weeks, which was >2 times longer than the duration of each of his prior therapies (bicalutamide, docetaxel, abiraterone). The patient enrolled in TRITON2 based on results of local genomic testing of an archival biopsy that indicated the presence of a BRCA1 T1399I (allelic fraction, 19%) mutation. Local testing also identified an ATM G1663C mutation, a TP53 P191del mutation, and a BRAF K601E mutation. Analysis of a plasma sample obtained before the patient started rucaparib detected the same alterations as those in the archival biopsy, but it also revealed the presence of a BRCA2 homozygous loss (whole gene, 26 of 26 exons) and several other alterations of unknown functional impact. We hypothesize the response of the patient's tumor to rucaparib was likely driven by DNA damage repair deficiency caused by homozygous loss of all BRCA2 exons. Following discontinuation from rucaparib due to clinical disease progression, the patient received carboplatin and cabazitaxel for ≈3 weeks. The patient died due to progression of his disease.


A 91-year-old woman presented to our institution with ST-segment elevation myocardial infarction (STEMI). The right radial access was chosen for the performance of percutaneous coronary intervention. After the introduction of 6 F sheath, there was difficulty in the advancement of 0.035 J wire that was exchanged with a Terumo hydrophilic wire. After the procedure and before sheath removal, radial arteriography was done and revealed perforation. Protamine sulfate was administered and prolonged balloon inflation was attempted but failed to seal the perforation, so a 7-F-long vascular sheath was inserted to internally tamponade the vessel, and the patient was sent to the coronary care unit for monitoring. Over the next 3 days, serial radial angiographies were done revealing the persistence of the perforation, and on the fourth day, angiography revealed multiple thrombi. Thrombus aspiration was done using Pronto V4 extraction catheter (Vascular Solutions, USA) and was followed by the deployment of a covered stent. The stent was dislodged and successfully snared. Finally, the perforation was sealed spontaneously and there were no signs of intra-arterial thrombi.


We describe a case in which the two technologies are used in combination during acute echocardiographic optimization of left pacing vector in a 63-year-old man, Caucasian, who showed worsening heart failure symptoms a few days after an implant, and the effect of the device’s optimization at 6-month follow-up.


A 78-year-old male patient presented with intermittent cervicalgia of 5 months duration accompanied by few weeks of a progressive severe right hemiparesis, up to hemiplegia. The magnetic resonance imaging (MRI) examination revealed an intramedullary expansive lesion measuring 10 mm×15 mm at the C1-C2 level; it readily enhanced with contrast. A total body computed tomography (CT) scan documented an 85 mm mass involving the right kidney, extending to the ipsilateral adrenal gland, and posteriorly infiltrating the ipsilateral psoas muscle. The subsequent CT-guided fine-needle biopsy confirmed the diagnosis of an RCC (Stage IV). The patient next underwent total surgical total removal of the C1-C2 intramedullary mass, following which he exhibited a slight motor improvement, with the right hemiparesis (2/5). He died after 14 months due to global RCC tumor progression.


A 32 year-old woman with a history of non-diabetic hemodialysis for 3 years suffered from severe involuntary movement, and brain magnetic resonance imaging showed symmetrical T2-weighted imaging (T2WI) and T2/fluid-attenuated inversion recovery (T2FLAIR) hyperintense nonhemorrhagic lesions in the bilateral basal ganglia. She was diagnosed with UE as syndrome of bilateral basal ganglia lesions, due to a combined effect of uremic toxins and hyperthyroidism. After treatment with high frequency and high flux dialysis, hyperbaric oxygen therapy and declining parathyroid hormone, the patient achieved complete remission with normal body movement and was discharged.


We report the case of a patient with a history of multiple diseases and 2 tumor-like lesions with internal lytic areas detected in the fourth right costal arch and in the eighth left costal arc; we describe his clinical manifestations, radiological and laboratory findings as well as the pathological results and outcome.


A 25-year-old gentleman presented with recurrent upper right vestibular abscess three months following a bimaxillary orthognathic surgery. A bonded molar orthodontic tube had dislodged into the wound during the operation. The clinical presentation initially mimics an odontogenic infection until our investigations revealed that it originated from the dislodged appliance. The abscess was drained, the wound site was explored, and the molar tube and neighbouring rigid fixation plates and screws were removed. The patient recovered well following the procedure.


A 22-year-old male was admitted for bilateral leg tremor while standing, with symptom onset eight months prior. One month before admission, the tremor disappeared in the left leg but persisted in the right leg. Electromyography recorded from the right gastrocnemius revealed a 6-8 Hz tremor, which appeared when the patient was standing and disappeared when he was resting or walking. Blood screening showed a phenylalanine/tyrosine ratio of 2.06 and a phenylalanine level of 140 μmol/L. Urine metabolic screening was negative. Whole-exome sequencing confirmed the presence of a compound heterozygous mutation, c.158G > A and c.728G > A, in phenylalanine hydroxylase (PAH) gene. After three months of levodopa/benserazide tablets (250 mg, tid) and a low-phenylalanine diet treatment, the tremor disappeared.


In this case report, we present a 16-year-old Ukrainian boy with acute hepatitis B. He had not been previously vaccinated against hepatitis B. Possible sources of infection included: a tattoo made at home, a finger cut made with hairdresser scissors during work, and unprotected sexual encounters. The clinical course of the disease was typical with jaundice and elevated aminotransferases levels without liver failure. During the follow-up visit 16 months after the onset of the disease, chronic hepatitis b was excluded but an ulcer around his anus was found. Additional tests for sexually transmitted diseases were ordered and they were positive for syphilis. The extended interview revealed that the patient had several unprotected bisexual encounters, which may have indicated a potential source of infections including the hepatitis B virus (HBV).


We report a case of an isolated intracranial RDD in a 53-year-old man. The patient had an episode of generalized seizures. Imaging studies of the brain were compatible with a meningioma en plaque. The mass was exposed by a right frontotemporal craniotomy. The tumor was adhered tightly to the adjacent cerebral cortex and was permeated by pial arteries of the brain surface. The sacrificing of these arteries was inevitable in order to achieve the total removal of the tumor. The patient had incomplete left hemiparesis after the surgery. Brain computed tomography (CT) imaging revealed a postoperative hemorrhage and a low-density lesion in the right frontal lobe. The patient was postoperatively diagnosed with isolated central nervous system RDD.


44-year-old African black patient of Burkinabe origin with no other medical history, admitted for chronic inflammatory low back pain associated with inflammatory right knee pain and a cough with phlegm. This symptomatology had been developing for seven months in a febrile context and with a general deterioration in health. The examination showed oligoarthritis of the right sternoclavicular joint and the left knee, associated with a pulmonary condensation syndrome and pleural effusion, a cold abscess at the level of the right sternoclavicular joint and a fistulous and purulent right inguinal lymphadenopathy. The biology showed an inflammatory syndrome. The GeneXpert test was positive in the sputum, without resistance to rifampicin. The intradermal reaction to the tuberculin was positive. The thoracic tomodensitometry showed a right sternoclavicular osteoarthritis and a spondylodiscitis of the L3-L4 spine. The standard radiography of the left knee objectified signs in favour of arthritis. The diagnosis of tuberculosis with multifocal, pleuropulmonary and ganglionar bone involvement was retained. The patient was given usual analgesics and antituberculous. The evolution was favourable.


A case report of an 84-year old male, who presented with an aggressively recurrent form of MCC on the lower lip, on the background of an 8-year history of untreated CLL. During the recurrences of MCC, coexisting regional lymphadenopathy, posed a problem in the differential diagnosis and treatment of lymph node involvement. Histopathology and immunoistochemistry showed that submandibular lymphadenopathy coexisting with the second recurrence of MCC, was due to B-cell small lymphocytic lymphoma. The subsequent and more aggressive recurrence of the skin tumor had involved the superficial and deep cervical lymph nodes. Surgical excision followed by involved field radiation therapy has been proven effective for both malignancies.


A 42-year-old female with history of uterine fibroids was admitted with abdominal pain and intraperitoneal fluid of unknown etiology. She was initially managed nonoperatively and empirically treated with broad spectrum antibiotics. Blood and urine cultures were unrevealing. Increasing abdominal pain and peritoneal fluid prompted diagnostic laparoscopy which revealed a dense fibrinous exudate covering the entire peritoneal cavity. Peritoneal fluid and biopsies were sent for cytology and culture. The peritoneal fluid was eventually sent for 16 s ribosomal analysis, which discovered Mycoplasma hominis RNA. Her antibiotics were narrowed, and she eventually made a full recovery.


We report a case of VEO-IBD associated with a monogenic mutation in a 2-year-old girl presenting mainly with gastrointestinal symptoms, including recurrent hematochezia and abdominal pain for more than 3 months. A gastroscopy revealed erosive gastritis and bulbar duodenitis, while a colonoscopy indicated erosive colitis. Abnormal results were obtained from the dihydrohodamine (DHR) assay and immunoglobulin testing. Whole-exome sequencing identified a heterozygous and de novo nonsense mutation (c.388 C > T; p.R130X) in the CYBB gene leading to deficiency of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase 2 (NOX2) (encoded by CYBB), a critical component of phagocytes. HSCT was performed successfully, and the DHR assay showed that normal neutrophil function was restored. Six months after HSCT, clinical remission was observed, and a repeat colonoscopy revealed intestinal mucosal healing was attained.


A 5-year-old girl with high-grade conventional osteosarcoma in the left distal femur underwent a series of surgeries. After three cycles of neoadjuvant chemotherapy, limb-salvage surgery was planned because femoral rotationplasty had been refused. At 6 years and 2 months old, distal femoral resection and temporary spacer insertion using a 7-mm-diameter intramedullary nail and molded polymethylmethacrylate was performed. At 7 years and 8 months old, secondary surgery was performed because the first spacer had been dislocated and the residual femur became atrophic. The distal end of the residual femur was removed by 1 cm, but the periosteum and induced membrane around polymethylmethacrylate was preserved. In order to stabilize the spacer against the tibia, a custom-made ceramic spacer with a smooth straight 8-mm-diameter stem was utilized. The bone-spacer junction was fixed with polymethylmethacrylate and then covered with the preserved periosteum and induced membrane. After surgery, the bone atrophy improved. At 9 years and 7 months old, the second spacer was removed because it had loosened, and the knee joint was reconstructed using a custom-made growing femoral prosthesis with a curved porous 8.5-mm-diameter stem. Cancellous bone tips from the proximal tibia were grafted around the bone-prosthesis junction underneath the induced membrane. At 10 years and 5 months old, the patient was able to walk unsupported and a radiograph showed further thickening of the cortex of the residual femur without any stress shielding. Although having 5 cm of limb length discrepancy, the patient and her mother were satisfied with the function. The MSTS score was 24 out of 30 points. Repeated limb length extensions are planned.


We present the case of a 16-year-old Persian man diagnosed as having a non-invasive form of multiple endocrine neoplasia 2B (medullary thyroid cancer, mucosal neuroma of the tongue, lips and inner eyelids). Our patient, who had a positive family history of medullary thyroid cancer, was of normal height with no signs of marfanoid habitus.


An 86-year-old male was admitted to our hospital with congestive heart failure due to low-flow low-gradient severe AS, a membranous VSD, a sub-aortic band, and a double-chambered right ventricle (RV). The patient was not deemed to be a surgical candidate because of advanced age and frailty even though surgical aortic valve replacement, VSD closure, sub-aortic band resection, and myectomy of RV would be considered as definitive treatment. Instead, we performed TAVI and VSD orifice closure using the skirt part of the self-expanding valve (26 mm Evolut Pro Plus™) because VSD occluder is not approved and thus not available in our country. The trans-catheter procedure resulted in a reduction of the mean aortic valve pressure gradient improved from 33 to 2 mmHg and a decrease in the shunt flow (Qp/Qs) from 1.9 to 1.2. The patient’s heart failure improved, and he was discharged to home 7 days after the procedure. He remained well and had not been admitted to hospital since discharge.


We report a case study with a 44-year-old man from Faryab Province in Afghanistan who presented chest pain and dizziness while suffering a common cold. After full investigation, the patient underwent coronary angiography which showed a myocardial bridge at the middle portion of the left anterior descending artery (LAD) with a significant stenosis causing ischemia. We treated the patient with a calcium channel blocker as initial treatment. The patient tolerated the medication well and remained asymptomatic during two years follow-up.


Here, we report the first clinical case of a cerebral nocardiosis revealed after seizure in a patient treated by pembrolizumab for a metastatic lung cancer, in the absence of any additional immunosuppressive therapy or risk factors for cerebral nocardiosis. The extended evaluation including a brain CT-scan did not reveal any lesion before pembrolizumab. Nevertheless, the 3-month delay between the start of Pembrolizumab and the diagnosis of cerebral nocardiosis suggests that the infection occurred prior to the CPI. Unfortunately, the patient died during treatment for cerebral nocardiosis, while the lung cancer tumor mass had decreased by 80% after the sixth cycle of pembrolizumab.


We report the case of a 72-year-old Caucasian woman with full-thickness rectal prolapse associated with fecal incontinence from severe neuromuscular damage.


It is a case report of a 13-year-old girl with the history of swelling over her right hand for 5 months. X-ray revealed that there was an osteolytic fusiform expansible lesion. The biopsy sent and it conferred the diagnosis of GCT. Dorsal approach used for the enbloc resection of the fifth metacarpals (except at the base) and partial excision of the surrounding muscles done. The capsule and collateral ligament of the fifth metacarpophalangeal joint were left. The fourth metatarsal was harvested from the foot along with its capsule and collateral ligament of the metatarsophalangeal joint and sutured to the counter capsuloligamentous structure at the recipient site.


In this report, we present the case of an RSV-associated death of a child who was born at full-term and developed normally up to the age of 2 years old. Cardiopulmonary arrest occurred within 3 days after the onset of symptoms, which included cough and high fever. Complete brain edema was prominent, and encephalopathy was developing. Viral antigen detection and microbiome analyses of oral swab and nasopharyngeal aspirate specimens verified an RSV infection, while bacterial culture of blood specimens yielded negative results. The RSV strain detected in this patient was subtyped as RSVB9, and no mutation was found in the six antigenic sites for targeted drugs or vaccines.


We present the case of a middle-aged patient diagnosed with a giant gastric GIST, which presented for intermittent gastric outlet obstruction symptoms, and emphasize the major imagistic, histopathological, and therapeutic challenges that may be encountered. There are only several cases of gastric exophytic gastric GIST provoking intermittent gastric outlet obstruction. Tumor resection should be adapted to every patient's status, focused on en bloc extraction, with preservation of invaded organs as much as possible.


A 71-year-old female who was being treated for type 2 diabetes with canagliflozin, metformin, and saxagliptin orally presented to the ED for evaluation of reduced oral intake, malaise, nausea, and abdominal pain. Although her blood glucose was not severely elevated (259 mg/dL), there was notable ketoacidosis (pH 6.89; CO2, 11.4 mmHg; HCO3, 1.9 mEq/L; base excess, - 31.3 mmol/L; 3-hydroxybutyric acid > 10,000 μmol/L) was observed. The uncontrolled acidosis improved following 3 days of continuous renal replacement therapy, but 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, and there was improvement in the patient's overall state; hence, she was discharged on day 18.


A 27-year-old male with a relapsed acute lymphoblastic leukemia presented with five-day-old polyarthralgia. He also had febrile neutropenia, cellulitis without abscesses, and methicillin-resistant Staphylococcus aureus bacteremia for which he received therapy with oxacillin and cefepime. However, the febrile neutropenia persisted, and an invasive fungal infection was suspected. A new set of blood cultures was taken and antifungal treatment was initiated. Arthroconidia were identified in the blood cultures and a matrix-assisted laser desorption ionization-mass spectrometry confirmed the presence of Geotrichum spp. Antifungal treatment was adjusted to 14 days of deoxycholate amphotericin B and four weeks of voriconazole. After a prolonged stay, he was discharged.


We present a case of subacute cervical cerebrospinal fluid (CSF) leak resulting from chiropractic manipulation of the cervical spine. The patient is a 29-year-old female who received manipulation one week prior to developing 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 and review the pertinent literature on complications of chiropractic manipulation.


We presented an interesting case of a 33-year-old female with a solitary polypoid nodule without apparent pigmentation on her vulvar skin. Her medical history was unclear, no ulcer was seen in the lesion area, and dermatoscopy was indicated a possible tumorous change, which has caught the attention of clinicians, and then further examined by the pathologist. The final diagnosis was nodular malignant melanoma (NM) (Breslow thickness 9.5mm, Clark level 4).


52-year-old female patient who reported chronic, burning pain radiating to the distal phalanx of the thumb with no traumatic history, which had been present for two years and limited her daily activities. The exploration was complemented with interphalangeal Doppler ultrasound, which is an excellent alternative due to its easy accessibility. A glomus tumor in the interphalangeal phalanx of the thumb was diagnosed. A H-approach was performed on the interphalangeal fold with subungual dissection and resection of the tumoral piece and follow-up by an external consultation where the surgical wound was found to be healing adequately. Physical exploration with the ability to mobilize the interphalangeal distal joint (IFD) and visual analogue scale (VAS) of 1 point. The anatomopathological evaluation reported the existence of a glomus tumor.


A 62-year-old previously healthy Sri Lankan native male from the Western province of Sri Lanka presented with high fever with malaise, myalgia and arthralgia for 17 days. On the 5th day of illness he developed intermittent resting tremor in his right arm and leg associated with stiffness, difficulty in carrying out normal work and difficulty in smiling. He denied similar previous episodes. There were no other associated neurological manifestations. Clinical examination revealed a high amplitude low frequency resting tremor in his right hand, a mask-like face and increased muscle tone limited to the right side with normal reflexes. The rest of the system examination was normal except for an eschar over the abdomen. His investigations revealed lymphocytic leukocytosis, high erythrocyte sedimentation rate and immunofluorescence assay-IgM and IgG against Orientia tsutsugamushi Karp antigen were positive with rising titers. With oral doxycycline and azithromycin his fever settled within 48 h and a complete recovery of Parkinson's features was observed within 2 weeks.


A 39-year-old woman, who visited to our hospital complaining of worsened right low back pain and fever, was diagnosed with right hydronephrosis due to ureteropelvic junction obstruction by contrast-enhanced computed tomography. Intraoperatively before the planned robot-assisted laparoscopic pyeloplasty, retrograde pyelography was performed to reveal concomitant ipsilateral retrocaval ureter. Laparoscopically, ureteropelvic junction obstruction due to aberrant blood vessel and coexisting retrocaval ureter was confirmed. Transposition of the ureter from posterior to anterior of the inferior vena cava and following dismembered pyeloplasty was performed. Two years after surgery, her right hydronephrosis improved and she had no complain of any symptom.


A 15-year-old boy who was previously diagnosed with SRU presented to our office with rectal bleeding, mucoid discharge, and abdominal pain. Additional colonoscopy evaluation revealed multiple polyposes varying in size and shape limited to the rectum. Histologic examination revealed a characteristic cap of granulation tissue covering tortuous nondysplastic crypts in the inflamed stroma, indicating that SRU had transformed into CP. Based on the assessments, we planned to perform endoscopic mucosal resection of the lesions in multiple sessions.


We present a case of 62-year-old male who presented after experiencing syncope and cardiac arrest. Given the clinical presentation and electrocardiographic findings, there was concern for acute coronary syndrome. However, coronary angiogram did not reveal significant coronary obstruction. Due to the unclear nature of his presentation, a bedside echocardiogram was rapidly performed and was indicative of right ventricular strain. Due to these findings, a pulmonary angiogram was performed that revealed massive pulmonary embolism. He successfully underwent catheter-directed thrombolysis and, after a prolonged hospital stay, was discharged home on lifelong anticoagulation.


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 also suffering from primary sclerosing cholangitis and ulcerative colitis. Diagnosis was based on clinical manifestations, serology results, as well as microbiological and histological findings. Treatment consisted of surgery and anti-Cytomegalovirus therapy.


We report the case of a 51-year-old Caucasian woman who presented with SAPHO syndrome with mainly axial involvement. She had been treated with sulfasalazine and anti-inflammatory drugs for many years without any success. A few weeks after starting treatment with tofacitinib, both clinical and biological parameters dramatically improved. Imaging also showed considerable regression of the vertebral and pelvic lesions. However, tofacitinib had to be discontinued due to the occurrence of pulmonary embolism. Consequently, recurrence of bone pain and biologic inflammation was rapidly observed.


Our patient was a 39-year-old Chinese woman who had a history of two cesarean sections and one miscarriage. She had a recurrent anterior abdominal wall mass around her cesarean scar, and the mass was initially suspected of being choriocarcinoma of unknown origin. The patient had concomitant negative or mildly increased serum β-human chorionic gonadotropin at follow-up and no abnormal vaginal bleeding or abdominal pain. However, she underwent local excision twice and had two courses of chemotherapy with an etoposide and cisplatin regimen. She finally opted for exploratory laparotomy with abdominal wall lesion removal, subtotal hysterectomy, bilateral salpingectomy, and left ovarian cyst resection, which showed the abdominal wall lesion, whose components were revealed by microscopy and immunohistochemical staining to be approximately 90% epithelioid trophoblastic tumors and 10% choriocarcinomas from a solely extrauterine mixed gestational trophoblastic neoplasm around an abdominal wall cesarean scar.


We report a 53-year-old female from a rural area in China who was hospitalized for lower limb edema, abdominal distension, cirrhosis, and hypothyroidism. We excluded the common causes of liver disease (drinking alcohol, using traditional Chinese medicines, hepatitis virus infection, autoimmunity, and hepatolenticular degeneration). When she was 23-years-old, she developed night-blindness that worsened to complete blindness, with no obvious cause. Her parents were first cousins, and both were alive. Analysis of the patient's family history indicated that all 5 siblings had night blindness and impaired vision; one sister was completely blind; and another sister had night-blindness complicated with cirrhosis and subclinical hypothyroidism. Entire exome sequencing showed that the patient, parents, and siblings all had mutations in the cytochrome P450 4V2 gene (CYP4V2). The CYP4V2 mutations of the parents and two sisters were heterozygous, and the others were homozygous. Two siblings also had heterozygous dual oxidase activator 2 (DUOXA2) mutations.


Herein we present a 63-year-old man with idiopathic spontaneous intraperitoneal hemorrhage (ISIH) caused by spontaneous rupture of non-aneurysmal inferior pancreaticoduodenalartery (IPDA).


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 are often recommended to support kidney health.

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., hyperkalemia, metabolic acidosis), and fluid overload, which can manifest clinically as fatigue, hypertension, and edema. Declining glomerular filtration rate (GFR) is a key biomarker for chronic kidney disease progression, and early intervention through pharmacological management, dietary modification, and monitoring of biomarkers such as serum creatinine and proteinuria is critical to slow disease progression and reduce cardiovascular risk.

The patient presented with right chest pain.

The blood biochemical tests showed lactate dehydrogenase (LDH) of 251 IU/L.

The blood biochemical tests showed alkaline phosphatase (ALP) of 469 IU/L.

The blood biochemical tests showed gamma-glutamyl transferase (γ-GTP) of 125 IU/L.

The blood biochemical tests showed creatinine (Cre) of 1.43 mg/dL.

The blood biochemical tests showed C-reactive protein (CRP) of 3.04 mg/dL.

The blood biochemical tests showed squamous cell carcinoma-related antigen (SCC) of 1.8 ng/mL.

The blood biochemical tests showed nerve specific enolase (NSE) of 21.6 ng/mL.

The blood biochemical tests showed soluble interleukin-2 receptor (SIL-2R) of 614 U/mL.

Computed tomography (CT) showed a huge 10-cm mass under the right diaphragm.

The tumor showed minor enhancement in the lower density areas close to the fat.

The tumor showed gradual, heterogeneous mild enhancement of tumor and liver margins.

The main feeder for the tumor is the right inferior phrenic artery.

The tumor was supposed to be a sarcomatoid malignancy originating from the diaphragm.

No findings were suggesting obvious pulmonary invasion.

Magnetic resonance imaging (MRI) demonstrated heterogeneous high signal intensity on T2-weighted images (T2WI).

Magnetic resonance imaging (MRI) demonstrated heterogeneous high signal intensity on diffusion-weighted images (DWI).

Contrast-enhanced MRI showed gradual heterogeneous enhancement similar to CT findings.

Findings of extrahepatic development were also obtained.

The possibility of adhesion to the liver was suspected.

Fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed abnormal uptake in the tumor with a maximal standardized uptake value (SUVmax) of 4.6.

A myxoid type sarcoma, such as myxoid liposarcoma, or benign tumor was considered.

A definitive diagnosis could not be achieved.

We scheduled a diaphragmatic resection for suspicion of benign tumors of the diaphragm.

We performed extended right posterior segmentectomy with combined resection of the diaphragm.

The major diameter of the diaphragmatic defect was 12 cm.

The patient’s postoperative course was uneventful.

The patient was discharged 14 days after surgery.

Pathological findings showed the mass was located just below the hepatic capsule/intraparenchymal space.

There was no continuity with the diaphragm.

Mitosis was unremarkable, about 0–1 cells/10 HPF.

The morphology suggested low-grade mesenchymal tumors such as solitary fibrous tumor (SFT) and perivascular epithelioid cell tumor (PEComa).

Immunostaining was negative for these tumors.

The tumor was diagnosed as a spindle cell tumor with smooth muscle differentiation.

The diagnosis was based on positive results of myosin markers such as αSMA, desmin, and h-caldesmon.

Some areas with high proliferative activity were observed.

1 year has passed since the surgery with no recurrence.

A 75-year-old man presented with fever and right chest pain.

He was suspected of a giant primary diaphragmatic tumor of extrahepatic origin by imaging studies.

The preoperative differential diagnosis included benign masses such as myxoid sarcoma and schwannoma.

Intraoperatively, dissection of the tumor from the liver was not possible.

An extended right posterior segmentectomy with combined resection of the diaphragm was required.

The patient had a good postoperative course.

One year has passed since the surgery with no recurrence.

The mass was located just below the hepatic capsule/parenchymal region.

The mass was adherent to the diaphragm, but there was no continuity.

The morphology suggested a low-grade mesenchymal tumor such as a solitary fibrous tumor and perivascular epithelioid cell tumor.

Some areas of high proliferative activity were observed.

The diagnosis of primary spindle cell tumor of the liver with smooth muscle differentiation was made.

The diagnosis was based on the positive results of muscle markers such as αSMA, desmin, and h-caldesmon.

The patient presented with right chest pain.

No findings were suggesting obvious pulmonary invasion.

Findings of extrahepatic development were also obtained.

The possibility of adhesion to the liver was suspected.

A definitive diagnosis could not be achieved.

The major diameter of the diaphragmatic defect was 12 cm.

The patient’s postoperative course was uneventful.

The patient was discharged 14 days after surgery.

There was no continuity with the diaphragm.

Mitosis was unremarkable, about 0–1 cells/10 HPF.

Immunostaining was negative for these tumors.

1 year has passed since the surgery with no recurrence.


She was referred to the department with unstable angina.

At the age of six, she underwent CABG to the second diagonal branch using the left internal thoracic artery.

At the age of six, she underwent CABG to the obtuse marginal branch using a saphenous vein graft.

At the age of six, she underwent mitral annuloplasty.

The initial CABG was performed for congenital LMCA.

The initial CABG was performed for moderate mitral regurgitation.

After the initial operation, 18 years passed without any signs of angina.

At the age of 24, she started to experience occasional chest pain on exertion.

By the age of 32, the chest pain had become more frequent.

Exercise stress myocardial perfusion scintigraphy revealed an extensive ischemic lesion on the left ventricular anterior wall.

A coronary angiogram showed a patent LITA to the second diagonal branch.

A coronary angiogram showed a patent SVG to the obtuse marginal branch.

The LAD was mainly supplied by collateral flow from the right coronary artery.

Multidetector-row computed tomography demonstrated a disruption of blood flow to the LAD from the LITA.

The disruption of blood flow to the LAD was due to an occlusion of the proximal part of the second diagonal branch.

To improve the ischemia of the LAD lesion, a redo CABG using the right internal thoracic artery was performed.

The distal LAD was too small to be grafted.

The proximal LAD was deep in the myocardium.

A bypass was performed to the first diagonal branch, which was connected to the LAD.

Postoperative coronary angiogram showed that all bypass grafts, including the RITA, were patent.

Postoperative coronary angiogram showed blood flow communication between the first diagonal branch and the LAD.

Pharmacologic stress perfusion scintigraphy revealed an improvement in the ischemia, especially in the left intraventricular septum.

She was discharged 10 days after surgery.

She has been in good health for over 3 years without recurrence of chest symptoms.

At the age of 6, she had undergone coronary artery bypass grafting of the second diagonal branch using the left internal thoracic artery.

At the age of 6, she had undergone coronary artery bypass grafting of the obtuse marginal branch using saphenous vein grafting.

The bypass grafting at age 6 was performed for left main coronary atresia.

A coronary angiogram showed a patent left internal thoracic artery graft to the second diagonal branch.

A coronary angiogram showed a patent saphenous vein graft to the obtuse marginal branch.

The left anterior descending artery was not being perfused by the grafts.

The disruption of blood flow to the left anterior descending artery was from the left internal thoracic artery.

We performed a redo coronary artery bypass grafting using the in situ right internal thoracic artery to the first diagonal branch.

The graft was to be connected to the left anterior descending artery.

The redo bypass grafting resulted in amelioration of the ischemia of the left anterior wall.

The patient was discharged 10 days after the operation.

The patient has been in good health for over 3 years without recurrence of chest symptoms.


He presented to an outside emergency department with a five-day history of cough.

He had a five-day history of shortness of breath.

He had a five-day history of nasal congestion.

He had a five-day history of loss of taste and smell.

He had a past medical history of asthma.

He had morbid obesity with a BMI of 50.5 kg/m2.

He had no known connective tissue disease.

He had no known hypertrophic scarring reactions.

He quit vaping one month prior to presentation.

He had a positive COVID-19 test three days prior to admission.

He was hypoxic to 88% on room air in the ED.

He improved to 90% saturation on 3 L nasal cannula.

Venous blood gas revealed a normal venous pH of 7.4.

Venous blood gas revealed an increased PCO2 of 50.

Chest x-ray revealed bilateral airspace disease consistent with known COVID-19 infection.

He required 15 L O2 via high-flow nasal cannula.

His respiratory status continued to decline over the night of admission.

He required BiPAP with a minute volume of 25 L.

He required BiPAP with a respiratory rate of 40.

He was started on ceftriaxone due to SIRS criteria.

He was started on azithromycin due to SIRS criteria.

He was started on ceftriaxone due to an elevated procalcitonin.

He was started on azithromycin due to an elevated procalcitonin.

Oxygen saturation was 92% on 100% FiO2 via ventilator.

Repeat CXR revealed diffuse bilateral interstitial infiltrates.

A SARS-COV-2-IGG antibody was non-reactive.

He received a transfusion of convalescent plasma.

Oxygen saturation was 53% despite maximal ventilatory support.

He was transferred to our institution for ECMO consideration.

Upon arrival, he went directly to the hybrid operating room.

He underwent unremarkable cannulation with no repositioning required.

He was supported on V-V ECMO for 14 days.

He was weaned gradually from the circuit for bedside decannulation on POD 16.

He was maintained on heparin for anticoagulation.

Chart review showed he was never subtherapeutic on unfractionated heparin.

Attempts to remove the cannula at the bedside failed due to immobility of the cannula.

An ultrasound of the right neck was unremarkable.

A longitudinal cutdown from the insertion site proceeding caudally was performed.

The cannula was freely mobile to the level of the first rib and clavicle.

The cannula was not obstructing the vein.

An upper sternotomy, confined to the manubrium, was performed.

The superior vena cava and proximal jugular vein were dissected.

A 2 cm segment of the distal SVC and proximal jugular vein was densely sclerosed and adherent to the cannula.

The vessel was opened across the adherent area at the level of the innominate vein.

The cannula was then able to be withdrawn without difficulty.

There was no evidence of thrombosis at the site of cannula adhesion.

There was no evidence of scarring at the site of cannula adhesion.

There was no evidence of local inflammation at the site of cannula adhesion.

The distal SVC was repaired to the level of the innominate vein entry to the SVC.

The jugular vein was ligated proximally and distally.

The patient had an unremarkable recovery to discharge.

Clinic follow-up demonstrated no sequelae or serious adverse events.

The Crescent catheter was examined by pathology at our institution.

The Crescent catheter was returned to the company.

Neither the catheter nor the company found any defects.

At our institution, we use Avalon, Crescent, and ProTek Duo cannulas.

We have never experienced adhesions with any of the cannulas.

The patient was a 25 y.o. with COVID-19 respiratory failure.

The patient required ECMO support for 16-days.

A 32 Fr crescent cannula became adherent to the SVC and proximal jugular vein.

Ultrasound of the right neck was unremarkable.

The cannula was then able to be withdrawn.

The patient had an unremarkable recovery to discharge.

He had a five-day history of shortness of breath.

He had a five-day history of nasal congestion.

He had a five-day history of loss of taste and smell.

He had a past medical history of asthma.

He had morbid obesity with a BMI of 50.5 kg/m2.

He had no known connective tissue disease.

He had no known hypertrophic scarring reactions.

He quit vaping one month prior to presentation.

He was hypoxic to 88% on room air in the ED.

He improved to 90% saturation on 3 L nasal cannula.

Venous blood gas revealed a normal venous pH of 7.4.

Venous blood gas revealed an increased PCO2 of 50.

He required 15 L O2 via high-flow nasal cannula.

He required BiPAP with a minute volume of 25 L.

He required BiPAP with a respiratory rate of 40.

He was started on ceftriaxone due to SIRS criteria.

He was started on azithromycin due to SIRS criteria.

Oxygen saturation was 92% on 100% FiO2 via ventilator.

A SARS-COV-2-IGG antibody was non-reactive.

He received a transfusion of convalescent plasma.

He was supported on V-V ECMO for 14 days.

He was maintained on heparin for anticoagulation.

An ultrasound of the right neck was unremarkable.

The cannula was not obstructing the vein.

The jugular vein was ligated proximally and distally.

The patient had an unremarkable recovery to discharge.

The Crescent catheter was returned to the company.

Neither the catheter nor the company found any defects.


On the 5th of August, 2020, a 58-year-old woman presented in our emergency department with seizures and hemiparesis.

She had a prior fever, malaise, and dry cough a week before admission.

She has had a history of hypertension since a year ago.

The vital sign is within normal limit except the blood pressure is 170/110 mmHg.

The results of the laboratory test were high blood glucose 254 mg/dL and HbA1C 6.5%.

Leukocytosis with white blood cells (WBC) was 14/L and neutrophil-lymphocyte ratio (NLR) was 33.

Increase level of erythrocyte sedimentation rate (ESR) 93 mm/h, D-dimer 21,176 ng/mL, and fibrinogen 446 mg/dL.

The result of the reverse transcription-polymerase chain reaction (rt-PCR) test from the nasal swab was observed to be positive for SARS-CoV-2.

Head contrast computed tomography (HCCT) showed cerebral edema at the right parietal lobe.

There were hyperdense veins and sinuses at the right parietal lobe area, superior sagittal sinus (SSS), and bilateral transverse sinuses (TS), which suggested the presence of a cerebral sinus venous thrombosis (CSVT), with a sign of venal hypertension.

CT venography (CTV) was also confirmed CSVT at SSS, bilateral TS, and bilateral sigmoid sinus.

The thorax CT scan showed ground-glass opacity and subpleural bilateral, with a fibrotic appearance in the left lung.

During the patient’s treatment of COVID-19, 60 mg subcutaneous enoxaparin was administered twice daily, for 5 days.

On the 5th day of treatment, D-dimer was decreased to 2092 ng/ml.

The decision was made to continue with enoxaparin until the normal D-dimer or the patient’s negative status for the COVID-19 virus is attained.

Other clinical manifestations also improved and the patient was discharged from the hospital on the 10th day.

The second case, a 72-year-old male, was consulted from the intensive care unit (ICU) because of sudden decreases in consciousness.

He had a history of high fever, dry cough, and shortness of breath a week before hospitalization.

The patient was being treated as severe COVID-19 with ARDS for 10 days in ICU.

He had no previous history of hypertension, diabetes mellitus, or cardiovascular disease.

He already received heparin intravenously for 10 days and halted, due to good recovery of shortness of breath and hypoxemia.

A day after heparin cessation, the patient suddenly unconscious and intubated due to severe hypoxia.

Upon examination, his consciousness is coma with a slow response to the light of both eyes.

He had hypothermia with a temperature of 35.4 °C, blood pressure of 140/69 mmHg on vasoconstrictor epinephrine support, and 90% oxygen saturation.

Laboratory test showed, critical increase level of WBC (53.09 × 103/L) and NLR 58.1.

We did not do a peripheral blood smear to examine any hematological disorder.

Coagulation function tests were APTT 20.2 s, PT 11.9 s, INR 1.11, D-dimer 5.308 ng/mL (previous was > 50,000), and fibrinogen 525 mg/dL.

The rt-PCR test from a nasopharyngeal swab sample was negative for SARS-CoV-2 on the 11th day.

Head non-contrast computed tomography (NCCT) showed hyperdense at superior sagittal sinus and right transverse sinuses, which suggested the manifestations of CSVT.

There was associated cerebral edema at the left frontal, parietal lobe, and cerebellum.

Thorax CT scan showed ground-glass opacity and subpleural bilateral with the fibrotic appearance in both lung and pulmonary angiography.

Thrombosis at segments 8 and 9 of both lungs was also observed.

The pulmonary CT-angiography (CTA) results were pulmonary embolism and thrombosis of both the left and right pulmonary arteries.

Due to the massive thrombosis, a decision was made to administer streptokinase and heparin, to the patient intravenously.

After 3 days of this treatment, the patient became desaturated (40% oxygen saturation) with spontaneous pneumothorax and passed away the next day.

Two cases of cerebral sinus venous thrombosis in COVID-19 patients were reported.

The cases were following respiratory, hematology, and coagulation disarrangements.

The disarrangements were triggered by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

The first patient was presented with a seizure.

The first patient had hypertension as a comorbidity.

The first patient had diabetes mellitus as a comorbidity.

The latter case showed more severe presentations of COVID-19 such as brain and lung thrombosis.

The latter case already had several days of intravenous anticoagulant administrations.

These two cases also have a different course of disease and outcomes.

She had a prior fever, malaise, and dry cough a week before admission.

She has had a history of hypertension since a year ago.

On the 5th day of treatment, D-dimer was decreased to 2092 ng/ml.

The patient was being treated as severe COVID-19 with ARDS for 10 days in ICU.

We did not do a peripheral blood smear to examine any hematological disorder.

Thrombosis at segments 8 and 9 of both lungs was also observed.


A 20-year-old man presented to the emergency department after four days of progressively worsening periumbilical pain.

He was moving heavy boxes for his job when he began experiencing pain.

He denied fever, chills, nausea, emesis, weight loss, and recent travel or illness.

Past surgical history included branchial cleft cyst excision as a child.

On abdominal exam, a one square-centimeter erythematous infra-umbilical mass was exquisitely tender to palpation.

Laboratory data on admission demonstrated a WBC count of 10.7 × 103 cells/μL.

The patient underwent diagnostic evaluation for suspected incarcerated umbilical hernia.

CT abdomen/pelvis revealed a four-centimeter segment of organized periumbilical inflammation with central lucency passing the ventral abdominal wall into the anterior abdominal compartment.

There was no evidence of communication with the urinary bladder.

These findings were consistent with an inflamed urachal remnant complicated by abscess.

The patient received intravenous antibiotics in preparation for an operation.

The patient underwent abscess incision and drainage followed immediately by urachal cyst excision through a four-centimeter infra-umbilical midline mini-laparotomy.

The urachal cyst and remnants were dissected inferiorly to confirm no communication with the urinary bladder before total excision.

Investigation of the cyst contents revealed white sebaceous material.

Pathology examined the 4 × 3 x 0.7-centimeter segment of fibromembranous tissue.

Pathology confirmed intraoperative impressions of the specimen.

The patient was admitted to the surgical floor.

The patient noted his pain was markedly improved.

The patient was discharged to home on post-operative day two with adequate pain control.

Two-week follow up in the outpatient surgery clinic confirmed an uncomplicated recovery.

The patient presented with periumbilical pain.

Physical exam showed a warm, erythematous infra-umbilical mass.

The patient underwent urachal abscess incision and drainage.

The patient returned home on postoperative day two.

Two-week outpatient follow-up confirmed an uncomplicated recovery.


The patient's chief complaints were pain and instability on his left knee.

He got injured when playing futsal with knee twisted externally.

He suffered severe pain, swollen and difficult to walk.

The MRI examination after the injury revealed ACL and PCL rupture of the left knee.

He underwent arthroscopic surgical reconstruction for both ACL and PCL by previous surgeon.

Two years after surgery, he felt instability, swollen knee without pain.

On the physical examination, posterior sagging was found.

The quadriceps active test was positive.

The anterior Lachman test for anterior cruciate ligament was negative.

On the MRI, failure of PCL graft with intact ACL was found.

On the MRI and three dimensional CT scan, the tibial tunnel placement done in previous surgery was not placed on its anatomical position.

The tunnel was placed too anterior to the PCL footprint.

We performed the PCL revision reconstruction surgery.

We performed the arthroscopic-assisted reconstruction surgery using transseptal portal approach.

We avoided to use only the jig to guide us when tunnelling the tibia.

We used additional technique to see the posterior aspect of proximal tibia clearly.

We chose to make a transseptal portal that penetrated from posteromedial side of the knee inside-out to the posterolateral side of the knee.

An incision was made on the posteromedial side of the knee with guidance of arthroscopic view and also transiluminatic arthroscopic light.

Blunt obturator with sheath was inserted gently passed through intercondylar notch to posterolateral side of the knee.

During arthroscopy procedure, the PCL was gone with small PCL remnant on femoral site.

The ACL was still intact and adequately attached.

We performed the reconstruction of PCL using peroneus longus tendon as the graft from the left ankle.

When tunneling the tibia, we used jig guide for tibial tunnel placement.

We also made a transseptal portal from medial to lateral in order to get better view of posterior aspect of the tibia.

We used it as the graft because hamstring tendon was already used in previous surgery.

The post-operative X-ray of the left knee showed tibial tunnel was revised to appropriate site of its footprint.

The shadow of two endobuttons on the medial femoral condyle was seen because the endobutton of previous surgery was not removed.

The patient had total rupture of ACL and PCL.

The patient underwent reconstruction for both ACL and PCL.

The failure of the PCL graft occurred 2 years after the surgery.

The failure of the PCL graft was related to the tibial tunnel placement.

The tibial tunnel was placed not in proper anatomical site.

The transseptal portal technique was used to ensure the tibial tunnel is placed in appropriate position.


The patient is a 38-year-old woman in her 19th wk of pregnancy (G2P1).

She was referred to the clinic for a sudden persistent pain on the left side of the waist on July 28, 2017.

The patient’s physical examination revealed tenderness over the left kidney area.

The patient had no significant medical history.

She had not undergone any related abdominal examination previously.

The patient was hospitalized and given conservative treatment.

Her left-side waist pain continued to be intense.

Because the size of the tumor was so large, and the fetal heart rate was unstable, the patient decided to undergo left nephrectomy after the induction of labor.

Laboratory tests indicated that the patient’s hemoglobin level was 80 g/L.

Ultrasound examination of the urinary system revealed a giant nonhomogenous lump in the left kidney area.

The lump had caused the left kidney to move to the midabdomen.

The size of the lump was approximately 159 mm × 100 mm.

The border of the lump was faintly visible.

The lump showed a “striped sign” in which the outer part was hypoechoic with a strong stripe echo.

The inner part near the left kidney was hyperechoic.

A stripe-shaped echoless zone was seen around the lump.

Color Doppler flow image showed some spot-like blood flow signals around the lump.

A hyperechoic nodule was seen in the right kidney with a size of 30 mm × 25 mm.

Preoperative CT showed a large, mixed-density mass in the left kidney.

The density of the area adjacent to the kidney was low.

The area far from the kidney showed high density.

The patient is a 38-year-old woman in her 19th wk of pregnancy.

She was referred to the clinic for a sudden, persistent pain on the left side of the waist.

She had not undergone any previous related abdominal examination.

Ultrasound of the urinary system revealed a giant nonhomogenous lump in the left kidney area.

The diagnosis was considered spontaneous rupture and hemorrhage of the left RAML in pregnancy via ultrasound.

She underwent computed tomography, which led to the same diagnosis.

The patient underwent left nephrectomy after the induction of labor.

The pathological result was the rupture and hemorrhage of a vascular leiomyoma lipoma.