A 65-year-old woman was referred to our hospital for assessment of a gallbladder tumor detected by abdominal ultrasonography.

Contrast-enhanced computed tomography revealed a papillary lesion (25 mm in diameter) in the fundus of the gallbladder.

The boundary between the tumor and liver was unclear.

Endoscopic retrograde cholangiography showed a complete filling defect in the cystic duct.

Serum carcinoembryonic antigen level was 2.1 ng/ml.

Serum carbohydrate antigen 19-9 level was 24 U/ml.

We diagnosed the tumor as gallbladder cancer invading the liver and cystic duct.

We decided to perform extended cholecystectomy.

Intraoperative ultrasonography revealed the tumor did not invade liver obviously.

The intraoperative frozen section of the cystic duct stump and 2 sentinel lymph nodes were negative for malignancy.

Macroscopic examination showed a superficially spreading papillary tumor with thick mucus on its surface.

The gallbladder wall was diffusely thickened.

The tumor was noninvasive and showed no evidence of lymph node metastasis.

These pathological findings were compatible with ICPN.

In immunohistochemical staining, MUC5AC and MUC6 were strongly positive.

CK7 and MUC1 were also positive, but not CK20, MUC2, estrogen receptor, and progesterone receptor.

Immunohistochemistry indicated that ICPN was predominantly gastric type, with focal pancreatobiliary type.

Many lymphocytes and multinucleated giant cells had infiltrated the thickened gallbladder wall with prominent Rokitansky–Aschoff sinuses.

These findings were especially seen at the fundus and were indicative of chronic granulomatous changes within the fundus.

Based on these pathological findings, we diagnosed the tumor as an ICPN concomitant with XGC.

The patient was discharged on postoperative day 8 with no complications.

She was clinically well with no evidence of recurrence at 3 months after resection.

A 65-year-old woman was referred to our hospital for assessment of a gallbladder tumor.

Contrast-enhanced computed tomography showed a papillary tumor in the fundus of the gallbladder.

The gallbladder wall had irregular thickening that spread into the cystic duct.

The patient was diagnosed with gallbladder cancer with liver invasion.

We performed extended cholecystectomy with liver bed resection.

The absence of cancer cells in the resection margin of the cystic duct was confirmed.

After pathological examination, the tumor was diagnosed as an ICPN with xanthogranulomatous cholecystitis.


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 factors including glomerular filtration rate (GFR), proteinuria, and comorbidities such as diabetes and hypertension. Early intervention with pharmacological agents, dietary modifications, and blood pressure control is critical to slow disease progression and reduce cardiovascular risk.

The patient was a 43-year-old Asian man.

He had a 3-year history of progressively invasive PC.

He presented with pain in his right eye.

He had been staged T4N3M1 (TNM classification).

He had lost his vision more than a month earlier.

He was diagnosed as having metastasis in the bilateral inguinal lymph nodes.

He had ipsilateral iliac node metastasis.

He had systemic metastasis to his liver and lungs.

His medical history was remarkable due to several surgeries.

He denied any family history of inherited diseases.

On presentation, his best corrected visual acuity was no light perception in his right eye.

On presentation, his best corrected visual acuity was 20/20 in his left eye.

His intraocular pressure was 13.0 mmHg in his right eye.

His intraocular pressure was 11.0 mmHg in his left eye.

The right eye pupillary reaction disappeared.

An external examination revealed mild proptosis.

A dilated fundus examination of his right eye showed post equatorial retinal detachment.

A dilated fundus examination showed a black eminence.

A dilated fundus examination showed a pale optic disk.

There were no obvious abnormalities in his left eye.

An ophthalmic B-scan ultrasound showed retinal detachment with hemorrhage.

Orbital MRI confirmed thickening and strengthening of the right lateral wall.

The internal rectus and lateral rectus muscles were thickened and hardened.

The 2-cm-long optic nerve was thickened.

The optic nerve stump was invaded by the metastasis.

T1-weighted images showed hyperintensity.

T2-weighted images showed hypointensity.

A contrast-enhanced MRI scan revealed inhomogeneous enhancement of the posterior wall.

The presence of lesions was associated with invasion of the optic nerve.

The presence of lesions was associated with invasion of the choroid.

The presence of lesions was associated with invasion of the sclera.

The deep layer, including the choroid, was infiltrated by cancerous tissue.

The patient had undergone right eyeball enucleation on February 3, 2015.

The procedure was under general anesthesia.

Histopathological examination led to a diagnosis of metastatic moderately differentiated penile squamous cell carcinoma.

The cancer infiltrated external intraocular sites.

Hematoxylin-and-eosin staining showed keratin pearls.

Hematoxylin-and-eosin staining showed infiltrative growth of keratinized cells.

Intercellular bridges were seen in the nests of moderately differentiated squamous carcinoma cells.

The patient received chemotherapy and radiotherapy during 6 months of follow-up.

The patient died due to brain metastasis.

The patient has a 3-year history of penile cancer.

The patient presented with metastasis in the right intraocular sites.

Magnetic resonance imaging showed hyperintensity in the T1-weighted images of the right eye.

Magnetic resonance imaging showed hypointensity in the T2-weighted images of the right eye.

The patient underwent enucleation of his right eye.

Histopathological analysis led to a diagnosis of metastatic, moderately differentiated penile squamous cell carcinoma.

The patient was a 43-year-old Asian man.

He presented with pain in his right eye.

He had been staged T4N3M1 (TNM classification).

He had lost his vision more than a month earlier.

He had ipsilateral iliac node metastasis.

He had systemic metastasis to his liver and lungs.

The right eye pupillary reaction disappeared.

An external examination revealed mild proptosis.

The 2-cm-long optic nerve was thickened.

T1-weighted images showed hyperintensity.

T2-weighted images showed hypointensity.

The procedure was under general anesthesia.

The cancer infiltrated external intraocular sites.

The patient died due to brain metastasis.

**System Role:**

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

**User Prompt:**

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

1. Level: Low Health Literacy (High Readability)

Target: Individuals needing the simplest terms for immediate action.

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

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

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

Faithfulness: Must align perfectly with the Gold Summary.

2. Level: Intermediate Health Literacy (Medium Readability)

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

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

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

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

Faithfulness: Maintains the main narrative of the Gold Summary.

3. Level: Proficient Health Literacy (Low Readability)

Target: Researchers, clinicians, or highly informed patients.

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

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

Strategy: Minimal paraphrasing. Retain all original technical terminology.

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

I will provide the following information:

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

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


The patient has type II diabetes mellitus for 4 years.

The patient has arterial hypertension for 10 years.

The patient developed severe non-proliferative diabetic retinopathy without macular edema 2 years after diabetes diagnosis.

The patient was treated with panretinal photocoagulation.

The patient had poor glycometabolic control.

The patient was unable to adhere to a close follow-up.

One year after panretinal photocoagulation, the patient developed severe visual loss due to diffuse non tractional bilateral diabetic macular edema.

The right eye was treated with an intravitreal triamcinolone injection.

The left eye was treated with an intravitreal triamcinolone injection 1 month after the right eye.

Laser grid photocoagulation was performed in both eyes 2 weeks after intravitreal injection.

After no visual recovery for over 2 months, an intravitreal injection of bevacizumab was given in the right eye.

One week after the bevacizumab injection, anterior ischemic optic neuropathy was observed.

The patient had a residual visual acuity of hand motion.

The patient had glycated hemoglobin >9%.

The patient had poor adherence to therapy.

The patient refused an intravitreal injection of bevacizumab in his left eye.

The patient signed an informed consent for subtenon injections of IFNα.

Before treatment, the best corrected visual acuity in the left eye was 20/200.

The patient received posterior subtenon injections of IFNα three times in one week.

The injections were given on Monday, Wednesday, and Friday.

Topical 0.4% oxybuprocaine surface anesthesia was used.

One ml of IFNα was injected into the inferotemporal quadrant under the Tenon’s capsule.

A 27-gauge needle on a 2.5-ml syringe was used.

Topical 0.3% netilmicin eye drops were prescribed three times a day for 7 days.

The patient had a good systemic condition during IFN-α therapy.

The patient had a glycated hemoglobin of 6.9%.

A complete ophthalmic examination was conducted preoperatively.

A complete ophthalmic examination was conducted 1 week after the last injection of IFNα.

A complete ophthalmic examination was conducted 1 month after the last injection of IFNα.

A complete ophthalmic examination was conducted 4 months after the last injection of IFNα.

A complete ophthalmic examination was conducted 1 year after the last injection of IFNα.

Spectralis OCT was used for macular scans.

Fifteen months after treatment, the best corrected visual acuity in the left eye was 20/40.

The patient gave written consent for the use of his data and images.

The patient had refractory DME to laser grid treatment.

The patient had refractory DME to intravitreal injections of triamcinolone.

The patient received a cycle of three subtenon injections/week of IFNα (1×106 IU/ml).

BCVA and CMT were evaluated preoperatively.

BCVA and CMT were evaluated at 1 week postoperatively.

BCVA and CMT were evaluated at 1 month postoperatively.

BCVA and CMT were evaluated at 4 months postoperatively.

BCVA and CMT were evaluated at 1 year postoperatively.

BCVA was 20/40 at 1 week postoperatively.

CMT was 237 μm at 1 week postoperatively.

BCVA remained stable during the 1-year follow-up.

CMT was 215 μm during the first follow-up visit.

CMT was 255 μm during the second follow-up visit.

CMT was 299 μm during the third follow-up visit.

CMT was still lower than the baseline value during the follow-up visits.

Mild subconjunctival hemorrhage at the injection site was recorded.

The patient has arterial hypertension for 10 years.

The patient had poor glycometabolic control.

The patient had glycated hemoglobin >9%.

The patient had poor adherence to therapy.

A 27-gauge needle on a 2.5-ml syringe was used.

The patient had a glycated hemoglobin of 6.9%.

Spectralis OCT was used for macular scans.


A previously healthy 24-year-old male presented at the emergency department with chest pain and diarrhoea.

The chest pain began 2 h prior to hospital admission.

The chest pain was described as a constant light chest pressure.

The chest pain was without correlation to breathing or body position.

3 days earlier, the patient and a friend had had chicken in a restaurant before boarding a flight to Sweden.

One hour after arrival in Sweden the patient experienced sudden abdominal pain, chills and diarrhoea.

During the following three days the patient had 6 diarrhoeas per day.

The patient had mucous but no visible blood in the stool.

The patient was diagnosed with C jejuni gastroenteritis after stool culture at a primary care facility.

No antibiotics were given at the primary care facility.

Upon admission to the ED the abdominal pain had subsided.

The patient was afebrile (37 °C or 98.6 °F) upon admission.

The patient was still experiencing diarrhoea upon admission.

Heart auscultation showed regular rhythm, no murmurs or extra sounds.

Laboratory examinations showed C-reactive protein at 89.1 mg/L.

Laboratory examinations showed leukocyte count at 11.3 × 109/L.

Laboratory examinations showed high-sensitive Troponin T at 108 ng/L.

ECG showed regular sinus rhythm, 64/min.

The patient was treated with Brufen 200 mg (tid).

The patient was treated with Omeprazol 20 mg (qd).

The patient was treated with Loperamid 2 mg.

The patient was admitted to a cardiac care unit for cardiac monitoring.

During the following 4 days the hsTnT reached a maximum value of 504.

Stool culture confirmed the diagnosis of C jejuni.

Transthoracic echocardiogram showed normal right and left ventricle function.

Transthoracic echocardiogram showed ejection fraction 60–65 %.

Transthoracic echocardiogram showed normal valvular structure and function.

Transthoracic echocardiogram showed no hypokinesia or pericardial effusion.

After one day the ECG-changes had resolved.

The patient was started on ciprofloxacin.

The patient developed urticarial rashes and severe itching.

The treatment with ciprofloxacin was discontinued.

The patient left the hospital after 4 days.

The patient was given a 10 day prescription of Azithromycin 500 mg (qd) upon hospital release.

The diagnosis was determined to be C jejuni-associated perimyocarditis.

At follow-up visit 4 weeks after discharge the patient was without complaints.

At follow-up visit 4 weeks after discharge physical examination was normal.

At follow-up visit 4 weeks after discharge both ECG and TTE were normal.

A previously healthy 24-yo male presented at the Emergency Department with recent onset of chest pain and a 3-day history of abdominal pain, fever and diarrhoea.

The symptoms began within a few hours of returning from a tourist visit to a central European capital.

The Electrocardiogram showed generalized ST-elevation.

Laboratory testing showed increased levels of C-reactive protein and high-sensitive Troponin T.

Transthoracic echocardiogram was normal.

Stool cultures were positive for C Jejuni.

Two days after patient A was admitted to the ED his travel companion, also a previously healthy male, presented at the same ED with almost identical symptoms.

Patient B declared that he and patient A had ingested chicken prior to returning from their tourist trip.

Laboratory tests showed elevated CRP and hsTnT.

In both cases, the diagnosis of C jejuni-associated perimyocarditis was set based on the typical presentation and positive stool cultures with identical strains.

Both patients rapidly improved and were fully recovered at 6-week follow up.

The chest pain began 2 h prior to hospital admission.

ECG showed regular sinus rhythm, 64/min.

The patient was treated with Brufen 200 mg (tid).

The patient was treated with Omeprazol 20 mg (qd).

The patient was treated with Loperamid 2 mg.

Stool culture confirmed the diagnosis of C jejuni.

After one day the ECG-changes had resolved.

The patient was started on ciprofloxacin.

The treatment with ciprofloxacin was discontinued.

The patient left the hospital after 4 days.


A 65 yr old female presented to the ENT clinic with a one-month history of a lump in the right neck.

On examination, a mobile lump was palpable in the angle of the mandible/upper cervical region.

Flexible endoscopy did not reveal any mucosal lesion in the posterior nasal space.

Flexible endoscopy did not reveal any mucosal lesion in the oropharynx.

Flexible endoscopy did not reveal any mucosal lesion in the hypopharynx.

Flexible endoscopy did not reveal any mucosal lesion in the larynx.

Clinically a lymph node mass was considered as a possible diagnosis.

Fine needle aspiration and MRI were performed.

MRI showed a well-defined oval shaped mass measuring 3 × 2 cm just inferior to the right parotid gland.

The epicenter of the lesion was in the intermuscular plane.

The lesion was medial to the sternocleidomastoid muscle but separate from it.

The lesion was heterogeneous on both T1 & T2 W images.

Following contrast administration, there was moderate heterogeneous enhancement.

A differential diagnosis of lymph nodal mass & Spinal Accessory nerve Schwannoma were considered.

FNA of the lesion showed a mix of bland epithelial cell.

The FNA findings were typical of a pleomorphic adenoma.

A decision to perform an excision biopsy was made.

At surgery, the tumor was found to be a pedunculated mass arising from the inferior aspect of the tail of the parotid gland.

The tumor was closely related and superficial to the spinal accessory nerve but separate from it.

The mass was excised completely incorporating a limited cuff of macroscopically normal parotid tissue.

The inferior branches of the facial nerve were not injured.

Histopathology showed uniform proliferation of epithelial elements within a partially myxo-chondroid stroma.

The histopathology findings were consistent with a diagnosis of a pleomorphic adenoma.

There was no definite salivary gland tissue within the specimen.

We present a case of a pleomorphic adenoma arising from the 'tail' of the parotid gland.

On imaging, the tumor appears to be extra parotid in location.

We review the anatomy of the parotid 'tail'.


The patient is a 49-year-old Japanese man.

He visited the department in November 2017.

His chief complaints were indolent right scrotum enlargement and a right inguinal mass.

He had a history of blackish feces and ill complexion in February 1997.

Gastrointestinal fiberscopy was used to treat duodenal ulcer bleeding.

Computed tomography showed a right retroperitoneal tumor.

The tumor was removed in the same month as the CT scan.

Histopathological examination showed a teratoma and yolk sac tumor.

He was diagnosed with primary retroperitoneal EGCT.

He underwent three courses of chemotherapy starting in May 1997.

The chemotherapy regimen was bleomycin/etoposide/cisplatin (BEP).

He was followed using periodic imaging, tumor markers determination, and self-palpation.

He was followed up on an outpatient basis 5 years after treatment.

In August 1999, he underwent surgery of the right hydrocele.

Perioperative findings were unremarkable.

There was no clear tumor in either testicle at the time of hydrocele surgery.

At the first visit, his height was 163 cm.

Heart rate was regular at 62 beats per minute.

He had no history of smoking or drinking.

There was nothing remarkable in the family history.

On physical examination, the right testicle was elastic, hard, and enlarged to 40 × 40 mm.

A 45 × 40 mm sized induration was palpable in the right inguinal area.

The inguinal induration was adequately mobile.

Neurological examination showed no abnormal findings.

Blood biochemistry, urinalysis, and tumor markers showed no abnormal findings.

Ultrasound showed a mosaic shadow inside the right testicle.

The left testicle showed no abnormal findings on ultrasound.

Enlargements of the right external iliac lymph node (24 × 14 mm) and right inguinal lymph node (43 × 29 mm) were found.

A 31 × 22 mm mass with uneven contents was found in the right testicle.

There was no evidence of distant metastasis.

The patient underwent high orchiectomy and resection of the right inguinal lymph nodes in November 2017.

The testicular tumor was 40 × 40 × 30 mm in size and weighed 34 g.

The lymph node was 40 × 40 × 30 mm in size and weighed 21 g.

The cut surfaces of both specimens were yellowish and solid.

The testicular tumor was localized in the testicle.

Histopathological findings showed irregular cobblestone proliferations of germ cell-like atypical cells with clear nucleoli.

Massive necrotic changes were present in the tumor.

The tumor did not extend into the tunica albuginea.

The tumor diagnosis was a classical seminoma with no other elements.

Lymph node metastases were diagnosed as a result of the seminoma.

The seminoma was diagnosed as pT1, pN2, M0, S0.

The patient received one course of BEP therapy and three courses of EP therapy.

Post-chemotherapy CT confirmed a complete clinical response at the right external iliac lymph node.

The complete clinical response continued 12 months later.

The patient is a 49-year-old Japanese man.

He visited the department in November 2017.

He had visited the department of gastroenterology in February 1997.

He was diagnosed with primary retroperitoneal EGCT.

He received three courses of chemotherapy.

The patient is a 49-year-old Japanese man.

He visited the department in November 2017.

He was diagnosed with primary retroperitoneal EGCT.

Perioperative findings were unremarkable.

At the first visit, his height was 163 cm.

Heart rate was regular at 62 beats per minute.

He had no history of smoking or drinking.

There was nothing remarkable in the family history.

The inguinal induration was adequately mobile.

Neurological examination showed no abnormal findings.

There was no evidence of distant metastasis.

The testicular tumor was localized in the testicle.

Massive necrotic changes were present in the tumor.

The tumor did not extend into the tunica albuginea.

The seminoma was diagnosed as pT1, pN2, M0, S0.


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.

She was admitted with a progressively enlarged mass in the rectovaginal space for 9 years.

The mass was found during a routine examination 9 years ago.

No obvious progression was seen in following annual examinations until a year ago.

The maximum diameter of the mass had significantly grown from 4.0 cm to 9.7 cm in a year.

Dents in stools were caused by tumor compression.

Endoscopy in a local hospital showed a submucosal protrusion.

No absolute tumor tissue but only inflammation was found after several times of endoscopic biopsies in the latest 2 years.

The patient had no previous medical history.

The patient and family had no history of previous similar illness.

The anterior rectum wall was plump during digital rectal examination.

Contrast-enhanced CT showed a mass with liquefaction necrosis inside the rectovaginal space.

Transabdominal US showed a heterogeneous hypoechoic mass with a maximum diameter of 9.7 cm in the rectovaginal space.

The mass was suspected to be a rectal GIST or exophytic uterine fibroid.

Transabdominal CNB was performed to make a definite diagnosis.

Written informed consent was obtained from the patient before the operation.

Some hemorrhage occurred from the vagina, causing premature end of the biopsy.

The hemorrhage spontaneously relieved several days later.

Strips of greyish shattered tissue were obtained, with the largest diameter smaller than 0.3 cm.

Pathology indicated inadequate biopsy tissue for diagnosis.

Another biopsy after ERUS assessment was recommended by multiple disciplinary treatment.

ERUS was performed with the MyLab Twice US system.

CEUS was performed with a bolus injection of 2.4 mL SonoVue.

CEUS was performed right before puncture to confirm the substantial part of the tumor for biopsy guidance.

The transperineal puncture site and path were decided.

A freehand biopsy of the lesion was performed with the guidance of in-plane needle.

The needle tip and its movements were continuously monitored in real time by ERUS during the whole puncture procedure.

Several strips of greyish tissue were obtained with a length of 0.3-1.2 cm.

She complained of a mass inside the rectovaginal space for 9 years.

The rectal SEL was suspected to be a gastrointestinal stromal tumor.

The rectal SEL was suspected to be an exophytic uterine fibroid.

A transabdominal core needle biopsy was unsuccessful.

The transabdominal core needle biopsy resulted in insufficient tissues.

A second biopsy was suggested after multiple disciplinary treatment discussion.

A transperineal core needle biopsy was guided by ERUS combined with CEUS.

The pathological diagnosis was rectal gastrointestinal stromal tumor.

Imatinib was recommended for first-line therapy.

Resection of the rectal gastrointestinal stromal tumor was performed through the posterior vaginal wall.

No recurrence or metastasis has been found by the last follow-up on December 13, 2019.

The patient had no previous medical history.


The patient presented with pain in the lower left posterior region of the mandible.

The patient had no significant systemic history.

The patient reported no previous extractions in the mentioned area.

Clinical examination revealed the absence of Teeth 37 and 38.

Palpation of the alveolar ridge showed no swelling or bony prominences.

Radiographic examination revealed that Tooth 37 was impacted transversely between Teeth 36 and 38.

Tooth 38 was in a vertical position close to the occlusal plane.

Tomographic imaging indicated that the crown of Tooth 37 was oriented lingually.

The mesial root of Tooth 37 was curved and thin.

The distal root of Tooth 37 was straight and thick.

The diagnosis was an impacted Tooth 37 in a transverse position with the crown oriented lingually.

Tooth 38 was retained in a vertical position.

A consultation with the orthodontics department was made to define the treatment plan.

Flap extraction of Tooth 37 was planned.

Subsequent eruption of Tooth 38 was planned.

Fixed orthodontic treatment was planned.

The ultimate goal was to restore masticatory function by positioning the third molar in place of the second molar.

The patient was informed regarding the surgical procedure.

The patient was informed regarding the risks associated with the procedure.

The patient was informed regarding the alternative treatments.

The patient signed the informed consent.

The surgical intervention for flap extraction of Tooth 37 was scheduled.

The procedure involved block anesthesia for the inferior alveolar nerve.

The procedure involved block anesthesia for the lingual nerve.

The procedure involved block anesthesia for the buccal nerve.

An L-shaped or monoangular incision was made at the level of the second molar.

The mucoperiosteal flap was elevated to expose the bone plate.

An osteotomy was performed in the occlusal bone to visualize the crown of the second molar.

The separated roots were sectioned for removal.

The distal segment (crown and root) was extracted first.

The mesial segment (crown and root) was removed after the distal segment.

Both segments were luxated with a flag elevator.

An alveolar curette was used to clean the bony crypt corresponding to the crown.

The procedure was completed with discontinuous suturing using 3/0 polyglycolic acid.

The extracted molar was observed in two parts.

Amoxicillin 500 mg every 8 h for 5 days was prescribed.

Sodium diclofenac 50 mg every 8 h for 3 days was prescribed.

Dexamethasone 4 mg every 8 h for 3 days was prescribed.

The patient was evaluated 6 months after the surgical intervention.

Bone healing was favorable according to an x-ray.

The report confirms 'alveolar walls preserved, no evidence of spicules or bony defects; defined borders, no radiographic signs of osteitis'.

The patient presented with pain in the lower left molar region.

Tomographic imaging showed Tooth 37 in a transverse position.

Tomographic imaging showed the crown of Tooth 37 oriented lingually.

Tomographic imaging showed Tooth 38 in a vertical position.

A vestibular approach was used for the extraction of Tooth 37.

Odontectomy was performed for the extraction of Tooth 37.

Space constraints were a factor in the extraction of Tooth 37.

The patient had no significant systemic history.

The mesial root of Tooth 37 was curved and thin.

The distal root of Tooth 37 was straight and thick.

Tooth 38 was retained in a vertical position.

Flap extraction of Tooth 37 was planned.

Subsequent eruption of Tooth 38 was planned.

Fixed orthodontic treatment was planned.

The patient signed the informed consent.

The separated roots were sectioned for removal.

Both segments were luxated with a flag elevator.

The extracted molar was observed in two parts.

Amoxicillin 500 mg every 8 h for 5 days was prescribed.

Dexamethasone 4 mg every 8 h for 3 days was prescribed.

Bone healing was favorable according to an x-ray.


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.

The patient has a past medical history significant for diabetes mellitus.

The patient has a past medical history significant for coronary artery disease.

The patient has a past medical history significant for chronic hypotension.

The patient has a past medical history significant for chronic obstructive pulmonary disease.

The patient has a past medical history significant for obstructive sleep apnea.

The patient has a past medical history significant for peripheral artery disease.

The patient presented to the ED with right buttock and scrotal swelling for three days.

The patient reported generalized weakness.

The patient reported shortness of breath.

The patient reported urinary retention with dysuria.

The patient noticed non-traumatic bruising to his scrotum one day prior to presentation.

The patient reported increasing buttock pain not controlled by home oxycodone/acetaminophen 5/325 mg tablets.

Upon arrival, the patient's oral temperature was 38.2°C.

The patient's blood pressure was 119/54 mm Hg.

The patient's heart rate was 93 beats per minute.

The patient's respiratory rate was 25 breaths per minute.

The patient's oxygen saturation was 97% on room air.

The physical examination was notable for an ill-appearing gentleman.

Heart sounds were unremarkable aside from tachycardia.

The abdominal examination was soft, protuberant, and nontender.

A focused genitourinary examination revealed an edematous, erythematous, and exquisitely tender scrotum.

There was a coin-sized, ecchymotic-appearing lesion on the scrotum.

Erythema and induration extended from the scrotum and perineum to the right buttock.

No crepitus or fluctuance was palpated on examination.

Laboratory results were remarkable for leukocytosis to 15,000 K/mm3.

The patient had lactic acidosis of 3.4 mmol/L.

The patient had marked acute kidney injury with creatinine of 5 mg/dL.

The patient had a venous blood gas pH of 7.22.

The patient was mildly hyponatremic at 133 mmol/L.

The patient was hyperkalemic at 5.3 mmol/L.

Emergent consultations with surgery and urology were obtained.

The patient decompensated into septic shock.

The patient's blood pressure decreased to 88/41 mm Hg during the ED course.

The patient was not stable for transport or advanced imaging.

The ecchymotic-appearing lesion and edema had expanded across his scrotum and perineum.

POCUS was used for the rapid assessment of the patient’s presumed clinical diagnosis of Fournier’s gangrene.

Transverse and sagittal views of the perineum and scrotum were obtained using a high-frequency linear probe.

The POCUS imaging revealed diffuse hyperechoic foci with posterior 'dirty' shadowing, representative of subcutaneous air.

The POCUS imaging revealed small fluid collections tracking along the fascial planes.

The patient was taken directly from the ED to the operating room for immediate surgical debridement.

An area of tissue measuring 25 cm × 30 cm was debrided from the scrotum, perineum, and right buttock.

Dark, necrotic tissue and foul-smelling fluid were noted during surgery, consistent with Fournier’s gangrene.

The patient was admitted to the intensive care unit.

The patient was transferred to a tertiary care center.

The patient ultimately died of complications related to his illness.

POCUS was used to rapidly confirm diagnosis.

The patient presented to the emergency department.

The patient reported generalized weakness.

The patient reported shortness of breath.

The patient reported urinary retention with dysuria.

The patient's blood pressure was 119/54 mm Hg.

The patient's heart rate was 93 beats per minute.

The patient's oxygen saturation was 97% on room air.

Heart sounds were unremarkable aside from tachycardia.

No crepitus or fluctuance was palpated on examination.

The patient had lactic acidosis of 3.4 mmol/L.

The patient had a venous blood gas pH of 7.22.

The patient was mildly hyponatremic at 133 mmol/L.

The patient was hyperkalemic at 5.3 mmol/L.

The patient decompensated into septic shock.

The patient was admitted to the intensive care unit.

The patient was transferred to a tertiary care center.


The patient is on long-term parenteral nutrition.

The patient presented on 3 occasions with central venous catheter infection due to Bacillus species.

On each occasion, she had fever after flushing of the central venous catheter.

She had initially presented in the first few months of life with chronic watery diarrhoea.

She was found to have tufting enteropathy.

Tufting enteropathy is a rare congenital enteropathy.

Tufting enteropathy requires indefinite dependence on parenteral nutrition from early infancy.

The child is on regular parenteral nutrition.

The child has had no previous history of significant infections, except for central venous catheter infections with coagulase negative staphylococci.

Immunoglobulins, neutrophil and lymphocyte counts were within the normal range.

There was no history of significant trauma, injuries or skin infections prior to this episode, except a small cut on her finger.

The small cut on her finger healed very well.

There is no history of contact with plant growth products.

There is no history of contact with animal probiotics.

The child presented with fever and rigors to her local hospital.

Bacillus species was isolated from blood taken from the central venous catheter.

The organism was reported sensitive to flucloxacillin.

She was treated with 4 weeks of intravenous flucloxacillin.

Bacteraemia had persisted despite 14 days of treatment.

The child was transferred to our hospital with recurrence of fever and rigors.

Empirical treatment was started with intravenous cefotaxime and flucloxacillin.

Bacillus species was isolated from central venous catheter cultures both before and whilst on cefotaxime and flucloxacillin.

The organism was later identified as Bacillus pumilus at the National Reference Laboratory.

The methods used to identify the organism included gram stain to determine whether spores are produced.

The methods used to identify the organism included a short biochemical profile based on ammonia salt sugars, Lecithinase and mannitol.

Bacillus pumilus is lecithinase negative.

The methods used to identify the organism included DNA sequencing.

Bacillus pumilus was reported to be sensitive to vancomycin.

Bacillus pumilus was reported to be sensitive to erythromycin.

There were concerns that the patient had previously reacted to systemic vancomycin.

Antibiotics were changed to intravenous clindamycin with vancomycin line locks given for 2 weeks.

Blood cultures, taken both during and after this treatment, were negative.

Echocardiography showed no evidence of vegetations at the tip of the catheter or in the heart.

Ten days after stopping the intravenous antibiotics the child presented for the third time with fever and rigors.

A Bacillus species was again grown from blood taken from the central venous catheter.

The central venous catheter was removed after 5 days treatment with intravenous vancomycin.

A new central venous catheter was inserted.

Subsequent blood cultures were negative.

There has been no recurrence of further fever or infections over a 9-month period.

We report a case of central venous catheter infection with Bacillus pumilus in an immunocompetent child with tufting enteropathy on long-term parenteral nutrition.

There were three episodes of central venous catheter infection with Bacillus pumilus in three months.

Despite adequate and appropriate use of intravenous antibiotics, the infection failed to clear.

The infection resulted in the need for removal of the catheter for complete cure.

The patient is on long-term parenteral nutrition.

She was found to have tufting enteropathy.

Tufting enteropathy is a rare congenital enteropathy.

The child is on regular parenteral nutrition.

The small cut on her finger healed very well.

There is no history of contact with animal probiotics.

The organism was reported sensitive to flucloxacillin.

Bacillus pumilus is lecithinase negative.

A new central venous catheter was inserted.

Subsequent blood cultures were negative.


The patient is a 55-year-old lady of Central African origin.

The patient has primary open-angle glaucoma.

The patient underwent bilateral XEN gel surgery.

The patient was referred with intraocular pressures of 38 mm Hg in the right eye.

The patient was referred with intraocular pressures of 22 mm Hg in the left eye.

The patient had been diagnosed with POAG several years before.

The patient had two selective laser trabeculoplasties.

The patient was on maximal medical therapy including oral acetazolamide.

The patient had mediocre self-reported compliance.

The patient had a positive family history for open-angle glaucoma in her mother.

Best-corrected visual acuity was 10/10 in both eyes.

Cup/disk ratio was 0.8 in the right eye with an inferior notch.

Cup/disk ratio was 0.7 in the left eye with a superior notch.

Gonioscopy showed bilaterally open angles.

Automated visual field examination showed bilateral nasal quadrantanopsia.

Optical coherence tomography imaging showed generally reduced RNFL thicknesses bilaterally.

Bilateral mitomycin C-augmented XEN gel stent implantation was organized.

Surgeries were performed following standard protocols described in the literature.

No intraoperative complications were noted.

The patient received topical combined tobramycin and dexamethasone.

The right eye had IOP normalizing between 12 mm Hg and 16 mm Hg at 3 months.

The left eye developed a 2-mm hyphema on the first day following surgery.

The initial intraocular pressure in the left eye was 2 mm Hg.

The hyphema in the left eye had completely resolved after 8 days.

IOP was stable at 12 mm Hg after 8 days.

After 1 month, the patient presented with an IOP of 50 mm Hg in the left eye.

The filtration bleb was shallow but diffuse.

An emergency revision procedure was organized.

The absence of filtration through the stent was confirmed intraoperatively.

The tube was sent for macroscopic analysis.

The patient made good recovery without any postoperative complications.

At 1-month, her IOP was stable at 17 mm Hg.

Macroscopic examination confirmed obstruction of the XEN gel stent on its AC extremity.

Translucent cell fragments were identified within the obstructed tube.

The left eye developed a 2 mm postoperative hyphema.

The hyphema resolved spontaneously within 8 days.

Intraocular pressure normalized at 12 mm Hg.

Intraocular pressure increased to 50 mm Hg after 1 month.

Intraoperative examination revealed a nonfunctioning XEN gel stent.

The stent was replaced and sent for laboratory analysis.

Macroscopic examination of the tube confirmed obstruction with cellular debris.

Tube replacement restored good filtration.

The patient has primary open-angle glaucoma.

Gonioscopy showed bilaterally open angles.

No intraoperative complications were noted.

IOP was stable at 12 mm Hg after 8 days.

The filtration bleb was shallow but diffuse.

The tube was sent for macroscopic analysis.

At 1-month, her IOP was stable at 17 mm Hg.


The patient was a 49-year-old man with a history of acromegaly.

He was admitted with recurrent shortness of breath and dyspnea on exertion during the previous 2 years.

He had experienced an episode of presyncope 2 weeks prior.

He had no past history of hypertension, diabetes mellitus, sleep apnea, or sudden cardiac death.

He had a history of stereotactic radiosurgeries twice in a decade or so.

He was adherent to treatment with octreotide 40 mg once per month through intramuscular injection.

He was 1.85 m tall, weighed 134 kg, and had a body mass index of 39 kg/m2.

His heart rate was 92 beats/min with sinus rhythm.

He had prominent superciliary arches and nose bridge.

He had enlargement of the tongue and lip.

Cardiac auscultation revealed irregular premature beats.

An electrocardiogram demonstrated sinus rhythm with wide (160 ms) QRS duration of left bundle branch block.

The patient’s condition was classified as New York Heart Association stage III–IV.

Magnetic resonance imaging showed pituitary macroadenoma.

Blood testing showed an elevated brain natriuretic peptide level of 740 pg/ml.

Hormone laboratory tests demonstrated excessive secretion of GH and IGF-1, twofold greater than the reference normal upper limit.

A Holter monitor showed frequent ventricular premature beats.

A chest x-ray showed a cardiothoracic ratio of 78%.

Echocardiography showed diffuse impairment of left ventricular systolic motion, reaching an LVEF of 16%.

The right ventricle and atrium and the left atrium were dilated.

There was moderate mitral regurgitation.

There was no associated systolic anterior motion of the mitral valve.

Coronary angiography showed normal coronary arteries without stenosis.

Left ventriculography revealed an EF of 20% with diffuse LV hypokinesis.

Acromegaly-induced cardiomyopathy was confirmed.

The patient was diagnosed with secondary dilated cardiomyopathy due to acromegaly.

The patient was diagnosed with congestive heart failure secondary to acromegaly-induced dilated cardiomyopathy.

The mainstay of treatment acknowledged globally is surgical resection of the pituitary adenoma.

Surgical resection was considered high-risk given the patient’s cardiac condition.

The patient was administered diuretics, vasodilators, an ACEI, β-blockers, and spironolactone.

Octreotide (200 μg/day) was administered for the control of GH excess.

After half a year, the serum GH concentration decreased from 32.50 ng/ml to 1.98 ng/ml.

The patient was hospitalized again because of uncontrollable cardiac failure.

Echocardiography showed a recovered EF value from 16% to 28%.

A significant ventricular mechanical dyssynchrony was detected.

Electrophysiological study revealed a nonsustained ventricular monomorphic tachycardia.

We recommended cardiac resynchronization therapy with defibrillator implantation.

The patient was discharged to home 5 days after CRT insertion.

The patient claimed symptom improvement following device insertion 1 month later.

Echocardiography at the last visit identified improved LVEF of 54%.

A chest x-ray showed reduced CTR of 60%.

The patient was in NYHA functional class II.

The patient has a history of acromegaly.

The patient presented with decompensated systolic heart failure.

Serial electrocardiograms showed wide (160–200 ms) QRS duration.

Echocardiography showed severe left ventricular dysfunction.

The left ventricular ejection fraction was 16%.

Surgical indication was rarely assessed by neurosurgeons.

Stereotactic radiosurgery together with pharmacotherapy produced infinitesimal effects.

Cardiac resynchronization therapy was performed.

The patient’s symptoms were successfully alleviated.

The patient was discharged from the hospital.

He had experienced an episode of presyncope 2 weeks prior.

His heart rate was 92 beats/min with sinus rhythm.

He had prominent superciliary arches and nose bridge.

He had enlargement of the tongue and lip.

Cardiac auscultation revealed irregular premature beats.

Magnetic resonance imaging showed pituitary macroadenoma.

A chest x-ray showed a cardiothoracic ratio of 78%.

There was moderate mitral regurgitation.

Acromegaly-induced cardiomyopathy was confirmed.

Echocardiography showed a recovered EF value from 16% to 28%.

A chest x-ray showed reduced CTR of 60%.

The patient was in NYHA functional class II.


The patient is a 42-year-old Native American female.

She presented to University of South Dakota Sanford Medical Center in December of 2020.

She developed numbness, tingling, and a sharp shooting pain in both arms immediately following parathyroidectomy for parathyroid adenoma.

The numbness, tingling, and pain were worse in the right arm.

The symptoms radiated across the upper back and chest.

Medical history was significant for a traumatic SCI caused by a motor vehicle collision at the age of 15.

She experienced paralysis of her bilateral lower extremities, classified by the American Spinal Injury Association (ASIA) as an ASIA B injury.

Her injury required thoracolumbar stabilization with Harrington rods.

She was only able to ambulate with a walker.

She did not report any history of upper extremity symptoms prior to parathyroidectomy.

Examination was significant for morbid obesity with a body mass index (BMI) of 51.

She had decreased temperature and light touch sensation in the upper extremities and neck in dermatomes C3 through T10.

Proprioception and vibration sense were preserved.

Hypocalcemia was suspected as a cause of her paresthesias.

Cervical MRI 2 days after symptoms onset demonstrated a T2 signal hyperintense area, just to the right of midline, that extended throughout the length of the central cervical spinal cord.

The MRI was consistent with an expanding syrinx.

Thoracic MRI showed the syrinx extended throughout the thoracic spinal cord as well.

The reading radiologist initially misread this MRI as longitudinally extensive transverse myelitis.

The radiologist specifically reported that they did not believe this was a syrinx because it was located in the lateral aspect of the spinal cord rather than in the central spinal cord canal.

There was mild peripheral contrast-enhancement around the syrinx.

An extensive infectious, autoimmune, and metabolic workup was negative.

A working diagnosis of longitudinal extensive transverse myelitis was made.

The patient was treated with 5 days of intravenous methylprednisolone.

Repeat cervical MRI 2 weeks after symptom onset revealed no changes from the previous MRI.

Six months after discharge, the patient presented to our neurology clinic for increasing weakness in the lower extremities.

She had worsening dexterity of her right hand.

These symptoms had progressed to the point of requiring her to move to an assisted living facility.

On examination, there was new pronator drift.

There was decreased right hip flexion strength.

There was decreased reflexes in the right upper extremity.

Based on the patient’s current and previous symptoms along with the previous imaging, we were able to arrive at a diagnosis of PTS, which had previously been missed.

Cervical MRI was repeated and showed rostral expansion of the syrinx into the brain stem.

With the advancement of her symptoms and growth of the syrinx into the brainstem, the patient received an urgent referral to an outside facility for neurosurgical evaluation.

The consulting neurosurgeon at the outside facility did not believe her condition warranted hospital admission.

The patient was not seen by the neurosurgeon for another 6 weeks.

During that time period, the patient became progressively weaker.

She developed a hoarse voice, concerning for vocal cord paralysis.

She developed dysphagia with several episodes of choking.

On evaluation at the outside facility, the evaluating neurosurgeon concluded that the patient’s symptom severity and rapid progression were indications for surgical drainage of the syrinx.

The patient was taken to the operating room, and a C7-T2 laminectomy was performed.

After removing the C7 through T2 lamina and entering the dura, the cord was noted to be quite dilated, nearly filling the entire dural tube.

The cord was rotated 90° within the dura.

A 2 mm hole was made in the dorsal root entry zone of the cord below the C8 nerve root to insert the shunt.

The syrinx cavity was encountered at a depth of <1 mm.

The cord immediately deflated after penetration of the syrinx.

A syringo-subarachnoid shunt was placed to allow the syrinx to continuously drain.

The surgery and immediate postsurgical period were uncomplicated.

She was discharged back to her previous nursing home 9 days following the operation.

The patient was ambulating back at her baseline with a walker.

Follow-up 2 months after surgery noted subjective persistent but not worsened right arm and leg weakness.

At this point, the patient was able to complete her ADLs independently although she had assistance at home.

It was determined that the surgery stabilized as well as halted the progression of her neurological symptoms but did not reverse them.

Cervical MRI 4 months after surgery showed dramatic reduction in syrinx size, with only a small residual fluid collection.

This confirmed that the shunt was patent and functioning.

Thoracic MRI showed possible persistent syringomyelia with slight enlargement compared to previous.

This was significantly limited due to hardware artifact.

The patient continues to live in a nursing home with assistance with her ADLs and frequent physical therapy.

Patient consent and hospital approval were obtained before the writing of this report.

She has a distant history of spinal cord injury.

She developed clinical and imaging findings consistent with acute expansion of post-traumatic syringomyelia.

The acute expansion occurred immediately following parathyroidectomy.

Her symptoms included acute numbness, tingling, and pain in both arms.

Magnetic resonance imaging revealed a syrinx in the cervical and thoracic spinal cord.

The syrinx was initially misdiagnosed as transverse myelitis.

She was treated for transverse myelitis without resolution of symptoms.

Over the following 6 months, the patient experienced progressive weakness.

Repeat MRI demonstrated expansion of the syrinx with new involvement of the brain stem.

The patient was diagnosed with post-traumatic syringomyelia.

She was referred for outpatient neurosurgery evaluation at a tertiary facility.

Treatment was delayed due to problems with housing and scheduling at the outside facility.

A syringo-subarachnoid shunt was placed.

Follow-up MRI confirmed correct placement of the shunt.

The procedure effectively halted symptom progression.

The procedure did not resolve all symptoms completely.

The patient has regained her ability to perform much of her activities of daily living.

The patient remains in a nursing home facility.

The patient is a 42-year-old Native American female.

The numbness, tingling, and pain were worse in the right arm.

The symptoms radiated across the upper back and chest.

Her injury required thoracolumbar stabilization with Harrington rods.

She was only able to ambulate with a walker.

Examination was significant for morbid obesity with a body mass index (BMI) of 51.

Proprioception and vibration sense were preserved.

Hypocalcemia was suspected as a cause of her paresthesias.

The MRI was consistent with an expanding syrinx.

Thoracic MRI showed the syrinx extended throughout the thoracic spinal cord as well.

There was mild peripheral contrast-enhancement around the syrinx.

An extensive infectious, autoimmune, and metabolic workup was negative.

A working diagnosis of longitudinal extensive transverse myelitis was made.

The patient was treated with 5 days of intravenous methylprednisolone.

She had worsening dexterity of her right hand.

On examination, there was new pronator drift.

There was decreased right hip flexion strength.

There was decreased reflexes in the right upper extremity.

The patient was not seen by the neurosurgeon for another 6 weeks.

During that time period, the patient became progressively weaker.

She developed a hoarse voice, concerning for vocal cord paralysis.

She developed dysphagia with several episodes of choking.

The patient was taken to the operating room, and a C7-T2 laminectomy was performed.

The cord was rotated 90° within the dura.

The syrinx cavity was encountered at a depth of <1 mm.

The cord immediately deflated after penetration of the syrinx.

A syringo-subarachnoid shunt was placed to allow the syrinx to continuously drain.

The surgery and immediate postsurgical period were uncomplicated.

She was discharged back to her previous nursing home 9 days following the operation.

The patient was ambulating back at her baseline with a walker.

This confirmed that the shunt was patent and functioning.

This was significantly limited due to hardware artifact.

She has a distant history of spinal cord injury.

The acute expansion occurred immediately following parathyroidectomy.

Her symptoms included acute numbness, tingling, and pain in both arms.

The syrinx was initially misdiagnosed as transverse myelitis.

She was treated for transverse myelitis without resolution of symptoms.

Over the following 6 months, the patient experienced progressive weakness.

The patient was diagnosed with post-traumatic syringomyelia.

She was referred for outpatient neurosurgery evaluation at a tertiary facility.

A syringo-subarachnoid shunt was placed.

Follow-up MRI confirmed correct placement of the shunt.

The procedure effectively halted symptom progression.

The procedure did not resolve all symptoms completely.

The patient remains in a nursing home facility.


The patient was admitted to the General Surgery Department.

The patient had local abdominal distension in the left lower flank.

The patient had intermittent abdominal pain for one year.

The patient had undergone laparoscopic rectal resection one year ago.

Five trocars were used during the laparoscopic rectal resection.

A 10 mm trocar was inserted at the umbilical site.

Two 5 mm trocars were placed in the left flank.

A 12 mm trocar and a 5 mm trocar were placed in the right flank.

Fascia layers were closed by an absorbable suture at the ≥ 10 mm trocar site.

A 20 FR soft rubber tube was inserted in the left lower quadrant stoma port.

The drainage tube was removed five days postoperatively.

The fascia layer at the drain site was not closed due to a tiny defect.

The patient was discharged on the ninth day after the operation.

The patient reported no discomfort postoperatively.

One month later, there was abdominal bulging in the left lower flank in the standing position.

The abdominal bulge disappeared in the supine position.

The patient felt a gradual progression of the abdominal bulge.

The patient had occasional dull abdominal pain over time.

The patient had a history of chronic bronchitis.

The patient had a history of hypertension.

The patient had a history of coronary heart disease.

The patient had a history of laparoscopic cholecystectomy.

The patient's blood pressure was well controlled.

There were no cardiovascular system symptoms.

There were no restrictions on the patient's daily activities.

The patient had no remarkable personal and family history.

A local palpable mass (3 cm in length) was found in the left lower flank above the former drain-site.

An abdominal wall defect (2 cm in length) was found.

Tenderness and rebound tenderness were not observed in the abdomen.

Routine serological examinations showed no obvious abnormalities.

A preoperative computed tomography scan confirmed the diagnosis.

The computed tomography scan showed an abdominal wall hernia at the drainage site in the left lower quadrant.

The hernia content consisted of the omentum majus.

The detected abdominal wall fascial defect was 2 cm in diameter.

The patient was admitted with intermittent abdominal pain.

The abdominal mass occurred one month after laparoscopic radical resection of rectal cancer.

The rectal cancer resection had occurred one year before admission.

A computed tomography scan showed an abdominal wall hernia at the 5 mm former drain-site in the left lower quadrant.

The hernia content consisted of the large omentum.

An elective herniorrhaphy was performed.

The fascial defect was closed during the herniorrhaphy.

The abdominal wall was reinforced with a synthetic mesh.

The postoperative period was uneventful.

The patient was discharged seven days after the operation.

There were no surgery-related complications at the 1-mo follow-up visit.

A 10 mm trocar was inserted at the umbilical site.

Two 5 mm trocars were placed in the left flank.

The patient had a history of chronic bronchitis.

The patient had a history of hypertension.

The patient's blood pressure was well controlled.

There were no cardiovascular system symptoms.

The hernia content consisted of the omentum majus.


She presented with non-progressive congenital flexion deformities of bilateral elbows.

She had difficulty in using the Indian toilet.

She had to sit with one leg extended for balance.

She was the firstborn child of a second-degree consanguineous marriage.

Her mother gave a history of delayed and decreased fetal movements during pregnancy.

Her social adaptive and language milestones were normal.

She had attained menarche at the age of 12 years.

On clinical examination, she had prominence in the suprascapular region on both sides.

She had mild-to-moderate restriction of cervical spine range of motion in rotation and lateral bending.

She had 20° of internal rotation deformity bilaterally.

Abduction was restricted to 120° at both the shoulders.

She had 22° of fixed flexion deformity at the left elbow.

She had 20° of fixed flexion deformity at the right elbow.

Bilateral passive forearm supination was restricted to 60°.

Bilateral passive wrist dorsiflexion was restricted to 35°.

Clinodactyly was noticed in bilateral ring fingers.

Her fingers were hyperextensible at the interphalangeal joints.

There were no signs of generalized ligamentous laxity.

She had hypoplastic left thenar eminence.

She had MRC Grade III power of the thenar muscles.

She had bilateral tendo Achilles contractures.

There was no passive dorsiflexion possible from neutral.

She had a restricted arm swing on both sides.

Mirror movements were demonstrated in bilateral fingers.

Mirror movements were demonstrated in bilateral elbows.

Mirror movements were demonstrated in bilateral toes.

Mirror movements were demonstrated in bilateral ankles.

Mirror movements of the toes and fingers worsened with fatigue.

Mirror movements at the elbows and ankles became less frequent as voluntary movements were continued.

Neurological examination was otherwise normal.

There were no craniofacial malformations.

X-rays and 3-D CT scan revealed bilateral Rigault Grade II Sprengel deformities.

X-rays and 3-D CT scan revealed mild scoliosis at the cervical spine segment.

X-rays and 3-D CT scan revealed mild scoliosis at the cervicothoracic junction.

X-rays and 3-D CT scan revealed mild scoliosis at the thoracolumbar junction.

There was no fusion at any vertebral level.

MRI revealed no central nervous system (CNS) or spinal cord malformations.

Ultrasonography revealed no renal or genitourinary anomalies.

She started on regular joint range of motion exercises.

She started on muscle stretching and strengthening physiotherapy.

She started on retraining therapy with techniques for increasing wanted movements.

She started on retraining therapy with techniques for restricting unwanted movements.

Her frequency of mirror movements decreased.

Her writing and typing coordination was getting better.

She presented with bilateral shoulder deformities.

She had difficulty in coordination while writing.

On examination, she was noted to have bilateral Sprengel deformities.

She had flexion contractures of upper-limb joints.

She had mirror movements of both upper and lower-limb joints.

She had difficulty in using the Indian toilet.

She had to sit with one leg extended for balance.

She had attained menarche at the age of 12 years.

Clinodactyly was noticed in bilateral ring fingers.

She had hypoplastic left thenar eminence.

She had MRC Grade III power of the thenar muscles.

She had bilateral tendo Achilles contractures.

She had a restricted arm swing on both sides.

Mirror movements were demonstrated in bilateral toes.

Neurological examination was otherwise normal.

There were no craniofacial malformations.

There was no fusion at any vertebral level.

Her frequency of mirror movements decreased.


The patient is a 38-year-old Sri Lankan female.

She presented with sudden onset severe right side headache.

She had vomiting at the time of presentation.

She developed right-sided complete ptosis.

She developed right-sided ophthalmoplegia.

The headache and vomiting lasted for one day.

The ptosis and ophthalmoplegia persisted.

She did not have a history of hypertension.

She did not have a history of dyslipidemia.

She did not have a history of any connective tissue disorder.

On examination, she had complete ptosis on the right side.

On examination, she had ophthalmoplegia on the right side.

On examination, she had a fixed dilated pupil (5 mm) on the right side.

Direct and consensual light reflexes were absent on the right side.

Vision and fundoscopic examination were normal.

Other cranial nerves including the sensory component of the trigeminal nerve were normal.

She did not have tenderness over the superficial temporal artery.

Brachial pulse was decreased on the right side compared to the left side.

Blood pressure on the right arm was 90/60 mmHg.

Blood pressure on the left arm was 120/80 mmHg.

She had a bruit over the right subclavian artery.

She had a bruit over the right carotid artery.

The rest of the cardiovascular, respiratory, and abdominal examination was normal.

She did not have features of Ehlers–Danlos syndrome.

She did not have features of Marfan syndrome.

She did not have manifestations of connective tissue disorder.

Noncontrast CT brain was done soon after admission.

Cerebrospinal fluid analysis was performed on day 2.

Cerebrospinal fluid analysis showed absent cells.

Cerebrospinal fluid analysis showed normal protein level.

Cerebrospinal fluid analysis did not reveal xanthochromia.

CT cerebral angiogram was done on day 4.

CT cerebral angiogram revealed generalized caliber reduction of the right ICA.

MRI done on day 23 showed significantly narrowed right ICA.

Dissection of the right ICA was noted in the cavernous sinus.

The dissection had a false lumen of 1.5 × 1 cm.

The thrombosed lumen was of intermediate signal intensity in T1, T2, and FLAIR images.

The thrombosed lumen did not enhance with contrast.

The thrombosed lumen was compressing the right cavernous sinus.

Multiple focal T2 and FLAIR hyperintensities with partially restricted diffusion were seen in the right parietal lobe.

These hyperintensities were suggestive of acute infarcts.

Cerebral digital subtraction angiogram showed total occlusion of the right ICA from its origin.

Blood supply to the right middle cerebral artery was maintained via the anterior communicating artery.

Blood supply to the right middle cerebral artery was maintained via the posterior communicating artery.

Aneurysmal dilation and stenosis were evident at the right proximal subclavian artery.

CT angiogram revealed aneurysmal dilatation (20 × 11 mm) of the first part of the right subclavian artery.

CT angiogram revealed stenosis of the first part of the right subclavian artery.

Tapering of the distal part of the right carotid bulb at the origin of the right ICA was seen.

This tapering was suggestive of right ICA dissection with thrombosis.

Fluorescent angiogram of the retina was normal.

Full blood count showed neutrophil leukocytosis.

Low hemoglobin was seen in the blood picture.

Normochromic normocytic anemia was seen in the blood picture.

Liver function tests revealed low albumin.

Serum creatinine was 150 μmol/L on admission.

eGFR using MDRD was 35.8 ml/min/1.73m2 on admission.

Serum creatinine later came down to 100 μmol/L.

eGFR using MDRD later came down to 57.2 ml/min/1.73m2.

Ultrasound revealed kidney sizes of 8.9 cm on the right and 8.7 cm on the left.

ESR was persistently high at 130 mm in the first hour.

Hepatitis B and C serology were negative.

Fasting blood sugar was within normal range.

Thyroid function tests were within normal range.

Bilateral cervical ribs were noted in chest x-ray.

Bilateral cervical ribs were noted in cervical x-ray.

She was started on high dose prednisolone (1 mg/kg).

Neurosurgical and vascular surgical opinion was taken.

After 2 weeks of steroids, ESR came down to 50 mm in the first hour.

After one month of steroids, ESR was 30 mm in the first hour.

Ophthalmoplegia and ptosis remained the same.

Azathioprine was added as a steroid-sparing agent.

The difference between right and left brachial pulses reduced.

She did not have any further vascular events.

A follow-up angiogram was planned in six months.

The authors followed the CARE guidelines when writing this case report.

The patient is a 38-year-old Sri Lankan female.

She had fixed dilated pupil on the right side.

She had complete ptosis on the right side.

She had ophthalmoplegia on the right side.

Imaging showed dissection and dilatation in the right internal carotid artery.

The dissection and dilatation extended from the origin up to the cavernous segment.

She had stenosis and aneurysmal dilatation of the right subclavian artery.

The patient is a 38-year-old Sri Lankan female.

She had vomiting at the time of presentation.

She developed right-sided complete ptosis.

She developed right-sided ophthalmoplegia.

The headache and vomiting lasted for one day.

The ptosis and ophthalmoplegia persisted.

She did not have a history of hypertension.

She did not have a history of dyslipidemia.

On examination, she had complete ptosis on the right side.

On examination, she had ophthalmoplegia on the right side.

Vision and fundoscopic examination were normal.

Blood pressure on the right arm was 90/60 mmHg.

Blood pressure on the left arm was 120/80 mmHg.

She had a bruit over the right subclavian artery.

She had a bruit over the right carotid artery.

She did not have features of Ehlers–Danlos syndrome.

She did not have features of Marfan syndrome.

Noncontrast CT brain was done soon after admission.

Cerebrospinal fluid analysis was performed on day 2.

Cerebrospinal fluid analysis showed absent cells.

Cerebrospinal fluid analysis showed normal protein level.

Cerebrospinal fluid analysis did not reveal xanthochromia.

CT cerebral angiogram was done on day 4.

The dissection had a false lumen of 1.5 × 1 cm.

The thrombosed lumen did not enhance with contrast.

These hyperintensities were suggestive of acute infarcts.

Fluorescent angiogram of the retina was normal.

Full blood count showed neutrophil leukocytosis.

Low hemoglobin was seen in the blood picture.

Liver function tests revealed low albumin.

Serum creatinine was 150 μmol/L on admission.

eGFR using MDRD was 35.8 ml/min/1.73m2 on admission.

Serum creatinine later came down to 100 μmol/L.

eGFR using MDRD later came down to 57.2 ml/min/1.73m2.

ESR was persistently high at 130 mm in the first hour.

Hepatitis B and C serology were negative.

Fasting blood sugar was within normal range.

Thyroid function tests were within normal range.

Bilateral cervical ribs were noted in chest x-ray.

Bilateral cervical ribs were noted in cervical x-ray.

She was started on high dose prednisolone (1 mg/kg).

Neurosurgical and vascular surgical opinion was taken.

Ophthalmoplegia and ptosis remained the same.

Azathioprine was added as a steroid-sparing agent.

She did not have any further vascular events.

A follow-up angiogram was planned in six months.


A case of tuberculosis of the cervix presenting as cervical carcinoma is being reported for its rarity.

The patient was a 26-year-old P2L2 Indian lady.

She had pain abdomen, irregular bleeding, and discharge per vaginum for three years.

She had a history of post-coital bleeding and inter-menstrual bleeding.

She had significant weight loss over the last two years.

There was no history of genitourinary malignancy or tuberculosis in the past or in the family.

The patient was a non-smoker, non-alcoholic, and did not have any other significant medical or surgical illness in the past.

On per speculum examination, the cervix was replaced by an irregular friable growth that was bleeding on touch.

PAP smear showed epitheloid like cell clusters without any dysplasia.

Biopsy taken from the cervical growth revealed granulomatous inflammation with caseous necrosis.

Smear from cervix was found positive for acid-fast bacilli.

Endometrial biopsy was normal with no AFB.

Sputum and urine samples were negative for AFB and failed to culture mycobacterium.

CECT abdomen showed a bulky cervix with evidence of soft tissue streaking in parametrium.

The patient was started on antitubercular treatment with four drugs: isoniazid, ethambutol, rifampicin, and pyrazinamide.

At six months, the cervix had an almost normal appearance and there was complete relief from symptoms.

On per speculum examination, cervix was replaced by an irregular friable growth.

A clinical diagnosis of carcinoma cervix was made.

The cervical biopsy revealed granulomatous inflammation.

Acid-fast bacilli were present on cervical smear.

The findings were consistent with tuberculosis.

The patient responded to six months of anti-tubercular therapy.


He had painless and progressive visual impairment of both eyes over two years.

The patient had no other positive symptoms apart from blurred vision.

The patient had no history of ocular diseases.

He was diagnosed with hypocalcemia when he was young.

He did not know the serum calcium concentration at the time of the hypocalcemia diagnosis.

He relied on a diet of milk or calcium-containing foods and calcium tablets to supplement his calcium levels at that time.

He did not take regular calcium supplements subsequently.

He started to experience muscle cramps in his upper extremities approximately ten years ago.

He did not seek help for the muscle cramps until the occurrence of epilepsy.

Seven years ago, he underwent cerebral surgery for epileptic seizures.

The ocular examination revealed a preoperative binocular visual acuity of 16/200.

The best-corrected visual acuity (BCVA) was not improved.

The intraocular pressure in the right eye was 15 mmHg.

The intraocular pressure in the left eye was 16 mmHg.

There was bilateral symmetrical opacity of the lens.

The lens opacity presented as punctate opacity in the posterior subcapsular cortex.

The lens opacity also presented as radial opacity in the peripheral cortex.

Fundus examination showed no pathological changes.

The serum total calcium level was 1.21 mmol/L.

The serum ionized calcium level was 0.72 mmol/L.

The serum phosphorus level was 1.67 mmol/L.

The serum magnesium level was 0.62 mmol/L.

An electrocardiogram showed a prolonged QT interval.

Anterior segment photography revealed punctuate opacity in the posterior subcapsular cortex.

Anterior segment photography also revealed radial opacity in the peripheral cortex.

He was previously diagnosed with hypocalcemia.

He did not take calcium supplements regularly.

He had no history of anterior neck thyroid surgery.

The serum calcium level was 1.21 mmol/L.

The intact parathyroid hormone level was 0 pg/mL.

Ocular examination revealed bilateral symmetrical opacity of the lens.

Phacoemulsification with an intraocular lens was performed in both eyes.

The surgeries were performed sequentially.

Postoperatively, the patient had a satisfactory recovery.

The patient had greatly improved visual acuity.


The patient was a 62-year-old male farmer.

He was hospitalized for fatigue and weight loss for more than 1 mo.

The peripheral blood examination in a local hospital indicated severe anemia with a hemoglobin level of 54 g/L.

The peripheral blood examination suggested a potentially malignant tumor from the blood system.

He was admitted to Huaihe Hospital of Henan University.

The patient had no history of exposure to industrial poisons or radioactive substances.

The patient was not smoking or drinking alcohol.

The percussion of the lungs presented a little dullness.

A few moist rales were heard at the left lung base.

Mild concave edema was seen in both lower extremities.

Laboratory evaluation at the Huaihe Hospital showed a hemoglobin level of 61 g/L.

Further blood examination indicated renal dysfunction.

Erythrocyte sedimentation rate was elevated.

Serum protein electrophoresis suggested an elevation of α2-globulin and γ-globulin.

The other band within α2 fraction was obscure.

Serum IFE showed two monoclonal bands in the λ region without corresponding heavy chain bands.

The results corresponded to the distinct elevation of serum λ FLC.

A second serum IFE showed two monoclonal bands in antisera to λ.

A second serum IFE showed one corresponding heavy chain band in antisera to IgD.

BM cytomorphologic examination found 82% plasma cells, mainly immature, of the BM nucleated cells.

Flow cytometry suggested positivity of monoclonal plasma cells at 70.12% of total nucleated red blood cells.

The immunophenotype was CD38, cytoplasmic lambda, and CD229.

All monoclonal plasma cells expressed CD229, CD38, and cytoplasmic lambda.

BM cytomorphologic examination and flow cytometry supported the diagnosis of plasma cell myeloma.

Chromosome karyotype analysis showed 46,XY;46,Y,t(X;4)(p11.2;q21).

Gene analysis of the blood tumor mutant group was mainly normal.

The patient was diagnosed with stage ISS III myeloma.

The patient was diagnosed as IgD-λ/λ myeloma.

The patient was admitted with weight loss.

The physical examination suggested an anemic face.

The physical examination found a few moist rales at the left lung base.

The physical examination found mild concave edema in both lower extremities.

Laboratory examinations showed elevated creatinine levels.

Laboratory examinations showed elevated β2-microglobulin.

Laboratory examinations showed elevated lactic dehydrogenase.

Laboratory examinations showed elevated erythrocyte sedimentation rate.

Laboratory examinations showed decreased neutrophils.

Laboratory examinations showed decreased granulocytes.

Laboratory examinations showed decreased hemoglobin.

Serum protein electrophoresis showed two inconspicuous M-spikes.

Serum IFE indicated an over-representation of lambda light chain.

Serum IFE yielded two monoclonal bands in λ region.

Serum IFE yielded one corresponding heavy chain band in the antisera to IgD region.

BM histology supported the diagnosis of IgD-λ/λ myeloma.

BM cytology supported the diagnosis of IgD-λ/λ myeloma.

The patient was a 62-year-old male farmer.

The patient was not smoking or drinking alcohol.

A few moist rales were heard at the left lung base.

Further blood examination indicated renal dysfunction.

Erythrocyte sedimentation rate was elevated.

The other band within α2 fraction was obscure.

The patient was diagnosed with stage ISS III myeloma.

The patient was diagnosed as IgD-λ/λ myeloma.

The patient was admitted with weight loss.

The physical examination suggested an anemic face.

Laboratory examinations showed decreased neutrophils.

Laboratory examinations showed decreased granulocytes.

Laboratory examinations showed decreased hemoglobin.

Serum IFE yielded two monoclonal bands in λ region.


He was brought to the Queen Elizabeth Hospital, Kota Kinabalu, Sabah at 8.30 am.

He was unable to give a history himself.

On examination his blood pressure was unrecordable.

Oxygen saturations were recorded as low.

The patient had no past medical history.

He had spent two weeks in the jungles of Borneo before leaving for an urban setting.

Ten days after leaving the jungle he experienced the onset of fever and body aches.

Two days later, he sought treatment at a government outpatient clinic.

He continued to complain of fever and myalgia.

He remained unwell for the next two days.

After resuscitation measures, his blood pressure was 58/44 mm Hg.

Resuscitation measures continued for one hour.

Coffee grounds were observed in the nasogastric aspirate.

The patient became asystolic after one hour.

Cardiopulmonary resuscitation was given for a further 20 minutes.

The patient was pronounced dead two hours after admission.

Dengue haemorrhagic shock was suspected.

A post-mortem examination was performed approximately 24 hours later.

He had elevated amino transferase values.

A blood sample taken 24 hours post-mortem showed >10% of erythrocytes infected with predominantly pigmented parasites.

Heavily pigmented monocytes were also present.

Plasmodium knowlesi, as a single species infection, was confirmed by nested-PCR.

Post-mortem dengue serology was negative.

Dengue, respiratory syncytial virus and enterovirus were not isolated in organ samples.

External examination showed a well-nourished adult male.

The conjunctivae showed tinges of jaundice.

The right eye had subconjunctival haemorrhages.

There were multiple petechial haemorrhages on the body.

Venepuncture sites were associated with marked bruising.

Coffee ground material was noted in the mouth.

The external surfaces of the cerebrum were dusky.

The cut sections showed multiple petechial haemorrhages.

The cerebellum also showed petechial haemorrhages externally and on multiple cut sections.

The brain stem and upper spinal chord were grossly normal.

The cut sections were congested and 'beefy' in appearance.

Petechial haemorrhages were present on the endocardium.

There were extensive subendocardial haemorrhages involving the left ventricular wall.

The haemorrhages were most prominent at the apex of the heart.

The cut surfaces of the spleen were soft and friable.

The gallbladder, pancreas and kidneys were grossly normal.

Haematoxylin and eosin stained sections from various organs were available for examination.

Parasitized red blood cells were abundant.

Parasite bodies were obscured by haemozoin pigment.

Chemical removal of pigment and oil immersion (×1,000) magnification revealed trophozoites that were discernibly bigger than those of P. falciparum.

Immunohistochemistry stained sections from the brain were Plasmodium anti-aldolase positive.

Immunohistochemistry stained sections from the brain were negative for P. falciparum-specific staining.

Many petechial haemorrhages (up to 600 μm diameter) arising from the rupture of the small vessels of the cerebrum and cerebellum were observed.

Sequestration of PRBC was evident within small blood vessels.

Congested larger vessels and areas of haemorrhage showed considerable amounts of malaria pigment.

Clumps of platelets or evidence of thrombi in vessels were not seen.

There was no evidence of vasculitis or perivascular chronic inflammatory reaction in the brain.

There was no evidence of perivascular or diffuse parenchymal oedema in the brain.

Diffuse astrocytosis or microgliosis was not observed.

There was no evidence for acute gliotic reactions about the haemorrhages.

There was no aggregation of polymorphs in the vessels.

There was no diffuse thrombotic microangiopathy.

Within one haemorrhage there was probably some fibrin at the site of the vessel.

Immunohistochemistry of sections from the brain was negative for CD54.

Sections from the spleen showed some autolysis.

Expansion of the red pulp and atrophy of the white pulp was noted.

Abundant pigment-containing macrophages and some haemophagocytosis was evident in the red pulp.

There was no necrosis or fibrin deposition in the spleen.

There were many PRBC's in the liver sinusoids.

Evidence of haemophagocytosis was present.

The portal tracts and sinusoids had moderate chronic lymphoplasmacytic inflammation.

The liver had severe macrovesicular steatosis.

There was no thrombotic microangiopathy.

The renal cortex showed dilated and congested blood vessels.

Many PRBC were observed within glomerular capillaries.

Pigment deposition was in the mesangium.

There was no evidence of thrombotic microangiopathy.

The tubules showed acute tubular necrosis and regeneration.

There were a small number of eosinophilic intra-tubular casts.

Sequestration of PRBC's was evident in the small vessels of the heart.

The heart muscle fibers appeared normal.

There was focal petechial haemorrhage in the subendocardium.

The focal petechial haemorrhage may relate to resuscitation.

The focal petechial haemorrhage may be secondary to malaria.

There was eosinophilic cytoplasm in the fasciculata layer.

There was no evidence of PRBC sequestration.

Samples of lung, intestine or bone marrow were not available for histopathology examination.

The overall picture was one of systemic malaria infection with multi-organ damage.

There was much vascular rupture and petechial haemorrhaging in the brain.

A formerly healthy 40 year-old male became symptomatic 10 days after spending time in the jungle of North Borneo.

He presented to hospital in a state of collapse and died within two hours.

He had elevated amino transferase values.

Dengue haemorrhagic shock was suspected.

A post-mortem examination was performed.

Investigations for dengue virus were negative.

Blood for malaria parasites indicated hyperparasitaemia.

Single species P. knowlesi infection was confirmed by nested-PCR.

Macroscopic pathology of the brain and endocardium showed multiple petechial haemorrhages.

The lungs had features consistent with ARDS.

Microscopic pathology showed sequestration of pigmented parasitized red blood cells in the vessels of the cerebrum, cerebellum, heart and kidney.

There was no evidence of chronic inflammatory reaction in the brain or any other organ examined.

Brain sections were negative for intracellular adhesion molecule-1.

The spleen and liver had abundant pigment containing macrophages and parasitized red blood cells.

The kidney had evidence of acute tubular necrosis.

Endothelial cells in heart sections were prominent.

He was unable to give a history himself.

On examination his blood pressure was unrecordable.

Oxygen saturations were recorded as low.

The patient had no past medical history.

He continued to complain of fever and myalgia.

He remained unwell for the next two days.

After resuscitation measures, his blood pressure was 58/44 mm Hg.

Resuscitation measures continued for one hour.

Coffee grounds were observed in the nasogastric aspirate.

The patient became asystolic after one hour.

Cardiopulmonary resuscitation was given for a further 20 minutes.

The patient was pronounced dead two hours after admission.

Dengue haemorrhagic shock was suspected.

He had elevated amino transferase values.

Heavily pigmented monocytes were also present.

Post-mortem dengue serology was negative.

External examination showed a well-nourished adult male.

The conjunctivae showed tinges of jaundice.

The right eye had subconjunctival haemorrhages.

There were multiple petechial haemorrhages on the body.

Venepuncture sites were associated with marked bruising.

Coffee ground material was noted in the mouth.

The external surfaces of the cerebrum were dusky.

The cut sections showed multiple petechial haemorrhages.

The brain stem and upper spinal chord were grossly normal.

The cut sections were congested and 'beefy' in appearance.

Petechial haemorrhages were present on the endocardium.

The haemorrhages were most prominent at the apex of the heart.

The cut surfaces of the spleen were soft and friable.

The gallbladder, pancreas and kidneys were grossly normal.

Parasitized red blood cells were abundant.

Parasite bodies were obscured by haemozoin pigment.

Sequestration of PRBC was evident within small blood vessels.

Diffuse astrocytosis or microgliosis was not observed.

There was no aggregation of polymorphs in the vessels.

There was no diffuse thrombotic microangiopathy.

Sections from the spleen showed some autolysis.

Expansion of the red pulp and atrophy of the white pulp was noted.

There was no necrosis or fibrin deposition in the spleen.

There were many PRBC's in the liver sinusoids.

Evidence of haemophagocytosis was present.

The liver had severe macrovesicular steatosis.

There was no thrombotic microangiopathy.

The renal cortex showed dilated and congested blood vessels.

Many PRBC were observed within glomerular capillaries.

Pigment deposition was in the mesangium.

There was no evidence of thrombotic microangiopathy.

The tubules showed acute tubular necrosis and regeneration.

There were a small number of eosinophilic intra-tubular casts.

The heart muscle fibers appeared normal.

There was focal petechial haemorrhage in the subendocardium.

The focal petechial haemorrhage may relate to resuscitation.

The focal petechial haemorrhage may be secondary to malaria.

There was eosinophilic cytoplasm in the fasciculata layer.

There was no evidence of PRBC sequestration.


He presented with headache and diplopia for three days.

The headache was not accompanied by vomiting.

The headache was not accompanied by dizziness.

Fundoscopy showed left optic nerve atrophy.

The findings were consistent with Foster-Kennedy syndrome.

Neurological examinations were otherwise normal.

A left frontal irregular space-occupying lesion was seen on MRI.

Enhancement was shown on contrast-enhanced scan.

The lesion appeared hyperintense on T1-weighted images.

Hypointense signals were noted on T2-weighted images.

The tumor was primarily located at the frontal lobe.

Brain CTA showed compression of the anterior and middle cerebral arteries.

Small branches from the middle and anterior cerebral arteries supplied blood to the tumor.

Meningioma was diagnosed prior to surgery.

Surgery was performed via the left frontotemporoparietal approach.

The tumor was removed four days after admission.

The tumor was located at the anterior cranial fossa.

The tumor adhered closely to the dura of the skull base.

Only the infiltrated dura was not removed.

Grossly, the tumor was a soft, well-circumscribed pigmented lesion with a capsule.

The tumor proved to be meningeal melanocytoma on histopathological examination.

Immunohistochemistry was positive for HMB-45.

Immunohistochemistry was positive for vimentin.

Immunohistochemistry was positive for S-100 protein.

Immunohistochemistry was negative for EMA.

Immunohistochemistry was negative for CK.

Immunohistochemistry was negative for PR.

A detailed physical examination was performed.

The patient denied a history of melanocytoma.

The patient received one-time 30 Gray radiation therapy after surgery.

The duration of radiation therapy was one day.

No tumor relapse was seen on follow-up MRI six months after surgery.

At follow-up two and a half years after surgery, the patient was free of symptoms.

No tumor recurrence was shown on the CT scan.

A 27-year-old man presented with headache and diplopia at our department.

Fundoscopy showed left optic nerve atrophy.

Neurological exams were otherwise normal.

A left frontal irregular space-occupying lesion was seen on magnetic resonance imaging (MRI).

Enhancement was shown on contrast-enhanced computed tomography (CT) scan.

CT angiography (CTA) revealed vascular compression around the lesion.

Prior to surgery, meningioma was diagnosed.

On postoperative pathohistological exam, the tumor proved to be a meningeal melanocytoma.

After surgery, the patient received radiation therapy.

No tumor was seen on follow-up MR images six months after surgery.

The patient was well after two and a half years.

There was no tumor recurrence on the follow-up CT.

Fundoscopy showed left optic nerve atrophy.

Meningioma was diagnosed prior to surgery.

Only the infiltrated dura was not removed.

Immunohistochemistry was negative for EMA.

Immunohistochemistry was negative for CK.

Immunohistochemistry was negative for PR.

The patient denied a history of melanocytoma.

No tumor recurrence was shown on the CT scan.


A 13-year-old young man was admitted to our hospital with non-sustained ventricular tachycardia episode.

The non-sustained ventricular tachycardia episode was noticed during routine athletic evaluation.

Resting ECG was normal, with sinus rhythm.

The heart rate on resting ECG was normal.

There were no significant alterations of the ventricular repolarization phase on resting ECG.

Exercise stress test (treadmill) didn’t show signs of inducible ischemia through maximal effort.

The METS achieved during the treadmill test were 21.

The maximal heart rate during the treadmill test was 194 beats per minute.

The treadmill test induced asymptomatic non-sustained ventricular tachycardia.

The non-sustained ventricular tachycardia had left bundle branch morphology.

The non-sustained ventricular tachycardia had an inferior axis.

The rate of the non-sustained ventricular tachycardia was 150 beats per minute.

The non-sustained ventricular tachycardia occurred during the second minute of the recovery phase.

Standard echocardiographic views showed a not clearly normal coronary pattern.

The right coronary artery appeared with high take-off from the aortic wall.

The right coronary artery ostium was not clearly identified.

Genetic screening for catecholaminergic tachycardia was performed.

Beta-blocking therapy with nadolol was started.

Beta-blocking therapy with nadolol was continued until the first cardiological follow up.

Coronary computed tomography angiography was performed.

The scan showed anomalous origin of all three branches of coronary arteries from a single origin from the left coronary sinus.

The right coronary artery had a malignant course, squeezed between the pulmonary trunk and the proximal ascending aorta.

The distal part of the right coronary artery took its normal course.

The left anterior descending artery caliber appeared to be normal.

The circumflex artery caliber appeared to be normal.

All the data from coronary computed tomography angiography were confirmed by cardiac magnetic resonance.

Myocardial scintigraphy with protocol of two days steps and treadmill stress test (exercise) was performed.

Myocardial scintigraphy showed no significant evidences of perfusion defects.

Catheter coronary angiography was performed.

The coronary angiography showed the rare coronary anomaly pattern.

The exam showed a significant milking effect at the middle segment of the left anterior descending artery.

Invasive Fractional Flow Reserve (iFFR) was 0.83.

Intravascular ultrasound (IVUS) showed a slit like right coronary ostium.

Intravascular ultrasound (IVUS) showed eccentric systolic compression in the proximal bridge segment of the right coronary artery.

The depth of the bridging muscle segment was 16 mm.

The length of the bridging muscle segment was 25 mm.

A surgical unroofing of the right coronary artery intramural section was performed.

Resuspension of the intercoronary commissure was performed.

The resuspension resulted in relocation of the coronary artery into the appropriate aortic sinus.

Surgical myotomy involving resection of the overlying muscle fibers on the middle segment of the left anterior descending artery was performed.

The patient's postoperative course was uneventful.

The patient stayed overnight in the intensive care unit.

The patient left the hospital on postoperative day 7.

No complications occurred during the first six months of follow-up.

Both anomalous origin of the right coronary artery and myocardial bridge on left anterior descending artery were detected concurrently.

Resting ECG was normal, with sinus rhythm.

The heart rate on resting ECG was normal.

The METS achieved during the treadmill test were 21.

Beta-blocking therapy with nadolol was started.

Coronary computed tomography angiography was performed.

The circumflex artery caliber appeared to be normal.

Catheter coronary angiography was performed.

Invasive Fractional Flow Reserve (iFFR) was 0.83.

The depth of the bridging muscle segment was 16 mm.

The length of the bridging muscle segment was 25 mm.

The patient's postoperative course was uneventful.

The patient stayed overnight in the intensive care unit.

The patient left the hospital on postoperative day 7.